I’m not sure I’ve ever met an opioid user who didn’t want to quit, and as an emergency room doctor, I’ve met a fair number of users. But the chemical need of the addiction can be indomitable. And the nature of that dependence is often misunderstood. It’s not only the high that keeps most users hooked—it’s also avoidance of the special hell of withdrawal.
This is why, when a heroin user who had just overdosed in his mother’s bathroom was brought to the ER where I work, he immediately shot up again in the hospital bathroom. Paramedics had given him naloxone, the antidote for opioid overdose. It saved his life, but the medication creates instant withdrawal. His brush with death had fazed him less than his roiling dope sickness.
It’s also why a man who had just been placed on a ventilator for a major overdose yanked out his breathing tube in the ICU, eloped from the hospital, and used again in the parking lot. One of my colleagues, heading home from the hospital, found him lifeless on the pavement and administered naloxone. We placed the man back on a ventilator and returned him to the ICU, where he woke up, yanked the tube, and escaped again in search of a fix.
With proper treatment, withdrawing from opioids won’t kill you, but it can make you want to die. The body comes to depend on the presence of opioids to maintain a sort of artificial homeostasis. “Morphine becomes a biological need just as water,” William Burroughs wrote in 1956. When the counterweight of an opioid is removed, the body responds with mayhem—diarrhea, vomiting, cramps, shivering, palpitations, anxiety, agitation, paranoia, and, weirdly, interminable yawning and sneezing. Burroughs called it a “nightmare interlude of cellular panic.”
Prescription medications like methadone and Suboxone, themselves opioids, are highly effective in blocking withdrawal, preventing overdose, and helping opioid users rebuild their lives. But some feel that these medications trade one form of dependence for another. And tapering off of methadone or Suboxone can trigger the same symptoms of withdrawal as heroin or oxycodone. We don’t have anything like a cure for opioid addiction.
The desperation of some users to get clean leads them to seek hope underground. A while ago, I began to hear about a rogue treatment called ibogaine. It’s illegal in the US but draws users south to Mexico, where a network of unregulated clinics has emerged to offer it. Extracted from the root of a plant native to West Africa, the drug produces psychedelic effects akin to a waking dream and is said by its advocates to spirit away withdrawal symptoms with a single dose, leaving users sober and uninterested in smack. But there’s a catch—apparently, the treatment could kill you.
A drug that provides rapid detoxification from opioids in a single dose struck me as hugely promising. It could change everything, unless the risks were real.
I wanted to see for myself how it was being used.
Standing about as tall as a man, Tabernanthe iboga is a fairly nondescript perennial shrub. Its leaves are long, thin, and sparse, and it produces tasteless orange fruit that look like vintage Christmas-tree lights. It grows in Western equatorial Africa, from Cameroon to Angola, and belongs to the family Apocynaceae, which Alexander Shulgin called the richest single source of pharmacologically active compounds in the plant kingdom.
The ritual use of iboga originated in western Central Africa among ancestral tribes. Father Joseph-Henri Neu, a French missionary, described in 1885 how root bark scrapings were ingested during elaborate ceremonies in order “to discover hidden things and to tell the future.” European chemists took an interest in the plant, and in 1901 a compound was isolated from the root. They called it ibogaine.
Then, in a New Jersey suburb in 1962, a 19-year-old recreational drug enthusiast named Howard Lotsof laid hands on 500 mg of powdered iboga root. Active in the underground psychedelic community, Lotsof had heard that higher doses of ibogaine could produce a bizarre trip lasting as long as 36 hours.
At first, Lotsof had no desire to spend a day and a half hallucinating, so he gave the dose to a friend. A month later, his friend called in the middle of the night and told him the drug was so revolutionary that they had to “tell Congress.” Lotsof decided he had to try it himself. His first experience with the drug was unlike anything else. There were endless hours of weird visions—a pulsating yellow screwdriver, dancing Neanderthals rolling a giant stone heart. He witnessed his own birth in reverse, plunging back into his mother’s womb from a diving board.
