Treating drug dependence with the aid of ibogaine: A qualitative study
EDUARDO EKMAN SCHENBERG, MARIA ANGÉLICA DE CASTRO COMIS, JOÃO FELIPE MOREL ALEXANDRE, BRUNO DANIEL RASMUSSEN CHAVES, LUÍS FERNANDO TO´ FOLI and DARTIU XAVIER DA SILVEIRA
Journal of Psychedelic Studies, 2017, 1, (1), pp. 10–19
Background : Substance use disorders are important contributors to the global burden of disease, but current treatments are not associated with high rates of recovery. The lack of approved and effective treatments is acutely problematic for psychostimulants like cocaine and crack cocaine. One promising alternative in the treatment of drug dependence in general and psychostimulants in particular is the use of the psychedelic alkaloid ibogaine combined with psychotherapy. This was recently shown to induce prolonged periods of abstinence in polydrug users, including psychostimulants. However, drug dependence treatments cannot be comprehensively evaluated with reductions in consumption alone, with current recommendations including secondary outcome measures like craving, family and
social relationship, quality of life, and self-efficacy.
Methods : We therefore employed a directed approach to qualitative content analysis to evaluate the outcomes of a treatment combining ibogaine with cognitive-behavioral therapy based on data gathered from patient’s reports obtained in semi-structured interviews. Main findings: The results revealed that patients benefited from the treatment in all the secondary outcomes, reporting decreases in craving and improvements in personal relationships, quality of life, and self-efficacy, thus supporting existing notions that treatments combining ibogaine and psychotherapy do have a therapeutic potential in the treatment of substance use disorders.
Keywords : ibogaine, cocaine, crack, addiction, treatment, dependence
Recent estimates suggest that 149–271 million people used illicit drugs worldwide in 2009 (Degenhardt & Hall, 2012). This illicit drug use causes considerable morbidity and mortality in many countries (Degenhardt, Chiu, Sampson, & Kessler, 2008) and is an important contributor to the global burden of disease, directly accounting for 20 million disability- adjusted life years (DALYs) in 2010, representing a 52% increase since 1990 (Degenhardt et al., 2013; Whiteford et al., 2013). This illicit drug use is estimated to cause 10.9% of the DALYs in mental disorders (Whiteford et al., 2013). This scenario is aggravated using the legal drugs such as tobacco and alcohol reaching nearly one and three billion people, respectively (Degenhardt & Hall, 2012; Ng et al., 2014). This legal drug use significantly contributes to DALYs in more than 20 countries, with tobacco smoking increasing from third to second largest risk factor in the global burden of disease between 1990 and 2010, while alcohol drinking increased from eighth to fifth in the same period (Lim et al., 2012), alone contributing to 9.6% of mental health DALY (Degenhardt et al., 2013; Whiteford et al., 2013). A minority of these users develop substance use disorders such as drug dependence, but this is still a serious problem affecting 15–39 million people for illicit drugs, 76 million for alcohol, and more than a billion for tobacco (Degenhardt & Hall, 2012).
The search for effective drug dependence treatments is therefore paramount. Current available options include behavioral therapies (Carroll & Onken, 2005), pharmacotherapies (Vocci, Acri, & Elkashef, 2005), and combinations of both approaches (Potenza, Sofuoglu, Carroll, & Rounsaville, 2011; Stead & Lancaster, 2012). However, differences in treatments apply for different drugs abused, for example, opioids and stimulants (Badiani, Belin, Epstein, Calu, & Shaham, 2011). Alarmingly, for stimulants like cocaine and crack cocaine, effective pharmacotherapies are still lacking and the effectiveness of current behavioral and psychotherapeutic approaches is generally low (Karila et al., 2011; Nutt & Lingford-Hughes, 2008; Phillips, Epstein, & Preston, 2014; Shorter & Kosten, 2011). One possible route in the development of a new therapeutic approach for drug abuse and dependence is the use of ibogaine, an alkaloid extracted from the root bark of Tabernanthe iboga (Alper, 2001; Alper, Beal, & Kaplan, 2001; Brown, 2013). Ibogaine induces a prolonged state of modified consciousness with changes in perceptions, emotions, and cognition that makes it hard to be classified, but the most adequate categories seem to be hallucinogen or psychedelic (Alper & Lotsof, 2007).
