Effortpost time.
The fact that some of the incidents
@Xorkoth mentioned occurred after a second dose of ibogaine, spread out over months (to years?) is interesting. I don't have a specific connection to make there at this point except that it probably feels like twice the bummer and failure. I've also heard, anecdotally, as you probably have, from people who've had really extreme psychedelic experiences that they felt somehow "not welcome back." I believe I first heard this phrase, which is far from a unique one and akin to the old adage about "hanging up the phone", put in the "mouth" of a supposed "entity" in a trip report for DMT or 5-MeO-DMT, many years before Bluelight. Interestingly these are drugs which are very intense but, unlike ibogaine, tend not to have very long lasting or traumatic psychological outcomes associated with single instances of use. Exceptions of course may apply. Some people certainly have a bad time, especially with 5-MeO-DMT, and don't want to do it again for love or money, but the short action of these drugs I think doesn't lend itself to being traumatically difficult to integrate. Obviously ibogaine is very different in this regard.
Anyway, put a pin in that. I don't have much to add here other than to say that revisiting "strong medicine" like ibogaine when not having had much success initially is probably at the best of times like trying to use the face of the hammer to pry up nails that were hammered in awry.
Psychologically, the "last resort/let down" conception makes sense, but perhaps there's something more pharmacological at time. Of course, this dichotomy is more of a question of medium and message being intertwined.
Take the "black box" warning placed on antidepressants (among other things) relating to suicide. Does (say) an SSRI "make" a person suicidal? I hesitate to say this because it imputes a power to drugs to carry intent or information. This I categorically deny to psychedelics, so it wouldn't quite follow to attach it to quotidian psych meds. The truth is at once simpler and more complex—when talking about drugs that change our perceptions, discussions can suddenly take an epistemological and ontological turn. A facetious
portmanteau I used to throw around during Twitter discussions of the validity of psychiatry and it's interventions was something along the lines of "epistomonosolontology." The intersection of diagnosis, perception, and being itself. I won't belabor this stuff too much, but hear me out. Psychological phenomenon and drug-effect are very finely braided together.
While in general, across populations, antidepressants reduce suicide risk, there is some evidence that some people, especially younger people, experience
de novo suicidal ideation after stating antidepressants. What there is very good evidence for is that someone with
past suicidal ideation will sometimes, after starting antidepressants, experience worsened suicidal ideation, and, particularly, incidents of attempted or completed suicide.
There's an essentially psychological explanation for this as well: a severely depressed individual is amotivated with respect to pretty much
all goal-directed behaviors, which, it turns out, includes suicidality; likewise, a general lessening in blunted emotional experience can include a sharper subjective experience of emotional pain. So some of the motivational issues can be dealt with before the suicidality really recedes, which can lead to unfortunate outcomes.
Something like this is probably going on with ibogaine. Given the very complex pharmacology in play, combined with the neurochemical and hormonal changes that come with cessation of long-term opiate (or other drug) use, it's a very thick soup that's being stirred, which will necessarily have complex experiential and psychological sequelae. Our intuitive understanding of why one might feel hopeless or suicidal after the failure of ibogaine treatment or post-ibogaine life fits right in here.
As in the case of the anti-depressants, though, it's probably more than a purely psychological or environmental issue. It's unsettling, if not insulting, to think that "mere" chemistry might lead one to take one's own life, but no matter what explanations we can muster, this appears to be a drug with a different relationship to these risks than merely experiencing failure, relapse or let-down.
Either way, I think it's a significant cause for concern. Our small sample size notwithstanding, I think there's plenty of reason to be concerned. In fact, I think this is something that should be of deep concern to
all uses of psychoactive drugs, and particularly in cases of what might be called the "experential paradigm" or "pharmacopsychotherapy", e.g. MDMA, classical psychedelics, ibogaine.
Incidentally, while often mentioned together with these, ketamine treatment for depression—which has the potential to be very helpful in some refractory cases involving suicidal ideation, including a set of cases not unlike those for which ECT is sometimes recommended—is somewhat different as there is no claim made that the subjective ketamine experience causes the antidepressant effect, it is more of a "pure" pharmacotherapeutic effect, albeit one not taken on a continuous basis. Ibogaine actually is a little of column "A," a little of column "B"—it's thought to pharmacologically interrupt the processes of addiction and habitation but also is often experienced as beneficially cathartic. One might even be tempted to draw the conclusion that there is a one-to-one equivalence here, but this is probably too clever by half (especially as nonpsychedelic ibogaine analogues may have efficacy for addiction.)