When it was over, he stepped out into the sunlight and noticed something odd. Lotsof was addicted to heroin, but after tripping on ibogaine he felt no withdrawal, and no craving. As he later told a friend who published Lotsof’s story as a book: “For the first time in months, I did not want or need to go cop heroin.” He was stunned. “I looked down the street, at the trees, the sky, my house, and realized that for the first time in my life, I didn’t feel afraid.”
He distributed the drug to 19 friends, seven of whom were also addicted to heroin. Five of the seven reported that their symptoms of dependence evaporated for up to six months after a single dose of ibogaine.
Lotsof continued on with his life. He studied film at New York University. Ibogaine was outlawed as a Schedule I substance, alongside heroin and LSD, in 1970. But he couldn’t forget the words a booming voice had spoken to him in a dark room during that first trip.
“You will bring ibogaine to the world, and set it free.”
Last October, I flew to San Diego and drove south across the border into Baja California. I was headed for Rosarito, a small town on the Pacific with glittering surf that has drawn an American crowd to its beaches and clubs since Prohibition. Orson Welles and Katherine Hepburn were regulars. In 1996, James Cameron built a replica of the Titanic there to film Titanic. Several ibogaine clinics are also located there. Aeden Smith-Ahearn, a Massachusetts native who grew up not far from the hospital where I work in Boston, had invited me to visit his.
As soon as I stepped out of the car at Experience Ibogaine, Smith-Ahearn's clinic in the hills above Rosarito, the first thing he asked was whether I had seen the islands.
The Coronado Islands looming out of the Pacific, off the coast of Tijuana, had been stunning in the matte light of evening as I hummed south along the Tijuana-Ensenada highway. Smith-Ahearn lit a cigarette, took a drag, and launched into an incredible soliloquy about being held at gunpoint by Mexican marines on one of the islands while trying to snorkel with a dope-sick patient.
“Eventually they let us go,” he said, blowing smoke down through his nose. “Jesus, that was crazy.”
Between drags, he continued talking about everything from American drug policy to Portugal’s experiment with radical drug legalization to the mechanics of the Santa Ana wind that was now kicking up dust all around us.
I had barely said a word.
Smith-Ahearn lit a second cigarette and gestured toward a broad expanse of empty land behind him, cluttered with construction material, trash, and general debris.
“Welcome to our wasteland—we do the treatments just behind that pile of sticks out there.”
He gave me a mischievous look.
“C’mon, Doc,” flipping his fresh cigarette into the wasteland, “lemme show you the clinic.”
Smith-Ahearn told me his story as we walked. He was wearing a New England Patriots cap, a Mexican-style shirt buttoned all the way up, pleated windowpane trousers, and a dusty pair of chukkas. He pointed out several different plants that he was cultivating—peppers, hibiscus, blue agave, and a San Pedro cactus, which contains mescaline. I asked if he was going to harvest it.
“Fuck no!” he said, “I’m going to let it get wise and shit.”
When he spoke he kept his hands folded over his midriff, like a friar, unless he was smoking a cigarette, which was often. Smith-Ahearn started smoking cigarettes when he was in fifth grade. Later that year he tried his first Budweiser in a stand of woods near his home. With middle school came pot and a commitment to try “everything else in the book.” By eighth grade he had sampled cocaine, codeine, and crack. In ninth grade he used heroin for the first time. His parents sent him to one youth rehab program after another. At 18, he started using heroin regularly. He moved into a friend’s car. Winter came, and he crashed that car. He took acid and a voice told him it was time for change.
He remembered having heard about ibogaine in high school. In 2012, when he was 23, his parents sent him to a clinic in Rosarito to try it. They told him it was his last chance.
“It was one of the most intense, painful experiences I’ve ever had,” he told me. He saw his entire life projected in front of him, like a film reel. He relived traumatic memories. He emerged from the trip, smelled the ocean, and never used opioids again.
Smith-Ahearn stayed on in Mexico, helping out at another ibogaine clinic. He suspected one of the people running it was an addict himself, and the experience was kind of a disaster. So in 2014 Smith-Ahearn established Experience Ibogaine. It’s housed in two ranch-style stucco buildings. A long porch offers a stunning panorama of the Pacific and a place to smoke. On a wall inside, a placard reads Good Things Are Going to Happen.
