Side Event: Heroin and Ibogaine Assisted Treatments in the Era of the Opioids Crisis

Organized by European Coalition for Just and Effective Drug Policies and Nonviolent Radical Party Transnational Transparty

Enrico Fletzer

Pagan religion in Gabon – ibogaine was found by problematic heroin user and wake up with no need to take heroin anymore. Already people here at CND that’ve done this. But it’s quite complex

Dr Chris Hallam, Global Drug Policy Observatory

Heroin Assisted Treatment

The supplying of pure pharmaceutical heroin to those who are dependent on the drug but have not benefited from traditional OAT. Estimates that 10% of people who are given oral methadone/buprenorphine don’t work. Alternative to street heroin and reduces harms related to using street heroin. Heroin assisted treatment (HAT) doses are given under direct supervision of medical practitioners. Distinguishes HAT from previous forms of heroin treatment such as the classic British system. Along with HAT there are other health support services required

History – Switzerland – although subject to criticism and proved highly effective – more effectively than the tradiontlal oral methadone theory of therapy. Early 1990s – very large street scenes with users gathering in parks and injecting heroin and cocaine. Quote from Georges Dulex, former Head of the Zurich Canton Police service: “Early in 1992, the city authorities could no longer tolerate the situation. As a result, Needle Park was closed down on February 4, 1992. What happened afterwards shows that the coordinated efforts of all the disciplines involved were inadequate at the time. The problem – the misery – simple moved elsewhere. Drug addicts wandered along the banks of the river and in neighbourhoods close to the city. The situation became unbearable for everyone: residents, business and authorities.”

5 murders in the space of a few weeks around the area. Pragmatism became the answer – developed new policies and programs and put them in place of traditional methods. Swiss model for prescribing heroin had a population in mind, people who’d received little or no treatment from orthodox programs. New treatment needed to be accessible and offer their drug of choice. Had to take account of potential problems – overdose, etc. supplemented by further studies. PROVE. Objectives were to retain clients in treatment, reduce clients illicit drug use, improve health and social function, the latter with particular refence to criminal activities.

Swiss studies were successful for clients – criticised for lack of scientific rigour – but followed up by a series of RCTs. In UK there was a trail called the RIOT project – 3 prescribing centres – London, Brighton and Darlington – service offered to those who hadn’t benefited from oral methadone. Clients randomised to heroin treatment did significantly better than those on methadone. Research found that HAT was more effective. Benefits of HAT – removing ppl from street heroin culture and reduced impact of heroin use on neighbourhoods. More effectively as a treatment and the evidence base is now powerful and should lead governments to utilise HAT.

Carla Rossi, University of Rome

I’m a mathematician – I try to see everything go together, and not separate topics. In Switzerland its applied because country passed it. Denmark trying to apply directly without making experiment – experiments are not needed anymore – we already have randomised control trials (RCTs) – then you have to use – it’s unethical to not adopt these programs when we know that they are the best programs. Clinical trials of best therapy have not been used on other opioid populations. OECD book on new heroin use in western countries. This is what happened in US. If you look [at slide], the yellow graph from heroin in US – is rapidly increasing after 2010. For contrast, this is what happens in Switzerland.

Western countries – average increase of 21% – Switzerland is decreasing.

Significant evidence 1: great advantage in retention in treatment – fundamental aspect to reduce mortality. Higher retention in treatment, you have lower overdose effect. 2 consequences – less criminality, and less opportunity for others to use heroin. If you want to analyse the overdose data better – if you divide the overdoses between those <20 and those >40yrs. Population using problematic heroin are ageing and older. Incidence of new users are decreasing. Overdoses in those <20 – we have an increase.

Significant evidence 2: heroin problems in Switzerland are mostly focused in long-term users, not new users. Epidemiologically it’s really important and also saves money and reduces criminal activities. Money gained by criminal organisations. Programs such as these will reduce corruption in countries. Subpopulation that needs this kind of treatment is about 10% of people who use heroin – but this 10% use about 50% of heroin in these communities. This should be implemented as therapy for this 10%

Maja Kohek – ICEERS

Ibogaine is found in the root bark – but also in 3 different extracts. Pure ibogaine, ibogaine with other alkaloids. Few years ago, we did a study with other ibogaine users – they took ibogaine for some type of addiction. One person who’s a polydrug user – said that ibogaine gave them breathing room and time to think. 12 steps did not work for them – made them more pessimistic of my chances of ever being able to live a normal life. But also – its not a magic pill – its not like you swallow it and all your problems are solved. Sometimes boosters would be used – and other aftercare was necessary. Treatment, psychotherapy, yoga – whatever words for you. Must be done on regular basis. Study published in the Journal of Psychedelic Studies: Wilkins et al 2017, Detoxification from methadone using low, repeated and increasing doses of ibogaine: A case report

Currently selecting participants – first clinical trial in Spain – randomise double blind study – developed on case report – slowly increasing dose of ibogaine and reducing methadone worked for the people. In this way you can avoid the potential negative effects of ibogaine – such as death – ibogaine should not be used with other substances – so this needs to be done properly. Split into two groups. Hopefully result will be published next year. Bigger project. Iboga community engagement initiative – on ICEERS website. Also published – most people who use iboga to treat for addiction use for opioids. Iboga users that take for drug dependence – only 16% use opioids only though. Ibogaine is regulated differently across the world – there is a treat to prohibit or regulate in different countries.

Unregulated models -it’s currently being overharvested – in Gabon. Can be fatalities – quality control is lacking, Availability – many people can’t afford this type of product. All of these issues call for some kind of regulation. Opioid crisis is quite a challenge – so much opioid use – people do know that ibogaine can help in these type of places. What type of approach would be suitable – in Western society our approach has certain issues – a medical model might create certain types of barriers. But most people who take ibogaine don’t take it to treat addictions. What happens to groups currently providing the treatment – some really have a lot of experience and do a good job – probably have to stop working and providing the treatment. Trying to think of broader approach to tackle regulation issue. How to do it in a sustainable way. And the indigenous perspective – we can learn from their knowledge. Need to consider models from the West and who can benefit from this. Need a sustainable way to regulate it. Revolution would be in a holistic view that would incorporate all elements. Current system has a lot of issues – doesn’t solve the problem and creates more issues.

Q: HAT treatment way cheaper in Switzerland: but who pays for heroin that is given, where is it from?

A: The country passes the therapy. Health service imports the heroin.

A: In Britain it came from Switzerland. Produced in Switzerland. Paid by social insurance. But they gain on the judicial system as they have less incarceration to pay for. Ibogaine and HAT examples – HAT proven by RCTs – when you start new therapy (like iboga) a pilot trial needs to be implemented. RCTs have proven benefits of HAT. We wrote a letter to Italian minister – NPS list included ibogaine.

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