Postacute risk of suicide associated with treatment—and to be clear I don't mean anything necessarily connected with the content of the subjective experience, as in the infamous case of an LSD research subject defenestrating himself, but rather the taking of the subject's life after the experience is finished but still due to it's neuropsychiatric effects—is actually something that I brought up repeatedly to people like Rick Doblin at MAPS and some of the people at Johns Hopkins, mostly to get a more or less cold shoulder and hear my concerns minimized. Due to the "Blue mondays" issue (mostly a serotonergic deficit, classically implicated in depression) I think it's a huge concern with MDMA that's overlooked, and one that I unfortunately would be considerably less than shocked to see lead to some very bad press for those organizations. At the very least, a cynic might worry that a single high profile suicide might set back the movement to regularizing these kinds of therapies back a decade or more.
My feeling in the case of MDMA has been for a decade or more that treatment in situations like that of PTSD (where there's a significant risk of suicide to begin with) should be undertaken in a pleasant, non-restrictive inpatient setting treatment, at least initially or in at-risk populations, and that inpatient care should extend for a period of time (perhaps 48-72 hours) after the experience for safety, reintegration, and aftercare. Ditto for psilocybin and similar, probably, although I suspect MDMA is higher-risk than typical psychedelics due to the depletion of serotonin.
I'd say these precautions are warranted in even stronger terms for the use of ibogaine. Unfortunately, this isn't the way treatment is done. Now, in my friend and yours' cases, this likely wouldn't have saved any lives; and certainly I don't expect a six-month inpatient aftercare period. In a suitable facility, this might not be a bad way to do ibogaine, with a therapeutic environment and multimodal treatments both before and after after fact, but sadly it isn't 1960 anymore, and we no longer have agencies which fund such an approach to psychiatry, although we sadly many patients who are in great need of it.
To make a good start in cases like his, what we need is good screening process and exclusion criteria, which would've ruled my friend out, unfortunately, the private clinic he attended in Mexico was probably not particularly rigorous here and he could've easily lied anyway, and, due to the gray-market nature of the treatments and consequential lack of integration into the broader healthcare system, there's no way for responsibile referrals to be done. Clinical studies of, e.g., MDMA, usually screen pretty well as far as that goes. Doesn't mean the issues won't come up where and when those treatments are done more indiscriminately.
All in all, a thorny and emotional set of problems to which I don't readily have answers.
The very least we can do is have a frank discussion of these issues and possible attempts to reduce risk with those who are interested in trying ibogaine. In fact, this might be one of those curious situations in which awareness of risk might be, by it's very existence, prophylactic towards risk—this seems to be the case with antidepressants and suicide at least to a small degree. Awareness that suicidal ideation may crop up "due to" a drug may make those very ideas and impulses easier to resist. This doesn't guarantee that they won't be ultimately followed through with, but we should take any help we can get here.
Drug prescribers and advertisers disclose this risk of suicidality due to liability first and foremost but also because it's genuinely helpful. The experiential pharmacopsychotherapeutics should be no different, in fact, we should be even more careful with them. Unfortunately practitioners, researchers and promoters tend to an evangelistic, magic-bullet presentation and a quasi- if not overtly religious miraculism—Dimitri Mugianis went so far as to get himself initiated into the
T. iboga-using Bwiti tribe, and putatively therapeutic ayahuasca use is very often tinged with shamanism, in and out of the jungle, not to mention less problematic and more staid research, e.g. at Johns Hopkins, which correlates a "mystical" experience with better therapeutic outcomes—all with to little thought given to paradigms of treatment and to management of risk. I've been sounding this alarm and making this criticism in various ways for many years now and have found only more reason to do so, sadly in this case due to very non-theoretical loss of life.
Edit: revised and expanded
) about addiction and recovery. I've escaped a fate worse than death. I just hope something I say helps somebody else do the same.