Experience Ibogaine charges $5,000 for five days, or $6,500 for seven. The package includes a medical evaluation by a physician; basic lab tests to check electrolytes, liver enzymes, and renal function; intravenous hydration; and one treatment with ibogaine, under medical supervision. I asked Smith-Ahearn how long it took for the clinic to become profitable. “It’s still not,” he said. “We’re getting by, but … I mean look at my shoes, dude.”
In 1982, Howard Lotsof decided it was time. Heroin was gutting his community. He set up a nonprofit and solicited donations to promote ibogaine. He filed a patent for the use of ibogaine in the treatment of addiction.
He traveled to Gabon and procured 40 kilograms of iboga root and began a collaboration with Dutch researchers. Their work yielded a 1988 study confirming that ibogaine attenuated opioid withdrawal in rats. The following year Lotsof approached Stanley Glick, a neuroscientist at Albany Medical College. Glick was intrigued. He conducted a series of experiments in rats confirming ibogaine’s effect on withdrawal and showing that ibogaine decreased self-administration of morphine, cocaine, methamphetamine, and nicotine in the animals.
Meanwhile, Lotsof was working with activists to begin treating humans with ibogaine in the Netherlands, where the drug was legal. Within a few years, they had data on 41 patients: Thirty-six percent reported abstinence for at least six months after treatment, and nearly all of them reported that their symptoms of withdrawal were gone.
Deborah Mash was a professor of neurology at the University of Miami when Lotsof invited her to the Netherlands in 1992 to observe a treatment. “Seeing is believing,” she told me recently when I spoke to her by phone. “I watched a man on 100 mg of methadone take the drug and come out of it with no withdrawal. He took a shower, shaved, and told me he was done.” She was fascinated. “I thought that if we understood how this drug worked, we would learn something fundamental about the nature of addiction.”
Mash decided to pursue research on ibogaine, and in 1993 the National Institute on Drug Abuse, a US government agency known as NIDA, approved funding for a small phase I study in humans. But that same year, tragedy struck. One of the patients in the Netherlands, a 24-year-old woman, died during treatment. NIDA was spooked, and Mash put the trial on hold.
Animal experiments by Glick and others had raised questions about ibogaine’s safety as well. There was evidence that very high doses of ibogaine could damage the cerebellum in rats and cause seizures in primates. Ibogaine also appeared to affect the heart, causing bradycardia and increasing the risk of a life-threatening arrhythmia called torsades de pointes.
NIDA also unearthed reports of a second death, in 1990. In June of that year, a French psychiatrist administered ibogaine to a 44-year-old woman. Several hours later, she suffered a cardiac arrest. On autopsy, pathologists found evidence of prior heart attacks and attributed the death to her extensive cardiovascular disease but couldn’t definitively exclude the possibility that ibogaine may have played some role.
In 1995, the lead NIDA administrator supervising the ibogaine project, a scientist named Frank Vocci, convened an interdisciplinary review committee. In attendance were physicians, research scientists, toxicologists, psychologists, and representatives from the pharmaceutical industry.
“We had a trifecta of concerning findings—cerebellar lesions in rats, seizures in monkeys, and bradycardia in dogs,” Vocci told me. “We had reports of about 60 patients who had used ibogaine, and there had been two deaths. That was an unacceptable ratio.”
The review committee voted 9 to 4 to end its support for the project. Mash’s study never got off the ground.
Vocci had some other ideas, beyond safety, for why ibogaine research got off to an uneven start. “You had people trying to do drug development who were real amateurs, and they messed it up,” he told me, referring to Lotsof. “You need to present yourself as someone who is a solid citizen, a dependable character. I’m not sure people found those promoting ibogaine to be so.”
Deborah Mash agreed that the stigma associated with ibogaine had been a barrier. “Ibogaine came from the underground,” she said. “It didn’t come out of an academic center. The water bearer was himself a former addict who didn’t have the patina of an academic professional.”
