- Why Ibogaine Is Not the Answer to the Opioid Crisis - September 29, 2020
- Why Ibogaine Is Not the Answer to the Opioid Crisis - September 29, 2020
Before the COVID-19 pandemic, news feeds were filled with stories of overdose, skyrocketing death rates, pill mills, and fentanyl. The headlines reflected the loss of lives even among the well-manicured cul de sacs of suburbia; read: White. Less reported, but just as deadly, were other familiar tragedies that were not at all that new. The nomenclature was very different where the poor, Black, and brown lived. They were junkies, and crack and meth heads; but, with the rise of addiction amongst White suburban soccer moms, or their offspring, strung out on “Chinese” fentanyl, came a more caring look at so-called addiction, and a demand for an answer. Treatment instead of incarceration is the rallying call; but, what is treatment?
Patchwork market overviews look at the existing treatment industry, shocking opioid crisis statistics, and the handful of ibogaine observational studies to bring together a very hopeful picture.
Enter the ibogaine advocate, moved by a sincere and urgent desire to help. With the rebranding of the addict from “criminal” to “sick,” ibogaine sheds some of its association with the underground dope scene. From its origins among drug user self-help organizations, it now found a way into the more clinical atmosphere of the psychedelic renaissance. Also moved are venture capitalists, now flocking to psychedelic therapies, some of whom have even started to place their bets on ibogaine. Patchwork market overviews look at the existing treatment industry, shocking opioid crisis statistics, and the handful of ibogaine observational studies to bring together a very hopeful picture. Thriving off of the excitement and energy of advocates, moneyed interests offer the promise of further legitimization.
We have worked with ibogaine and iboga professionally for a combined total of nearly 30 years. It has changed our lives dramatically for the better, perhaps more than anything else has. We have also each witnessed thousands of others who have benefited from ibogaine as well, regardless of how “successful” their outcome would look as a treatment metric. The changes are real, but this does not make it the missing piece in solving the opioid crisis, and it definitely does not make it the missing piece to pull together the addiction treatment industry. Ibogaine is not an addiction treatment.
Back in 1939, when the first edition of the Alcoholics Anonymous Big Book was published, page one was a letter titled “The Doctor’s Opinion.” The physician who authored it described his sense of powerlessness at not being able to help the alcoholics who came to him, and the fascination he developed witnessing the results some people had through AA. It’s a story not dissimilar to the first doctors who witnessed people taking ibogaine for opioid detox back in the early 1980s. It’s also not dissimilar to the doctors today who have to admit that their patients’ health has improved immediately after returning from an ibogaine treatment.
There are more similarities between the ibogaine movement and the 12-Step movement. For one, both of them were developed outside of professional frameworks. In AA, this is baked into the 12 Traditions, a document that defines the group’s structure. Tradition eight states: “AA will remain forever nonprofessional.” With ibogaine, it was simply a response to the disinterest on the part of the FDA and NIDA in pursuing further clinical research. This resulted in the organic growth of a community of practitioners outside of any legal framework, most of them current or former users.
We believe that other similarities will emerge as well. No 12-Step fellowship refers to itself as a treatment, but it has become the standard in addiction treatment centers. While AA’s 11th Tradition states, “Our public relations policy is based on attraction rather than promotion,” many of the people who have negative experiences with 12-Step programs were forced into them by court order or through some other hierarchical system of diagnosis by which the steps were prescribed. What was, at first, a voluntary network of self-diagnosis, self-help, and self-empowering mutual aid, morphed into what it was never intended to be, a system that now stands in stark contrast to its own founding documents, no longer a fellowship of the willing.
By the time that folks come to ibogaine, most have already been through the treatment circuit many times over. The rote, cookie-cutter approach is often exhausting and punitive, its level of care drastically hit-or-miss, depending on which doctor or counselor walks into the room. Drug treatment should be about how we treat people who use drugs. Instead, it is a clear extension of drug prohibition, its objectives directed by the very same metric that we have used to police the broader war on drugs: to end illicit drug use.
Ibogaine advocates are calling for the inclusion of ibogaine into this same existing system, citing safety, accessibility, and professional accountability. However, within the existing regulatory framework, there are numerous financial and sexual scandals. Even when treatment is not overtly coerced, there are high-pressure sales techniques and inadequate facilities. Its design is dictated by insurance companies’ willingness to pay, which is how we arrived at the 28-day rehab model to begin with. It becomes a never ending, and hugely profitable, revolving door, with the vast majority of people ultimately labeled as failures when they don’t stop their drug use.
12-Step fellowships have succeeded in providing space for community, connection, exploration, and healing, with or without the cessation of drugs, but they have failed to deliver within the treatment system and according to its metrics. Advocates seem to argue that injecting ibogaine into this same system is the way forward, but this would be just as ineffective. We would have to ignore a large part of the therapeutic benefits that have come from a similar culture of self-empowering mutual aid. Once approved as a prescription, coerced ibogaine treatment is not far behind.
