Some providers have found it useful to make a “life contract” with patients prior to the administration of a saturation or flood dose. The contract might contain simple agreements such as that the person will not leave the space for the duration of the ibogaine’s effects, etc. but can also include the agreement that if the patient has the opportunity to permanently leave their physical body then they will come back and continue their life.1This practice was suggested by Ann Shulgin, and has proven useful in some cases. One provider recounts the story of an older alcoholic patient who saw himself in the water drifting out towards the open ocean, thinking he would just float out to sea. He then remembered making the life contract and turned around to come back to shore. While the patient experienced this vision his blood pressure increased to a life threatening level and he had to be administered sublingual hypertension medication, which stabilized his condition. There are several other similar stories in which patients and practitioners have reported a value in establishing the contract.
Manner of Administration
In some schools of psychedelic therapy for the practitioner to place the medicine in a container on the table rather than delivering it directly into the patient’s hand or mouth. This sensitivity provides the psychological context for the patient to accept to enter into their experience of their own free will. It is beneficial to consider this level of attention to set and setting (Ch. 1).
A test dose is a single threshold dose (usually 2 to 3 mg/kg) of ibogaine hydrochloride that is administered at least two hours prior to the remaining dose in order to monitor for allergic reaction2There is one unpublished report of a 28 y/o male, allergic to penicillin, who responded with an itchy rash and shortness of breath about 20 minutes after being administered a test dose of 2.5 mg/kg (150mg HCL)., and to observe metabolic reactions to the medicine.3As mentioned previously (Ch. 2), one preclinical study recommends as much as halving the dose for CYP2D6 poor metabolizers (Glue 2015). This data is based on a very small sample size in a low dose range. If a patient is a phenotype outlier, it may signal that greater attention should b given. Regardless, careful observation of the test dose response can provide clinically useful information about the patient’s metabolism. With sufficient clinical experience, observations should inform any further decisions about dosing.
There are varying schools of thought around the administration of a test dose prior to ibogaine treatment. With sufficient preparation and screening this is not necessary.
Extreme Weight Considerations
It is very important to consider that dosing in mg/kg might not be literal in cases of extremely over or underweight patients. In these situations it may be necessary to take into consideration the relative size of the person’s digestive system. Careful monitoring of dose response in extreme cases is highly recommended.
Many who seek ibogaine are diagnosed with liver conditions, or have elevated liver enzymes caused by Hepatitis C, HIV, or other conditions. Although more clinical research is needed to confirm, there are case reports of reduced viral loads after ibogaine treatment (Lotsof 2006).
However, during treatment, even slightly elevated liver enzymes or liver damage can result in drastic changes in metabolism of ibogaine and other medications. This can result in very rapid, or greatly prolonged and/or intensified effects. This should be taken into consideration and patient should be observed on a test dose for at least eight hours before continuing.
Patients should not receive a full dose until all the conditions for close supervision (Ch. 12) are met, and their vitals, drug use and general condition are stable. Supervisors should observe that they are well rested, have had at least two regular bowel movements, and are sufficiently nourished and hydrated.
In order to avoid complications of co-administration and potentiation of on-board opioids, dosing should not begin until significant discomfort from withdrawal symptoms is noted. Objective Opioid Withdrawal (OOWS) scores of 3 to 7 are considered optimal.
However, dosing should be delayed if withdrawal symptoms are fully expressed. OOWS scores of 10 or higher are considered excessive. If full-blown withdrawal symptoms are present, patient should be re-stabilized on morphine sulfate and ibogaine-assisted detox should resume at the next best opportunity.
Once dosing has begun it can be unnecessarily distressful to be in the midst of withdrawal symptoms while under the effects of ibogaine. Symptoms should be assessed objectively, and sufficient material should be used to reach the therapeutic goal as long as it is safe to continue administration.
It should be noted that doses in excess of 12mg/kg have been reported to have high er instances of cardiac abnormalities, and should be considered higher risk. Dosing should never exceed 24mg/kg in a 24-hour period.
Booster doses are threshold doses (usually 1 to 5 mg/kg) administered outside of the single large treatment dose. Optimally, in order to avoid cardiac complications, booster doses should not be given later than 2 or 3 hours after the initial dose, or at least 24 to 36 hours later. In the days and weeks following ibogaine therapy, judicious use of booster doses can help to treat residual withdrawal symptoms (verify with SOWS and OOWS) or other unresolved psychotherapeutic issues, and to prolong ibogaine’s therapeutic effects.
In some cases discomfort similar to withdrawal symptoms may present because of dehydration, lack of sleep, or other conditions. In these cases, the basic treatment course interventions (Ch. 15) are preferable to booster doses.
Patients being treated for certain SUDs, especially SUDs of extended duration and involving long-time use of long-acting opioids, may require more material in order to manage residual withdrawals and cravings. An honest assessment should be made, as early as possible, about the anticipated treatment protocol to be needed to reach that goal.