Ibogaine’s safety has continued to be a concern. Kenneth Alper, a psychiatrist at New York University, published an extensive analysis of all known deaths associated with ibogaine outside of West Africa, from 1990 to 2008. He found a total of 19. The causes of death varied widely, including pulmonary embolism, arrhythmia, heart attack, heart failure, and suspected drug overdose. A majority of the people who died had serious medical conditions of one kind or another. The authors found it challenging to relate all of the deaths directly to ibogaine, although they couldn’t rule out some interaction between the drug and the patients’ underlying medical conditions.
I asked Mash about these risks. “Ibogaine can be given safely—there’s no doubt about it,” she told me. “But there is some cardiotoxicity, and it has to be given under full medical supervision.”
Smith-Ahearn estimates that his clinic has treated about 2,000 patients with ibogaine. All treatments are done under the supervision of Paul Casillas. When I met him, Casillas, an emergency physician trained at the Autonomous University of Baja California, was dressed in black and wore wraparound sunglasses. He began working with ibogaine nearly 10 years ago. He was on shift in the ER at Rosarito’s general hospital when a man approached him and started talking about ibogaine. “I thought he was crazy,” Casillas told me, but he agreed to observe a treatment. “I couldn’t believe it,” he said. “It works, but it’s just the beginning.”
Patients undergo a medical evaluation by Casillas, including a physical exam, blood testing, and an EKG. Sometimes Casillas consults a cardiologist in Tijuana. If anything abnormal comes to light, Smith-Ahearn says, they don’t clear the prospective patient for treatment. “It sucks turning them around,” he told me, “because where else are they going to get the help?”
The ibogaine trip begins with a test dose—2.5 milligrams per kilogram of body weight. Casillas watches for any negative effect on the heart before administering the full dose, which is usually 12 to 15 milligrams per kilogram. During the trip, Casillas observes patients on a cardiac monitor for 12 to 24 hours, with a defibrillator at the bedside. “It’s vital,” Casillas told me, due to the possibility of potentially lethal cardiac arrhythmias. As the monitor traces the steady tine of each heartbeat, the patient lies on a queen-size bed in a dim room. Headphones pipe in African drums as visions begin to take shape.
Casillas says that no one has died from ibogaine under his care. He has seen several dangerous arrhythmias during treatments, though, including torsades de pointes and ventricular fibrillation. He shocked those patients, he told me, and saved them.
During my visit to the clinic, I spoke to several patients who had just come through treatment.
Max, a gentle, middle-age Italian man, was one. A cousin introduced him to heroin at age 17. He’d tried methadone, detox and rehab programs, buprenorphine, and cold-turkey in empty motel rooms. “Every time you relapse, you fall harder and faster,” he told me over a cigarette on the smoking porch. The Pacific shimmered. He had taken ibogaine three days earlier. “When you come out of it, your withdrawal—it’s just gone,” he said, taking a drag. “It’s incredible.” His hands were steady as he held the cigarette to his lips.
Andy, from Sacramento, began with oxycodone tabs when he was 20. “I fell in love with them,” he said. “There’s an invincibility that they give you. But at some point there’s a change; you’re using just to stay afloat, you need more and more.” When he was 22, a dealer offered him heroin. Ten years later, he had tried methadone, buprenorphine, detox programs. He’s overdosed three times. “That never really changed anything,” he said, shrugging. “This is a last-ditch effort to get clean for me.”
His trip was wild. “I was literally stuck in a mess of WHITE PIPING,” he wrote in an email not long after we met. It was a potent representation of how the past decade of his life had felt—“just stuck in an addiction you can’t get out of.” After the visions ended, he had no withdrawal symptoms and no cravings. His head was clear. “It was magical, bro,” he wrote.
Matt, from Los Angeles, told me that he’d been to detox 19 times. He couldn’t stay clean. At his last detox, a staff member said "I’m not supposed to do this" and handed him some information on ibogaine.
He was a few days out from his trip when we met. I asked him about withdrawal symptoms.
“None at all,” he said, looking out over the placid morning water. His craving to use heroin had also disappeared. “It doesn’t make sense to do it anymore—why would I?”
In 1996, Mash went rogue. After NIDA pulled back from funding her clinical trial, she took her research abroad, establishing an ibogaine clinic on the Caribbean island of St. Kitts. “I went offshore because we couldn’t get the work funded,” she told me. “I had to finish what I started.”
