This case report (2017) explores using low, repeated, and increasing doses of ibogaine for someone who is heroin-dependent and is currently undergoing methadone maintenance treatments (MMT). It found that every administration of ibogaine reduced the withdrawal symptoms for several hours, and attenuated the tolerance to methadone until all withdrawal symptoms vanished with no serious adverse effects at the end of the treatment. This is the first such case report on ibogaine treatment using low and cumulative doses for MMT.
Abstract
“Background and aims: Ibogaine is a natural alkaloid that has been used in the last decades as an adjuvant for the treatment of opiate withdrawal. Despite the beneficial results suggested by animal studies and case series, there is a lack of clinical trials to assess the safety and efficacy of ibogaine. Moreover, the majority of reports described cases of heroin-dependent individuals, with and without concomitant use of methadone, using high doses of ibogaine. Therefore, it is not clear if ibogaine at low doses could be used therapeutically in people on methadone maintenance treatments (MMT).
Methods: Case report of a female on MMT for 17 years who performed a self-treatment with several low and cumulative doses of ibogaine over a 6-week period.
Results: The patient successfully eliminated her withdrawals from methadone with ibogaine. Each administration of ibogaine attenuated the withdrawal symptoms for several hours, and reduced the tolerance to methadone until all signs of withdrawal symptoms disappeared at the end of the treatment. No serious adverse effects were observed, and at no point did the QTc measures reach clinically significant scores. Twelve months after the treatment, she was no longer on MMT.
Conclusions: To our knowledge, this is the first case report describing an ibogaine treatment using low and cumulative doses in a person on MMT. Although preliminary, this case suggests that low and cumulative doses of ibogaine may reduce withdrawal symptoms in patients undergoing MMT.”
Authors: Clare Wilkins, Rafael G. dos Santos, Jordi Solá, Marc Aixalá, Pep Cura, Estefanía Moreno, Miguel A. Alcázar-Córcoles, Jaime E. C. Hallak & José C. Bouso
Summary
INTRODUCTION
Opioid misuse is increasing alarmingly in both the EU and North America, with 78 Americans dying every day from an opioid overdose. The European Monitoring Centre for Drugs and Drug Addiction reported an increase in opioid-related deaths in 2016.
The World Health Organization recommends that people with opioid use disorders begin an opioid substitution treatment (OST), generally using methadone or buprenorphine. However, OSTs tend to become a perpetual treatment, and people who terminate OSTs have more medical, cognitive, and emotional problems.
Ibogaine is an alkaloid found in Tabernanthe iboga, an African plant used in ethnomedicine in traditional communities. It has been used to treat substance use disorders, but high doses of ibogaine may induce bradycardia and prolong the QTc interval, which can be life-threatening.
A clinical trial with noribogaine showed no significant reduction in withdrawal symptoms in people on methadone who were switched to morphine, but a concentration-dependent increase in QTc was observed. We present here the case of a successful detoxification from long-term methadone dependence using low, repeated, and increasing doses of ibogaine.
CASE PRESENTATION
A 47-year-old woman started an ibogaine treatment after 17 years on methadone to treat her previous heroin dependence. She occasionally used heroin, amphetamine and ethanol, and was a daily cannabis user.
The patient acquired hepatitis C virus as a consequence of her former intravenous use of heroin. She underwent a complete blood count and biochemistry, hormones, urine biochemistry, coagulation, serology, and molecular biochemistry exam before initiating this treatment.
Objectives of the treatment, procedures, and assessment materials
The main objective of the treatment was to completely detoxify the patient safely and with as much comfort as possible from methadone. The Opiate Withdrawal Scale, Short OWS, Brief Psychiatric Rating Scale, and Udvalg for Kliniske Undersogelser Side Effects Rating Scale were used to assess withdrawal symptoms, psychiatric safety, and side effects.
Treatment
The patient contacted the ICEERS Support Service and was put in contact with Pangea Biomedics, a clinic in Mexico with 10 years of experience in treating substance dependencies, such as MMT with ibogaine. The patient underwent the detoxification while being supervised live through Skype video in Spain. The treatment consisted of low and increasing doses of ibogaine administered in between progressively decreasing methadone dosages. The patient only needed to use the sample from South Africa one, and an EKG machine with QTc lecture was used for cardiac monitoring.
The patient took 150 mg of ibogaine one hour after stopping methadone, and then half the basal dose of methadone for 3 days, and then ceased self-administering methadone, and took 300 mg of ibogaine three more times, alternating ibogaine doses with decreasing methadone doses.
Outcome and follow-up
The patient successfully eliminated her withdrawals from methadone with ibogaine. She used a benzodiazepine after the first ibogaine session and cannabis oil after the other ibogaine sessions, and did not continue using methadone, benzodiazepines, nor cannabis oil after the last ibogaine session.
There were no clinically significant decrements in QTc or BP with the 400 and 500 mg doses, but HR increased with sitting or standing up.
The ibogaine sessions appeared to lack visionary content, but the patient had psychological insights regarding biographical events with emotional, non-distressing reactions. 12 months after the ibogaine treatment, she was no longer an MMT patient, and was without any symptoms of post-acute withdrawal syndrome.
DISCUSSION
To our knowledge, the first protocol to detoxify from methadone based on low and multiple doses of ibogaine administered intermittently between decreasing methadone doses has been performed. It may provide a relatively brief but successful alternative to classical methods based on conventional detoxification.
The ibogaine literature is confusing regarding its efficacy with methadone-dependent patients, and a singular large dose does not completely eliminate the withdrawal symptoms of methadone.
Ibogaine has withdrawal-mitigating properties, and its metabolite noribogaine has been proposed as the molecule responsible for its anti-withdrawal effects. Noribogaine has a long half-life, and may explain the sustained anti-withdrawal effects of only one dose of ibogaine administered to heroin and/or other short-acting opiate users.
The withdrawal symptoms appeared again after 6 hr with the initial lower dose, and after almost 24 hr following the incremental doses. This could be due to the fact that the ibogaine reduced the methadone tolerance, and thus the withdrawal symptoms took longer to reappear.
The clinical trial that assessed the anti-withdrawal properties of noribogaine found no significant effects. It is possible that combining both the effects of ibogaine and noribogaine may be necessary to obtain a complete anti-withdrawal effect, at least in patients dependent on opioids with a long half-life.
Ibogaine accumulates in the brain until reaching the necessary levels to completely reverse/eliminate withdrawal symptoms. It may be necessary to alternate doses of ibogaine with periods of methadone to achieve psychological integration.
The authors thank the patient for her kindness and Sarita Wilkins and Douglas Greene for their invaluable assistance with manuscript editing.
Conflict of interest: CW is the Director of Pangea Biomedics, RGdS is a Fellow of the Brazilian National Postdoctoral Program, and JECH received a CNPq Productivity Fellowship Award.