Editor’s Note: This post by Anny Ortiz is the first in our Pharmaceutical Inequalities series. She explores the existing research landscape of psychedelics and then draws upon her own lived experience of working in a treatment center that offered ibogaine-assisted detoxification to discuss the affordances and unanswered questions of using psychedelics in treatment. The Pharmaceutical Inequalities series is funded by the Holtz Center and the Evjue Foundation.
In recent years, psychedelic substances have taken the world by storm (Raison, 2018). A short few decades ago, to want to conduct mental health research with psychedelic substances was considered to be professional and/or academic suicide. Starting in the mid 1990’s however, psychedelics have been slowly, but increasingly looked upon as potentially effective tools in the field of mental health to assist in the treatment of depression, anxiety disorders and substance use disorders (Carhart-Harris & Goodwin, 2017).
Small academic studies to date have yielded data that is turning skeptics into hopeful critics and strengthening the resolve of researchers that have been advocating for the responsible integration of psychedelics into the mental health professional field since the 1970’s. Although there had been steady research with psychedelics since the 1950’s, in 1970 research with psychedelics almost completely came to a halt due to the establishment of the Controlled Substances Acts (CSA). The CSA landed psychedelic drugs in Schedule 1, thus rendering them as substances of high addictive potential, and no therapeutic benefit. At the time of this writing however, research with psychedelic substances is becoming one of the fastest growing areas of research in prestigious academic institutions around the globe, and research centers dedicated exclusively to investigating the therapeutic potential of these drugs are being, or have been set up, at places such as Johns Hopkins University, University of California, San Francisco, University of California, Berkeley, University of Wisconsin-Madison, and many more in the United States and abroad.
Taking into consideration the amount of cultural stigma associated with psychedelic substances; a stigma that for several decades significantly impeded scientific research with these drugs (Belouin & Henningfield, 2018), seeing the exponentially growing interest they have generated over the past 10 years, and which has really intensified in the last five, is a most interesting phenomenon to witness and unpack. What is driving this growing interest? It could be fairly argued that there are two lines of evidence that are fuelling this burgeoning explosion of interest. On one hand, the fact that there are very high relapse rates in various mental health conditions like depression and substance use disorders, which represent a significant unmet clinical need, and on the other hand, the mounting evidence, despite significant roadblocks to legitimate research with this class of drugs showing that psychedelic-assisted therapy can be robustly effective and efficacious in treating some of the most highly refractory conditions such as treatment resistant depression (Watts et al., 2017).
As a PhD student at the University of Wisconsin-Madison’s School of Human Ecology, I recently completed my preliminary examination, which consisted of a 40-page essay answering the question “What are the known and theoretical mechanisms by which psychedelic substances produce therapeutic effects, both short and long term?”. In this essay, I outlined the biological and psychological mechanisms elucidated to date, from cell-based effects at the level of individual neurons and higher order association brain networks, to psychological mechanisms involving the occurrence of “mystical-type” and “ego-dissolution” experiences, and tried to unpack the most comprehensive hypothesis and theoretical framework of psychedelic effects posited to date: the entropic brain hypothesis and the REBUS and the anarchic brain model, where REBUS stands for “Relaxed Beliefs Under pSychedelics”.
A future article submission will address these known and theoretical mechanisms, as we endeavor to consider and bring to light issues related to pharmaceutical inequalities, such as patient accessibility, equity, diversity, and inclusion in the growing field of psychedelic research and therapy. For now, however, following in on the vein of opioid addiction topics that were recently explored through this site’s “Methadone marathon”, I want to focus this first article on a different type of opioid addiction treatment available in Mexico, which is where I am originally from, namely, ibogaine treatment.
Ibogaine is a psychoactive agent that comes from the Iboga shrub (Tabernanthe iboga), which is endemic to Gabon in Central Africa. Iboga has been used by the natives there for thousands of years as a tool for initiations and rites of passage in the Bwiti religion. In the modern Western world, it was thanks to a man named Howard Lotsof that the anti-addictive properties of ibogaine were discovered. Howard, a heroin addict himself took ibogaine just looking for a new high, and he was gladly surprised when he realized it had been over a couple days that he had last taken heroin and somehow was not experiencing withdrawals. He decided to experiment further and gave ibogaine to several fellow addicts and found the same results. Details about this serendipitous discovery are included in the documentary “Rite of passage” available here.
Ibogaine has a very unique pharmacology. Unlike other relatively better-known psychedelics like psilocybin (found in Psilocybe mushrooms) and mescaline (found in the Peyote and San Pedro cacti), which act primarily on the serotonin receptor 2A receptor (5HT2A), ibogaine does not have an effect on the 5HT2A receptor. Ibogaine interacts with various opioid receptors, acts as an antagonist at the NMDA glutamate receptor, and functions as a serotonin reuptake inhibitor (like anti-depressant drugs). Additionally, ibogaine has been shown to interact with the acetylcholine and dopamine systems and alter the expression of several proteins including brain derived neurotrophic factor (BDNF), which has been implicated in the mechanism of action and therapeutic effects of psilocybin.
Ibogaine’s mechanism of action is complex. In simple terms, ibogaine binds to opioid receptors in the brain, and “resets” the sensitivity of these receptors, effectively “interrupting” the dependency cycle that leads to the incessant use of opioids, by ameliorating withdrawal symptoms and eliminating opioid cravings and tolerance.
