This ethnographic study (2007) of ibogaine use (n=3414, estimated users) finds that it is mostly being used for opioid withdrawal (53%). The study also identifies four different types of use (medical, lay provider, self-help, religious).

Abstract

“Aim of the study: Ibogaine is a naturally occurring psychoactive indole alkaloid that is used to treat substance-related disorders in a global medical subculture, and is of interest as an ethnopharmacological prototype for experimental investigation and possible rational pharmaceutical development. The subculture is also significant for risks due to the lack of clinical and pharmaceutical standards. This study describes the ibogaine medical subculture and presents quantitative data regarding treatment and the purpose for which individuals have taken ibogaine.

Materials and methods: All identified ibogaine “scenes” (defined as a provider in an associated setting) apart from the Bwiti religion in Africa were studied with intensive interviewing, review of the grey literature including the Internet, and the systematic collection of quantitative data.

Results: Analysis of ethnographic data yielded a typology of ibogaine scenes, “medical model”, “lay provider/treatment guide”, “activist/self-help”, and “religious/spiritual”. An estimated 3414 individuals had taken ibogaine as of February 2006, a fourfold increase relative to 5 years earlier, with 68% of the total having taken it for the treatment of a substance-related disorder, and 53% specifically for opioid withdrawal.

Conclusions: Opioid withdrawal is the most common reason for which individuals took ibogaine. The focus on opioid withdrawal in the ibogaine subculture distinguishes ibogaine from other agents commonly termed “psychedelics”, and is consistent with experimental research and case series evidence indicating a significant pharmacologically mediated effect of ibogaine in opioid withdrawal.”

Authors: Kenneth R. Alper, Howard S. Lotsof & Charles D. Kaplan

Summary

Ibogaine is ingested in the form of scrapings of Tabernanthe iboga root bark in Gabon and elsewhere in West Central Africa. It is used to treat addiction in the colonial era and has retained significant social and political importance since.

In the colonial era, iboga was used to treat infertility and to treat diseases caused by prostitution and the physical relocation of indigenous workers. Iboga alkaloids are also active against Candida albicans, Mycobacterium tuberculosis, human immunodeficiency type 1 virus, and Leishmania amazonensis. Ibogaine was first observed in 1962 as treatment for substance-related disorders. The ibogaine subculture has elicited wariness from the “superordinate culture” of conventional clinical medicine, but has also been invoked regarding the null hypothesis that ibogaine’s reported effect in opioid withdrawal is not pharmacologically mediated. Ibogaine is unscheduled in most of the world, except the US, Belgium, Denmark, France, Sweden, Switzerland, and Australia where it is illegal. Ibogaine is not self-administered, and does not produce withdrawal signs following chronic administration in animals.

Ibogaine HCl is the only iboga alkaloid that has reportedly been administered to humans, and is used to treat opioid withdrawal. It has a longer duration of action than other standard treatments for opioid withdrawal. Ibogaine has not been studied in randomized controlled trials, but there are two open label case series that include self-reported outcomes of 52 treatments involving 41 different individuals. Twenty-five individuals had full resolution of opioid withdrawal without drug seeking behavior. A clinic in St. Kitts treated 32 patients with ibogaine HCl for the indication of withdrawal from heroin. The patients reported resolution of withdrawal signs and symptoms at 24 h after the last use of opioids.

Seventeen of 21 patients identified opioids as the primary drug of dependence for which they had sought treatment. Five patients stopped using all substances following treatment, while nine others continued to use alcohol or cannabis.

The iboga alkaloids ibogaine and noribogaine, and a synthetic congener, 18-methoxycoronaridine (18-MC), have been shown to reduce withdrawal signs in the rat, mouse, and primate, and to diminish dopamine efflux in the nucleus accumbens (NAc) in response to opioids or nicotine.

Ibogaine has been shown to decrease ethanol consumption and improve mood in rats following administration of ibogaine. This suggests that GDNF may mediate improvement in hedonic functioning and mood in chronic withdrawal from addictive substances, but does not appear likely to explain efficacy in acute opioid withdrawal.

Ibogaine produces visual phenomena that occur with the eyes closed and are suppressed with the eyes open, and often involve a sense of location within an internally represented visual or dream landscape.

This study provides a history and description of the ibogaine subculture in the U.S. and Europe from 1962 until 2001. It also provides a typology of the ibogaine medical subculture and a systematic collection of quantitative data regarding treatment and the purpose for which individuals took ibogaine.

This study included all known ibogaine scenes outside of Africa involving publicly identified providers, except for a scene in Gabon that involved European and US participants and African Bwiti adept providers. No data was encountered regarding the use of Lambarene, a tablet that was marketed in France between 1939 and 1970.

The authors conducted a survey of providers of ibogaine in early 2001 and obtained quantitative information on cumulative numbers of people treated, percentage seeking treatment for addiction and specifically acute opioid withdrawal, as well as ibogaine form and dosage and the cost of treatment.

