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Fatalities Temporally Associated with the Ingestion of Ibogaine


Abstract and Figures

Ibogaine is a naturally occurring psychoactive plant alkaloid that is used globally in medical and nonmedical settings for opioid detoxification and other substance use indications. All available autopsy, toxicological, and investigative reports were systematically reviewed for the consecutive series of all known fatalities outside of West Central Africa temporally related to the use of ibogaine from 1990 through 2008. Nineteen individuals (15 men, four women between 24 and 54 years old) are known to have died within 1.5-76 h of taking ibogaine. The clinical and postmortem evidence did not suggest a characteristic syndrome of neurotoxicity. Advanced preexisting medical comorbidities, which were mainly cardiovascular, and/or one or more commonly abused substances explained or contributed to the death in 12 of the 14 cases for which adequate postmortem data were available. Other apparent risk factors include seizures associated with withdrawal from alcohol and benzodiazepines and the uninformed use of ethnopharmacological forms of ibogaine.
Content may be subject to copyright.
Kenneth R. Alper,
M.D.; Marina Stajic
Ph.D.; and James R. Gill,
Fatalities Temporally Associated with the
Ingestion of Ibogaine
ABSTRACT: Ibogaine is a naturally occurring psychoactive plant alkaloid that is used globally in medical and nonmedical settings for opioid
detoxification and other substance use indications. All available autopsy, toxicological, and investigative reports were systematically reviewed for the
consecutive series of all known fatalities outside of West Central Africa temporally related to the use of ibogaine from 1990 through 2008. Nineteen
individuals (15 men, four women between 24 and 54 years old) are known to have died within 1.5–76 h of taking ibogaine. The clinical and post-
mortem evidence did not suggest a characteristic syndrome of neurotoxicity. Advanced preexisting medical comorbidities, which were mainly cardio-
vascular, and or one or more commonly abused substances explained or contributed to the death in 12 of the 14 cases for which adequate
postmortem data were available. Other apparent risk factors include seizures associated with withdrawal from alcohol and benzodiazepines and the
uninformed use of ethnopharmacological forms of ibogaine.
KEYWORDS: forensic science, toxicology, ibogaine, iboga alkaloid, substance abuse, human, fatality, opioid, opioid detoxification,
The iboga alkaloids are a group of monoterpene indole alkaloids,
some of which reportedly reduce the self-administration of drugs of
abuse and opiate withdrawal symptoms in animal models and
humans (1,2). Ibogaine (Fig. 1), the most extensively studied iboga
alkaloid, occurs in the root bark of the West African Apocynaceous
shrub Tabernanthe iboga Baill. In Gabon, eboga, the scrapings of
the root bark, has been used as a psychopharmacological sacrament
in the Bwiti religion for several centuries (3,4). Elsewhere, includ-
ing North America, Europe, and South Africa, ibogaine is used for
the purpose of acute opioid detoxification, and to reduce craving
and maintain abstinence from opioids and other abused substances
including stimulants and alcohol, as well as for psychological or
spiritual purposes (5).
Ibogaine is used most frequently as a single oral dose in the
range of 10–25 mg kg of body weight for the specific indication
of detoxification from opioids (5,6). It is most commonly used in
the form of the hydrochloride (HCl), which certificates of analysis
typically indicate is 95–98% pure, with present retail prices in the
range of c. $125–$250 USD per gram. Ibogaine is also used in the
form of alkaloid extracts or dried root bark (Fig. 2).
Ibogaine is a schedule I substance in the United States, and simi-
larly is illegal in France, Denmark, Sweden, Belgium, Switzerland,
and Australia. However, it is unregulated in most countries, where
it is neither illegal nor officially approved. Lay providers administer
ibogaine in nonmedical settings and have accounted for the
majority of treatments (5). Ibogaine is administered in medical set-
tings in countries such as Mexico and South Africa, where physi-
cians have the legal prerogative to prescribe unapproved
Published case series and individual accounts regarding ibogaine
remission of acute withdrawal symptoms following a single admin-
istration that is subsequently sustained without further ibogaine
treatment or the use of opioids (1,6,7). This effect of ibogaine
appears to be pharmacologically mediated and not accounted for
by placebo, which has clinically negligible effects in opioid detoxi-
fication (8–10). In the naloxone-precipitated withdrawal model of
opioid detoxification, iboga alkaloids have attenuated opioid with-
drawal signs in 13 of 14 independent replications in two rodent
and two primate species (11–24). Ibogaine administered to rats or
mice as a single dose reduces the self-administration of morphine
(25–28), cocaine (26,29,30), and alcohol (31,32), with sustained
treatment effects for 48–72 h averaged for an entire sample, and an
even longer duration in individual animals (25,26,28,30). The
serum half-life of ibogaine in the rat is c. 1–2 h (33,34), indicating
that the prolonged effect on self-administration outlasts the presence
of ibogaine itself, without compelling evidence that it is mediated
by a long-lived metabolite (35).