Just like 12 Steps, ibogaine is an opportunity, allowing space for exploration, and perhaps some sort of healing.
Not an Addiction Treatment
Ibogaine is not an addiction treatment, nor should it be. Care providers make their way around this fact by describing it as an “addiction interrupter,” calling it “just a tool,” or “just a detox.” However, it’s not that it is just one part of a treatment plan. It’s something else altogether. Just like 12 Steps, ibogaine is an opportunity, allowing space for exploration, and perhaps some sort of healing. The result of placing it into a linear trajectory towards sobriety, or “getting clean,” is a possibility, but it’s limiting to its potential. If the matrix of its evaluation is the same one by which we have evaluated the “failure” of 12-Step programs—a high long-term abstinence rate—then ibogaine will also fail.
Of the few observational studies that have followed people after opioid detox with ibogaine, only one provides a long-term abstinence rate. Thirty percent of the participants at one Mexican clinic self-reported that they never used opioids again (Davis, 2017). The problem with these kinds of numbers is understanding exactly what they measure. Of this 30%, only half were interviewed after a period of one year, some of them over much shorter timeframes. Also, self-reported data can be unreliable because people are more likely to report what they think people want to hear. Even after considering all of that, it’s important to take into consideration that this was a retrospective study in which the clinic called previous clients. That means the number does not represent the clinic’s entire patient population, and we can assume those with better results were more likely to respond and opt-in to the research.
In another study, 23% of participants self-reported abstinence “within the previous 30 days” at the 12-month mark (Brown, 2017). They showed that participants’ cessation of opioid use peaked at 30 days, and then decreased over time. While these numbers are significant in the context of other detox and treatments, they are also not hard and fast results, and require a high degree of interpretation. Aside from the unreliability of self-reports, these only measure a population of people who have self-selected themselves for treatment, and who had to cross a fairly high threshold to get there, traveling out of the country and paying out of pocket.
Based on our experience, we believe that the rate of sustained long-term abstinence is much lower. However, each of these observational studies also looked at things like partial reduction of withdrawals, partial reduction of cravings, and improvements in other areas of life, such as family relationships or legal status. “Favorable outcome” in one was defined as continued participation in the study for 9–12 months, and at least a 75% reduction in drug use scores. Forty percent of the 30 subjects enrolled met that criteria, a very significant result (Brown, 2017). What this begins to show is also what we’ve observed: that there are other positive benefits besides abstinence.
We have to look at ibogaine without such a fixation on finality, which is a hard pill to swallow when individuals, families, and communities are feeling the effects of chaotic drug use and some are at great risk of death. We must be cautious that the tool we’re advocating for isn’t simply an excuse to extend the lifespan and profitability of a broken system, and deployed as a more effective weapon in the War on Drugs. What is important is whether ibogaine can provide what the late harm reduction pioneer Dan Bigg called for: “any positive change” in the life of a drug user.
Increasingly, over the last five years, detoxes have faded out and been replaced almost universally by long-term opioid maintenance programs like methadone and buprenorphine.
No Demand for a Detox
There is a distinction to be made between detox and treatment. Detox, particularly from opioids, is a short-term process that focuses on the physiological aspects of withdrawal. It is the most medically-intensive and risky part of the recovery process. Treatment is focused on long-term behavioral change. Increasingly, over the last five years, detoxes have faded out and been replaced almost universally by long-term opioid maintenance programs like methadone and buprenorphine. The basic function of these medications is to stabilize people’s use with these long-acting opioids.
Buprenorphine, the active opioid component of Suboxone and Subutex, was first brought to the FDA as a medication to assist short-term detox. People can switch onto it from heroin or other short-acting opioids, then quickly taper their dose down to zero. Used in this way, it provides a relatively effective and painless detox. When used in the longer-term as a maintenance drug, it is a different story altogether. It’s long-acting effects help many people to stabilize their lives, taking people out of the cycle of having to use every few hours. Naloxone, the other component of Suboxone, also blocks the effects of other short-acting opioids, reducing the incentive to use them. However, after stabilizing, many find some of its side effects undesirable. People report things like weight gain, lethargy, depression, and sexual dysfunction. It’s long-acting effects also greatly extend the withdrawal process, and many people find it difficult and painful to get off of.
There need to be options to support people who want to detox. However, the plain fact is that detox increases the biggest risk for drug users, overdose death. This is the reality that dictates the market, and it’s why buprenorphine is now rarely used this way. Regardless of the treatment, including ibogaine, the majority of people go back to some level of drug use. Some studies have demonstrated that patients who complete inpatient detox are at increased risk for mortality within the first year, compared with people who don’t complete the same programs (Strang, 2003; Evans, 2015; Walley, 2020). Insurers, the treatment providers, the public health structures, and harm reductionists all look at this and see danger.
Reducing opioid tolerance is something that ibogaine is quite effective at, and therefore the risk of overdose greatly increases afterwards.
“Any person who is addicted to drugs who wishes to be free of that addiction shall be able to have that choice.”