From 2013 to 2016 I had the opportunity to work at a treatment center that was offering ibogaine-assisted detoxification to individuals from the US and Canada that were going to Mexico to receive this treatment. I was hired to design and implement a seven-day program for this detox process. While working there, I got to witness how ibogaine indeed has the potential to change lives by helping individuals overcome their physical dependance, but as I used to tell program participants, ibogaine is not a “magic bullet”. After the treatment, one needs aftercare as well as further therapeutic support to take maximum advantage of the opportunities the treatment offers. But it does seem to be a unique tool in helping individuals “cure” their addiction, as it significantly reduces withdrawal symptoms and eliminates cravings.
Ibogaine treatment room
Ibogaine, being a psychedelic substance, produces an altered state of consciousness that can bring up unprocessed emotional traumas and individuals get to face their own psyches in this process, aided by the visionary plant. In carefully curated therapeutic contexts, and under medical supervision, this can have a powerful effect on long-term recovery from opioid dependence.
During my time working at this clinic, I got to meet a handful of individuals who, after sometimes up to 10 years of methadone maintenance, they were going thru the process of switching to short-acting opioids like oxycodone or even heroin in order to be able to come do an ibogaine treatment at the clinic. Because methadone has such a long half-life, the clinic had a protocol that required patients to be off methadone for a least three weeks prior to ibogaine treatment to reduce the potential for “residual withdrawals”. Methadone is very hard to quit, I learned working at this treatment center. I remember some of the program participants that were on this process of getting off methadone saying they were doing it because they felt totally dulled out to life. The same was true of individuals who were trying to get off buprenorphine (Suboxone), a newer maintenance therapy drug used in opioid addiction treatment. Withdrawal symptoms in the form of physical pain is what I remember being the most significant long term side effect of years of daily methadone or buprenorphine program participants reported. Rather than three weeks, I would think that a more drawn-out process of slowly getting off the long-acting opioids before an ibogaine treatment would prevent some of those residual withdrawals and make the treatment more effective.
Individuals who completed an ibogaine treatment to get off heroin or other legal opioids had an easier time detoxing with ibogaine. The reset effect that ibogaine has on the brain successfully eliminates tolerance, while also providing insight into the underlying reasons and mechanisms that led the person to the addictive patterns through the visionary experience it engenders. The dreamlike visionary experience has been described as an introspective life-review, that can be challenging, but if navigated well, can lead to emotional breakthroughs.
A psychoeducation class about the nervous system and ibogaine that I taught at the clinic each week for program participants.
The seven-day program at this clinic included individual counseling, group therapy, psychoeducation modules on the effects of drugs of abuse and the mechanism of action of ibogaine, somatic-based practices (Heart Rate Variability training), relapse prevention education, art therapy practices, self-compassion journaling exercises, goal planning for after-care , and a 5-MeO-DMT therapy session. A future post will address the emerging use of 5-MeO-DMT as a mental health tool.
This clinic had medical staff on-site 24 hours, and was located on a beautiful beach-front house in Rosarito, Mexico, an hour south of San Diego, California. I have no idea what a treatment like that would cost in the US or Canada, but in Mexico, the treatment cost was roughly $7000, USD.
To me this begs the following questions: what percentage of the population needs access to a treatment like ibogaine to overcome opioid addiction? And what percentage of that population in need can afford $7000 for a one-week long detox?
It is interesting to think about how at the time methadone clinics in the 70’s were being implemented without much safety data available, as the film Methadone: An American Way of Dealing documented, and the government was actually paying for these clinics, so too were psychedelics being placed in Schedule 1, making research with them nearly impossible, and funding for psychedelic research next to nonexistent. This lack of federal funding for psychedelic research continues by and large through to today, despite mounting evidence of psychedelic’s safety and efficacy, and despite the huge unmet clinical need, although that appears to be starting to shift.
Enter VETS, which stands for Veterans Exploring Treatment Solutions, a non-profit organization co-founded by Marcus and Amber Capone. As it turns out, shortly after I stopped working at this clinic, the clinic’s owner shifted away from treating opioid dependance and started offering ibogaine treatment for US veterans with severe post-traumatic stress disorder (PTSD). The seven-day program turned into a three-day program and an study that was published in 2020 showed remarkable treatment effects, with significant and very large reductions in depression, anxiety, PTSD, suicidal ideation and impairments associated to traumatic brain injury among a sample of US veterans. A second study published recently also showed significant decreases in retrospective report of alcohol use and PTSD symptoms among US veterans.
In light of this treatment’s positive effects Marcus Capone himself experienced, he and his wife, Amber, founded VETS in 2019 to offer “healing grants” to US Special Forces Operations veterans who struggle with symptoms of PTSD in an effort to stop the current veteran suicide epidemic. To date, they have facilitated access to psychedelic-assisted treatment for hundreds of veterans, and they recently received a 3 million endowment to expand their grant giving capacity. They have also garnered institutional support for psychedelic-assisted therapy for veterans in some unlikely places. In 2021, VETS worked closely with policymakers in Texas, including former Texas Governor Rick Perry to pass the “historically bipartisan” Senate Bill 1802, which authorized the use of state funds for the first-ever clinical trial of psilocybin-assisted therapy for the treatment of PTSD in US veterans.
Could psychedelic-assisted therapy ever win federal support the way methadone clinics did in the 70’s? Could medically supervised ibogaine treatments become legalized and covered by the state, the way Narcan kits to reverse opioid overdoses are? Much remains to be seen in the unfolding psychedelic renaissance. I am glad to know organizations like VETS exist to help bridge the current gap in funding to facilitate patient accessibility to those most in need.
Feature image caption: an art therapy/fire circle ceremony activity we would have for participants on the day of their ibogaine treatment. They each would feed the fire with a piece of paper that had something in it representative of what they were wanting to let go of through their ibogaine treatment. All images can be found within ‘A Look at Crossroads Ibogaine Treatment Program – A Walkthrough with Crossroads Ibogaine‘ Youtube video.