In 2001, Mash published data on 32 patients treated for opioid dependence with ibogaine. All had marked reduction in withdrawal symptoms, with no adverse events. The drug’s effect on opioid withdrawal was “stunning,” Mash told me. Whether ibogaine could produce long-term abstinence, though, was still unclear.
Thomas Brown, an anthropologist at UC San Diego, had a longstanding interest in the therapeutic effects of psychedelics. One year at the Burning Man festival in the Nevada desert, a friend who worked with patients at an ibogaine clinic introduced him to Rick Doblin. The founder of the Multidisciplinary Association for Psychedelic Studies (MAPS)—a nonprofit organization dedicated to supporting the scientific study of psychedelics—Doblin had long wanted to sponsor research on ibogaine. Brown hatched a plan to join forces with MAPS for a longitudinal study. They would follow patients for 12 months after an ibogaine treatment, to learn whether it might actually reduce cravings for opioids rather than just ease the withdrawal.
Brown recruited 30 patients from two ibogaine clinics in Baja California and brought on Kenneth Alper, the psychiatrist from NYU, to analyze the data. Shortly after the study got underway, MAPS sponsored a similar study with a team of researchers in New Zealand, where the drug is also legal. That study enrolled 14 patients. The results of both studies were published in the American Journal of Drug and Alcohol Abuse in 2017.
The studies confirmed what Mash had found—withdrawal symptoms improved markedly among participants. But the primary question these studies were designed to answer—whether ibogaine could produce long-term abstinence—was more challenging to resolve than expected. Twelve months after treatment, only 14 patients remained in the Mexico group and 11 in the New Zealand group. The rest had dropped out or disappeared.
“The biggest surprise was how difficult it was to reach patients for follow-up,” Brown told me. He called them every month after treatment and also reached out to friends and significant others to corroborate what patients were telling him about their sobriety. “It was really challenging to reach people,” he said, “sometimes because they were couch surfing or were in a residential rehab that didn’t allow me to reach them or simply because they were using again … We basically had to assume that if someone was unreachable, they had relapsed.”
Brown also encountered a surprising amount of hostility from some study subjects during his attempts at follow up. One patient yelled “Stop calling me!” into the phone. When Brown reached another patient’s significant other, the man shouted “He doesn’t want to be involved!” and hung up.
For those that completed the full 12-month study, some did achieve sobriety. At one year after treatment, seven of the 14 patients remaining in the Mexico group reported they had not used opioids in the previous 30 days. In the New Zealand group, six of the 11 remaining patients were sober, with urine testing to prove it.
I asked Joji Suzuki, director of addiction psychiatry at Brigham & Women’s Hospital in Boston, what he thought about the studies. Suzuki was highly critical of their methods. The absence of control groups and reliance on self-reporting in the Mexico study seemed especially problematic to him. “That’s bullshit,” he said. “Do a real study. Compare it to placebo.” (Alper responded: “Good luck finding a convincing placebo for ibogaine.”) Suzuki is a fierce advocate for Suboxone and feels that the focus should be on providing greater access to medications that we already know save lives, prevent withdrawal, and are safe.
He pointed to other problems with both studies: The sample sizes were very small, they weren’t randomized, and they had high attrition rates. “If there’s a role for ibogaine in opioid addiction treatment, we would welcome it,” he told me. “We’re in the middle of a crisis. We do need better therapies, there’s no question about it. But I think it’s very premature to say that this is an effective treatment.”
He made one more point: “Dozens of deaths is kind of concerning.”
Suzuki was referring to the deaths that have been associated with ibogaine over the years, but the New Zealand trial had added to the toll: One of the participants died during treatment.
A coroner’s investigation deemed fatal arrhythmia to be the most likely cause.
It didn’t take Stanley Glick long to realize that ibogaine’s hallucinatory and toxic effects were going to be a problem. “I didn’t think that ibogaine would ever be approved by the FDA,” he told me. “It was just too weird.” He teamed up with a medicinal chemist to find a derivative of ibogaine with similar effects on withdrawal and craving, but without the cardiotoxicity or strange visions.