– Howard Lotsof, who discovered ibogaine’s effects on opioid withdrawal
Reducing opioid tolerance is something that ibogaine is quite effective at, and therefore the risk of overdose greatly increases afterwards. Ibogaine also requires intensive screening and medical supervision to mitigate cardiac risks, and this has become a huge component of treatment design. In 2012, the first study on ibogaine fatalities reported a risk window of 72 hours for adverse cardiac events (Alper, 2012). This requires intensive and highly specialized staffing; but, while fatal overdoses during that window were included because they were still under medical supervision, the later overdose rates, where most people die, have rarely been discussed.
One answer to ibogaine’s risk profile has been the development of 18-methoxycoronaridine, or 18-mc, and other newer derivatives. A synthetic analog of ibogaine, 18-mc was originally developed with the hopes of removing both the cardiac risks and the psychedelic effects. It is curious why folks would work day and night to remove the psychedelic aspect of ibogaine—to take the psychedelic away from people who use stigmatized drugs—in an era where there is blind promotion of the therapeutic value of psychedelics. One of the benefits of such a medication over ibogaine would be to prescribe it in outpatient settings, without such intensive medical oversight. However, if it has the same function of removing tolerance to opioids, it doesn’t differ greatly from other existing detox options.
Other low-cost options include high dose Vitamin C or NAD infusions, and a plethora of other unstudied methods for autodidacts who are familiar with Reddit forums, such as switching onto kratom.
There are many other effective, low-threshold and inexpensive detox options that already exist, but are not the standard of care for the reasons listed above. Other low-cost options include high dose Vitamin C or NAD infusions, and a plethora of other unstudied methods for autodidacts who are familiar with Reddit forums, such as switching onto kratom. Finally, there are other options, like rapid detox, that haven’t taken off specifically because they have similar intensive requirements for medical supervision and similar mortality risks to ibogaine treatment. So far, no other detox has come close to solving the opioid crisis. It is hard to imagine why ibogaine would.
While many drug users want access to detox options, including ibogaine, they are not the ones who dictate the market. The ones who do include the pharmaceutical companies, insurers, and the government public health institutions. The public health logic of reducing overdose risk is why increasing doses of maintenance medications are prescribed, so that tolerance remains high and overdose risk is lower. This is an obvious case where mortality metrics simply do not capture the totality of human experience.
Is Ibogaine Efficacious?
All of these forms of risk are important to consider when measuring ibogaine’s potential public health impact, but another is cost-effectiveness. Ibogaine detox is, at minimum, a three- to five-day process, with a base cost of $5,000 when it’s done in places like Mexico, where the cost for medical staff is dramatically lower than in the US, Canada, or Europe. It’s often much longer and more costly and, if it were conducted elsewhere, these costs would multiply.
While the clamber for aftercare is universal around psychedelics, and particularly ibogaine, evidence from drug treatment points to little in terms of reduction in relapse. Recommendations for longer stays at treatment centers, other measures, like longer stabilization, or in-patient aftercare, all add significant additional costs. These are attempts to make up for the lack of inherent “efficacy.”
We understand the need for a rest and reboot for drug users and their family, but they decrease cost-effectiveness. Talk therapy, cognitive, trauma-informed, somatic, and equestrian therapy, body work, 12 steps, SMART Recovery, yoga, tai chi, etc., are all therapeutic modalities that have been touted as aftercare in support of long-term cessation of drug use. We believe people should have access to all of these; but, again, in our opinion, the focus should be on “any positive change.”
If the idea is that we simply place ibogaine into the nightmare of the American treatment industry and its predatory capitalism, it would be an attempt to try to resuscitate an industry that is proven to be ineffective, cruel, and capricious.
The Addicts’ Opinion
Ibogaine clearly illustrates the error behind the implicit goal of the so-called psychedelic renaissance, which is to mainstream these therapies. If the idea is that we simply place ibogaine into the nightmare of the American treatment industry and its predatory capitalism, it would be an attempt to try to resuscitate an industry that is proven to be ineffective, cruel, and capricious.
What makes ibogaine a bad fit in the treatment industry is also its biggest advantage: the expansiveness of time. The experience just takes so long. In Gabon, the centuries-old consumption of iboga (the plant source of ibogaine) has given rise to the elaborate, rich, and varied spiritual practice known as Bwiti. In both of our travels and participation in this tradition, we have experienced a deep honoring of the individual, intensive care, and extensive time given by the entire community.
This is not a call to use Bwiti as drug treatment or for any other purpose removed from its traditional intent in Gabon, but simply points to its artistic and vigorous celebration of that expansiveness of time. It is just an example of what emerges when released from the constraints of efficacy in terms of time, expense, and result. This type of co-created celebration, play, spiritual technology, and performance art as healing art, could be one of those expressions that replaces treatment. It should be treated with that kind of reverence because ibogaine is a big deal, and so are human beings.
Art by Marialba Quesada.
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