Ibogaine does not appear to be an abused substance. The
National Institute on Drug Abuse (NIDA) did not identify potential
abuse as an issue in the context of its research program on iboga-
ine, which included preclinical testing and the development of a
clinical trial protocol (1). Animals do not self-administer 18-meth-
oxycoronaridine (18-MC), a closely structurally related ibogaine
congener with the same effects as ibogaine on self-administration
and withdrawal in preclinical models (36). Aversive side effects
such as nausea and ataxia limit ibogaines potential for abuse.
Ibogaine potentiates the lethality of opioids (33,37–39). This is
apparently because of an enhancement of opioid signaling (1,40),
and not because of binding at opioid receptors as an agonist (such
Departments of Psychiatry and Neurology, New York University School
of Medicine, 550 First Avenue, New York, NY 10016.
Department of Forensic Toxicology, New York City Office of Chief
Medical Examiner and Department of Forensic Medicine, New York Uni-
versity School of Medicine, 520 First Avenue, New York, NY 10016.
New York City Office of Chief Medical Examiner and Department of
Forensic Medicine, New York University School of Medicine, 520 First
Avenue, New York, NY 10016.
Received 28 July 2010; and in revised form 17 Nov. 2010; accepted 20
Nov. 2010.
J Forensic Sci, March 2012, Vol. 57, No. 2
doi: 10.1111/j.1556-4029.2011.02008.x
Available online at:
398 2012 American Academy of Forensic Sciences
as methadone) or antagonist. Doses of ibogaine used in opioid
detoxification do not produce signs of overdose in individuals who
lack tolerance to opioids, such as African Bwiti adepts, or individu-
als in non-African contexts who take ibogaine for psychological or
spiritual purposes or the treatment of addiction to substances other
than opioids. If ibogaine was acting as an opioid agonist, it would
not be tolerated by opioid-nave individuals because the methadone
dosage of 60–100 m g day that is used to stabilize withdrawal
symptoms in the maintenance treatment of opioid-dependent
patients (41) substantially exceeds the estimated LD
of 40–50 mg
in humans who are not pharmacologically tolerant to opioids (42).
Other evidence that ibogaine alters signaling through opioid recep-
tors but is not itself an orthosteric agonist includes its potentiation
of morphine analgesia in the absence of a direct analgesic effect
(22,38,39,43–47). Ciba Pharmaceutical patented the use of ibogaine
to reduce tolerance to opioid analgesics in 1957 (47).
Although ibogaine contains an indole ring and is designated as a
‘‘hallucinogen,’’ it is pharmacologically distinct from the ‘‘classi-
cal’’ hallucinogens such as LSD, mescaline, or psilocybin, which
are thought to act by binding as agonists to the serotonin type 2A
) receptor (48). Serotonin agonist or releasing activity does
not appear to explain ibogaines effects in opioid withdrawal
(2,49). There is no anecdotal or preclinical evidence for a signifi-
cant effect of classical hallucinogens in acute opioid withdrawal,
and in the animal model ablation of 90% of the raphe, the major
serotonergic nucleus of the brain does not significantly affect the
expression of opioid withdrawal (50). Descriptions of subjective
experiences associated with ibogaine differ from those associated
with the classical hallucinogens (5,48,51). The visual effects of
classical hallucinogens are typically most strongly experienced with
the eyes open and limited to alterations of colors, textures, and pat-
terns. In contrast, the psychoactive state associated with ibogaine is
experienced most intensely with the eyes closed and has been
described as ‘‘oneiric’’ and likened to a ‘‘waking dream,’’ with
Iboga alkaloid R1R2R3
Ibogaine OCH3HH
Noribogaine OH H H
Ibogamine H H H
Ibogaline OCH3OCH3H
Tabernanthine H OCH3H
Voacangine OCH3HCO
FIG. 1—Chemical structures of ibogaine and its major metabolite norib-
ogaine, and the alkaloids ibogamine, ibogaline, tabernanthine, and voacan-
gine that co-occur with ibogaine in T. iboga. In the Chemical Abstracts
system the positions of R
, and R
on the ibogamine parent structural
skeleton are respectively numbered 12, 13 and 18, whereas in the Le Men
and Taylor system these same positions are numbered 10, 11 and 16.