This is a class of substances including lysergic acid diethylamide (LSD) and psilocybin that is increasingly recognized as having important therapeutic potentials in the treatment of substance use disorders (Bogenschutz, 2013; Johnson, Garcia-Romeu, Cosimano, & Griffiths, 2014; Krebs & Johansen, 2012; Sessa & Johnson, 2015; Tupper, Wood, Yensen, & Johnson, 2015; Winkelman, 2014). Evidence of ibogaine efficacy in the treatment of drug addiction spans a wide variety of methods, from anecdotal evidences (Alper, 2001; Brown, 2013) to small clinical trials (Alper, Lotsof, Frenken, Luciano, & Bastiaans, 1999; Mash et al., 2001), also including improvements in some pre-clinical animal models of drug addiction (Benwell, Holtom,Moran, & Balfour, 1996; Dzoljic, Kaplan, & Dzoljic, 1988; Glick, Rossman, Rao, Maisonneuve, & Carlson, 1992; Glick, Rossman, Steindorf, Maisonneuve, & Carlson, 1991; Leal, Michelin, Souza, & Elisabetsky, 2003; Maisonneuve, Keller, & Glick, 1991; Parker, Burton,
McDonald, Kim, & Siegel, 2002; Parker & Siegel, 2001; Rezvani, Overstreet, & Lee, 1995; Sharpe & Jaffe, 1990).
Physiologically, ibogaine is metabolized to noribogaine by CYP2D6 enzymes in the liver. Noribogaine has a much longer half-life, being detected in blood after 15 min from ingestion of ibogaine and remaining in relevant concentrations even days after ingestion and clearance of the parent compound. Both compounds are lipophilic, cross the blood– brain barrier, and interact with different receptors in the brain, including N-methyl-D-aspartate, opioid receptors (κ and μ), and sigma-2 receptor sites (Litjens & Brunt, 2016). Ibogaine also increases the levels of glial cell linederived neurotrophic factor, a result related to its antiaddictive properties (He et al., 2005). Ibogaine may have important cardiotoxic effects mediated by its action at hERG potassium channels, resulting in prolongation of the QTc interval (Alper et al., 2016; Koenig, Kovar, Boehm, Sandtner, & Hilber, 2014; Koenig et al., 2013; Thurner et al., 2014), an effect related to fatalities after ingestion of the ibogaine or other materials, such as plant extracts (Alper, Stajic, & Gill, 2012).
In previous research with retrospective methodology, it was shown that a treatment combining ibogaine with cognitive therapy facilitated prolonged periods of abstinence (median of 5.5 months with one ibogaine session and 8.4 months with multiple ibogaine sessions) in drugdependent patients who were considered as polyusers of alcohol, cannabis, cocaine, and crack (Schenberg, de Castro Comis, Chaves, & Da Silveira, 2014). This is the first evidence of efficacy of administering ibogaine in a sample whose drug problem was not majoritarily related to opiates, and therefore, it constitutes an alternative form of psychostimulant dependence treatment.
However, drug dependence is a chronic condition involving mental and physical health, social relationships, and quality of life. Therefore, a comprehensive evaluation of treatments for substance use disorders cannot be completely achieved by measuring only quantity and frequency of drug use (Dodge, Krantz, & Kenny, 2010; Tiffany, Friedman, Greenfield, Hasin, & Jackson, 2012). According to recent proposals, secondary outcome measures that should be considered in the evaluation of drug dependence treatments include craving, family relationships, network support, changes in self-efficacy, and quality of life (Tiffany et al., 2012). In this study, we employed a directed approach to qualitative content analysis (Hsieh & Shannon, 2005), also termed deductive content analysis (Elo & Kyngäs, 2008), to test the hypothesis that an ongoing treatment in Brazil combining ibogaine administration in a hospital with pre- and post-ibogaine cognitive therapy is beneficial to patients with substance use disorders.