He’s pretty sure he found it.
“We tested over 60 compounds and landed on one called 18-MC.” That was in the mid-'90s. His lab removed a methoxy group from one carbon and added a carbomethoxy group to another. The resulting molecule had no effect on the heart. It didn’t interact with serotonin receptors, meaning it was unlikely to have psychedelic effects. It showed no signs of neurotoxicity in rats. To Glick, it seemed a beautiful example of rational drug design, where a natural compound is tailored to produce a safe and effective medicine.
Glick found that 18-MC attenuated opioid withdrawal and decreased self-administration of morphine, cocaine, nicotine, and methamphetamine in rats, just as ibogaine did. He believed he had found a key to opioid addiction, and perhaps even to addiction itself.
He published his findings, and nothing happened. He approached dozens of pharmaceutical companies, and none was interested. Then, in 2012, a small pharmaceutical startup called Savant acquired the license to 18-MC. Stephen Hurst, the firm’s CEO, says he took major flak from his venture capital friends. “I wouldn’t touch addiction with a 10-foot pole,” he said one told him. Another investor thought that a better solution to the opioid crisis was to “let all the addicts die.”
In 2012, NIDA got back in the game. It awarded Savant $6.7 million to prepare for a phase I trial for 18-MC. Savant recruited 14 volunteers in Brazil and reported that the drug appeared to be well-tolerated in healthy humans. They applied for a second grant to conduct more trials, but NIDA denied their application. “No one ever actually told us why,” Hurst said.
I contacted NIDA to find out. A press officer told me that the agency would not discuss why Savant’s second grant application had been rejected; only information on approved grants was public. I asked why NIDA hadn’t sponsored any additional research on ibogaine, especially given the urgency of the opioid crisis.
The response from NIDA seemed like standard boilerplate: “The accelerated development of treatments that can help stem the current opioid crisis is an issue of top priority. Treatments for addiction, like other medical treatments, must not only be effective, but must also pose no unacceptable risks to the patient,” referencing the safety concerns raised in 1995. “Even though ibogaine is used in other countries, it cannot become federally approved as a drug-addiction treatment in the US unless both its safety and efficacy are established to the satisfaction of the FDA.”
This struck me as strange logic. How are the safety and efficacy to be established if NIDA and other public institutions are unwilling to sponsor the work?
Hurst ultimately turned again to private investors. He approached more than a hundred firms. “I thought that with everything in the press about the opioid crisis we wouldn’t have any trouble,” he said. “I was quite wrong about that—we got nowhere.”
Finally, earlier this year, Hurst found a group of Canadian investors who were interested in 18-MC’s effect on opioid addiction. In June, they helped him launch a new company called Mind Medicine dedicated to the development of therapeutic psychedelic medicines, including 18-MC. He’s hoping the company will be able to resume clinical trials soon.
Smith-Ahearn seemed to understand that ibogaine created an opportunity rather than a cure. “The benefit of ibogaine is that it gets you through withdrawal so you can get on with the work of sobriety,” he told me. Those next steps, he said, were even more important. One evening, I overheard him ask a patient named Chase about his plans after treatment. Chase was hoping to join a religious recovery community in rural Alabama, “to get away from my old people.” Smith-Ahearn encouraged him. “I think that’s such a good idea,” he said. “Whatever keeps you clean. If something keeps a guy clean, I’m not going to kick it.”
“Hey man, that might be pretty hot, be careful,” he murmured as Chase ladled a bunch of hot sauce over a quesadilla.
Recently, I sent several emails to each of the three patients I talked to at Experience Ibogaine. I wanted to know how they were doing. Max got back. He said he hasn’t touched heroin or other opiates since his ibogaine treatment last October, and is now closing in on one year of abstinence. “It was life-changing,” he said. I never heard back from Matt or Andy.
I remembered one of the nurses at the clinic calling ibogaine an addiction “interrupter.”
“It isn’t a cure,” he had told me. “After you walk through the door, it’s up to you.”
Clayton Dalton is a resident physician at Massachusetts General and Brigham & Women’s Hospitals, in Boston.
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