On January 14th, 2016, the government of São Paulo, Brazil issued a statement that calls for further research into the medical use of psychotropic substances. The announcement also makes a strong recommendation that opens the door for less restricted medical use of ibogaine in the treatment of substance use disorders in the state of São Paulo. This stance is expected to eventually influence decisions that will extend to the rest of the country.
Ibogaine, the primary active alkaloid in Tabernanthe iboga, a West African shrub that has been used as a medicine and sacrament for centuries in the Gabonese spiritual discipline of Bwiti, is a powerful psychoactive that has been shown to dramatically reduce withdrawal symptoms from opiates as well as cravings for opiates, alcohol, stimulants, and other substances.
The fact that ibogaine is administered once, or at most several times, rather than as an ongoing replacement medication, makes it one of the most unique and effective pharmacotherapies available for addiction treatment. But because of its onierogenic, or “dream inducing” effects, it was listed as a Schedule 1 narcotic in the United States in 1970. Subsequently, the research necessary to seek FDA approval for its medical use has been difficult to fund.
But the U.S. is only one of several countries where ibogaine is illegal internationally. In most of the world it is simply unrestricted. As a result, since the 1980s, ibogaine has been used in a variety of settings as a detoxification assistance therapy on an experimental basis. This includes “compassionate care” administration by physicians in hospitals and individual practices, as well as private centers and peer-to-peer drug user support networks.
Ibogaine has been available for medical professionals to prescribe in Brazil, but with complicated restrictions. Physicians are required to import ibogaine from outside of the country on a per-patient basis. Excess medicine from each treatment must be discarded. This level of bureaucracy meant that the treatment was only offered by pioneering therapists, and was not widely or easily available. The January statement reinforces the importance of this work and is expected to lead to easing of importation barriers.
Even under these conditions, some 1,200 treatments have been conducted in São Paulo hospitals under the supervision of Dr. Bruno Rasmussen Chaves since 1997. A retrospective study published by a Brazilian research team in 2015 examined the outcomes of 75 of these patients, who were users of alcohol, cannabis, cocaine and/or crack (72 percent of which were polysubstance users). Each of the patients participated in a residential detoxification program of at least 30 days before receiving ibogaine treatment, after which the study found that 61 percent remained free from their substances of abuse for at least one year.
These results are significant because, while there are FDA approved maintenance medications for use in the treatment of opioid use disorder, there are no similar treatments available for cocaine and other stimulant users. Existing therapeutic modalities — such as the use of benzodiazepines to facilitate relaxation and sleep, or Cognitive Behavioral Therapy (CBT) to help navigate habituation — help, but simply don’t address the intensity of cravings that follows the cessation of regular cocaine or crack use. As such, ibogaine therapy may present one of the most promising emerging options to alleviate some of the problematic cocaine and stimulant use in Brazil, which is the world’s second largest cocaine market (after the United States).
The city of São Paulo itself is home to the famous Cracolândia (or “Crack Land”) neighborhood, where crowds gather daily to smoke the drug openly in the streets. The government has responded with a number of measures. Prior to the 2014 World Cup hosted in Brazil, many neighborhoods were subjected to clearing operations, and the government increased funding for involuntary treatment programs, all in an effort to move drug use away from urban destinations. However, these efforts have failed to resolve the situation. Harm reduction programs are being implemented, but the problem of Cracolândia remains. Though still awaiting official data, there is indirect evidence that the crack cocaine trade has grown in other cities and towns across the country.
Last year the Brazilian National Secretary on Anti-Drug Policy (SENAD) asked for proposals to be submitted regarding alternative treatment options. Various options have been selected to receive funding including medical marijuana, ayahuasca, and modafinil. But the fact that the recent statement from the desk of the São Paulo State Office on Drug Policy (CONED-SP) has singled out ibogaine as a potential addiction treatment highlights the support that it has gained from city and state officials.
The recommendation specifically states that the administration of ibogaine should be done “in a hospital environment, with medical supervision and control, meeting the exercise of the profession and the recommendations of good clinical practice, including rigorous clinical and psychiatric examinations and psychological assessment and psychotherapeutic monitoring.”
This level of medical supervision is recommended because ibogaine is not without a degree of medical risk. A paper, published in 2012 in the Journal of Forensic Sciences, examined existing cases of adverse medical events and fatalities and found all of them were connected to a number of common and identifiable factors. These include pre-existing heart conditions, co-administration of opioids or other drugs, depletion of electrolytes, and seizures related to the withdrawal symptoms from benzodiazepines or alcohol.
In 2015, as the Director of the Global Ibogaine Therapy Alliance (GITA), I led the publication of the Clinical Guidelines for Ibogaine-Assisted Detoxification, which outlines a medical risk management strategy for ibogaine treatment. According to the recommendations that we presented in that document, the 30-day preparation that São Paulo patients currently experience prior to administration, and the medical context supported by the São Paulo government, provides an ideal level of support to prevent medically adverse events.
The true implications of the decision, and its ability to address the country’s substance use challenges remains to be seen. Chaves, a GITA board member and co-author of the guidelines, says that, “This is a big step for ibogaine and for psychedelic medicine here.”
“Not only does this show that some people in key positions are open minded enough to understand the value of ibogaine, so we can hope for more support,” Chaves says, that the decision means that they can “finally begin to really regulate this kind of treatment.” He believes that, “The recommendation to do treatments only in hospitals will protect people from undesired and potentially dangerous side effects.”
This declaration is one of the first of its kind in the world. The only other country that has approved ibogaine in the treatment of substance use disorders is New Zealand, where in 2009 Medsafe, the national regulatory authority, listed ibogaine as a “non-approved prescription medicine.” Although administration requires a doctor’s prescription, it does not mean that the treatment must be provided in a hospital.
Also, despite its federal Schedule 1 status — and in some ways following in the footsteps of state-level marijuana activism in the U.S. — a bill has been submitted and scheduled for the Vermont state legislature’s 2016 legislative season that would support the opening of a not-for-profit ibogaine center in the state.
While there is still a long road towards full approval in Brazil, it is hopeful that these and other similar discussions reflect a changing tide in global attitudes around the War on Drugs, and perhaps demonstrate a step towards reversing some of the predictable negative consequences that prohibitionist policies have had on drug users and communities.
The legal status of ibogaine in Brazil, Vermont, and elsewhere will part of a series of important discussions happening at the 2016 Global Ibogaine Conference in Tepoztlan, Mexico from March 14-16th.
Jonathan Dickinson is the Executive Director of the Global Ibogaine Therapy Alliance (GITA), a not-for-profit that is dedicated to supporting the sacramental and therapeutic uses of iboga and its derivatives. Since 2009 he has worked with ibogaine, iboga’s primary psychoactive and medicinal alkaloid, in therapeutic contexts in Canada, Mexico, Costa Rica, and Panama. He has published and presented on his work globally. In 2015 he led the development of the Clinical Guidelines for Ibogaine-Assisted Detoxification, which serves as a risk management resource for the ibogaine therapy community. He acts as a liaison between academics, government officials, researchers, not-for-profits, and care providers in regards to ibogaine research and practice. In 2014, he was initiated into the Dissoumba/Fang branch of the spiritual practice of Bwiti at the Ebando village in Gabon.