The study reviewed the academic literature, the “white literature”, and the most frequently used ibogaine list server, and searched the Internet for new scenes. It also contacted all known treatment providers to update the quantitative information.

The authors reviewed the references cited by the articles retrieved utilizing the search terms “ibogaine” and “iboga”, and found relatively little material that was new to them.

The authors interviewed providers and patients in 19 medical model scenes and obtained independent corroboration from providers regarding other providers, and other informants. The authors omitted providers who had not publicly disclosed their activity, which would tend toward underestimation of the total numbers of individuals who have taken ibogaine.

The setting is the physical and ecological location in which the treatment takes place, and the provider is the individual or group that administers ibogaine to the patient participant. The provider’s set includes beliefs, expectations, attitudes and motivation that determine the intention to provide ibogaine.

In the medical model, the provider is the physician investigator who prescribes ibogaine. The provider’s set includes the aim of emulating existing conventional medical standards in the treatment of addiction, clinical research, and/or psychotherapy.

Many physicians were interested in ibogaine as an adjunct to psychotherapy, as an experimental model of psychosis, and as a means of brainwashing or incapacitating an adversary. Ibogaine was also investigated by the US Central Intelligence Agency as a “truth serum”.

The most common setting for experimental treatment with ibogaine is a private clinic with less frequent use of hospitals. The standard of care varies among scenes in the medical model, but at a minimum involves pretreatment laboratory and electrocardiogram, vital signs and evaluation of nurses and physicians.

Ibogaine may be used for the medical treatment of addiction, psychotherapy, and/or spiritual growth. It is typically given in dosages of 10 – 50 mg daily over periods of several days or weeks, and has been observed to reduce opioid tolerance.

Regardless of their beliefs regarding ibogaine’s psychotherapeutic benefits, lay treatment providers are aware of the medical risk of ibogaine use. They use exclusion criteria and pretreatment laboratory tests to minimize this risk. The “ibogaine underground” (Freedomroot) is a scene in the US that was modeled after the earlier aggressive advocacy in the Netherlands. It involves individual providers who actively reach out to heroin users in New York and some other US cities.

The activist/self-help type views individuals with severe opioid dependence as a marginalized population abandoned by the institution of conventional medicine, and attributes aspects of the medical model to “underground providers” who only have lists like this and the internet to help share information with each other.

The Bwiti ritual culture is a religious or ceremonial context for the use of ibogaine, and individuals who take ibogaine in this context tend to be seeking a spiritual experience, although a third of participants primarily seek treatment for substance dependence.

3414 individuals across all scenes have taken ibogaine, with 68% taking it for the treatment of substance-related disorders and 53% specifically for opioid withdrawal.

We estimated the true number of participants in the ibogaine subculture by asking editors of the most frequently utilized ibogaine list server and a popular ibogaine Web site to estimate the “hidden proportion”. The estimates fell within a range of 20 – 30%.

The expansion of the ibogaine subculture coincides temporally with a substantial increase in the public health impact of opioid use disorders, and the use of hallucinogens and MDMA among young adults in the US did not increase between 2002 and 2005.

The ibogaine subculture is not a counterculture because it is not defined on the basis of opposition to conventional medicine. It shares with the conventional medical culture the goal of providing treatment, and does not focus on criminality per se.

The participant-observer approach may conflict with the imperative of scientific objectivity, and the authors’ collective access and intensive observation of the ibogaine subculture suggests that this study approaches an exhaustive, and not merely representative sampling of publicly identified ibogaine scenes.

Ibogaine has significant literal merit as a drug candidate, as it has undergone substantial preclinical and open label study evidence, preclinical toxicological studies, and some initial Phase I safety and pharmacokinetic data. Recent Cochrane reviews on the management of acute opioid withdrawal with 2 -agonists, buprenorphine, or methadone taper evaluated 56 studies. Only 3 of the 56 studies included a placebo comparison, and all indicated a strong distinction of placebo from any active drug treatment.

11 individuals have died within 72 h of taking ibogaine, most commonly from cardiac causes in association with significant risk factors such as a prior myocardial infarction, cardiomyopathy or valvular disease, or to pulmonary embolism. Other deaths were regarded as mixed drug overdoses involving opioids with or without the additional ingestion of cocaine. A study of rats administered ibogaine at high dosages prompted concern regarding potential neurotoxicity. However, other work indicated no evidence of neurotoxicity.

Ibogaine may provide a prototypic example of an agent with a novel mechanism of action, affecting signal transduction in second messenger pathways linked to G protein-coupled receptors (GPCRs). This mechanism may be involved in the highly dynamic neuroadaptations associated with opioid tolerance and withdrawal.

The subculture of iboga users is growing, indicating a demand for new treatment, which is sought regardless of medical risk, inconvenience, expense, and in some cases legal prohibition. Ibogaine’s effect in opioid withdrawal merits further investigation as a paradigm for neurobiological research and rational pharmaceutical development.