FIG. 2—Forms of availability of ibogaine: Ibogaine is available in form of the hydrochloride (HCl) dried root bark, or alkaloid extract. The upper left
photo shows 96% pure ibogaine HCl in the form of powder in the upper left quadrant of the photo. In the lower left quadrant of the photo are five capsules.
The four lighter colored capsules contain 96% pure ibogaine HCl; the smaller two contain 120 mg and the larger two contain 250 mg respectively. The larg-
est capsule is darker and contains 330 mg of 85% ibogaine HCl. In the lower right quadrant of the photo is ground dried root bark. The upper right photo
shows alkaloid extract with an estimated total iboga alkaloid content of about 40–50%. The lower photo shows a partially scraped dried Tabernanthe iboga
root, with external bark layer, an inner bark layer, and wood. The alkaloid content is mainly concentrated in the inner root bark layer, which is exposed
along the lower border of the bare wood in left middle portion of the photo (photos courtesy of Robert Bovenga Payne and Rocky Caravelli).
interrogatory verbal exchanges involving ancestral and archetypal
beings, and movement and navigation within visual landscapes.
Another frequently described experience is panoramic memory, the
recall of a rapid, dense succession of vivid autobiographical visual
memories. Mechanistically, these subjective experiences associated
with ibogaine might possibly suggest functional muscarinic cholin-
ergic effects, which are prominent in the mechanisms of dreaming
and memory (52). In animals, ibogaine is reported to enhance spa-
tial memory retrieval (53,54), and to produce an atropine-sensitive
EEG rhythm (55,56), commonly regarded as a model of REM
sleep (57).
Ibogaines highest affinity receptor interactions are as an agonist
at the r
receptor, and an antagonist at the N-methyl-d-aspartate-
type (NMDA) glutamate and a3b4 nicotinic acetylcholine recep-
tors (1,2,58). Initially, ibogaines mechanism of action in drug
self-administration and withdrawal was hypothesized to involve
NMDA receptor antagonism (59); however, this hypothesis is now
viewed as unlikely because the synthetic ibogaine congener 18-
MC has negligible NMDA receptor affinity but is equally effec-
tive as ibogaine in reducing withdrawal and self-administration in
the animal model (2). Studies of iboga alkaloids and nicotinic
agents (60–64) provide some support for antagonism of the a3b4
nicotinic receptor as a possible mechanism of action with regard
to drug craving and self-administration but do not appear to
explain detoxification in the setting of extensive physical depen-
dence on opioids. Likewise, the increased expression of glial cell-
derived neurotrophic factor may mediate reduction in drug craving
and self-administration (32) but does not explain ibogaineseffect
in opioid detoxification.
Ibogaine was administered to human subjects in a clinical Phase
I dose escalation study under a physician-initiated Investigational
New Drug Application approved by the FDA in 1993 (65). The
study was eventually discontinued because of disputes related to
contractual and intellectual property issues (66); however, the avail-
able safety data indicated no adverse events (65). Most of the
available preclinical pharmacological, toxicological, and pharmaco-
kinetic data on ibogaine are derived from research supported by
NIDA between 1991 and 1995. NIDA eventually ended its iboga-
ine project without having initiated a clinical trial apparently
because of its high cost and complexity relative to NIDAsexisting
resources (1). Ibogaines underlying structure cannot be patented
because it is naturally occurring, which limits the financial incen-
tive for its development. Ibogaine continues to be used in unregu-
lated contexts with associated risks because of a lack of clinical
and pharmaceutical standards (5).
Deaths have occurred temporally related to the use of ibogaine.
This article presents a systematic review of all available autopsy,
toxicological, and investigative reports on the consecutive series
consisting of all known fatalities temporally related to the use of ib-
ogaine that have occurred outside of West Central Africa from
1990 through 2008.
Materials and Methods
The Institutional Review Board of the New York University
School of Medicine and the General Counsel of the New York City
Office of Chief Medical Examiner (OCME) approved this research.
Identification of Cases
This series spans the time interval beginning with the first
reported fatality in 1990 (1) until December 2008. Eighteen of the
19 fatalities in this series were found through contact with ibogaine
treatment providers since the mid-1990s (5,6,67,68). One of these
fatalities was also investigated by the OCME (69) as are all unex-
pected, violent, and suspicious deaths in New York City. One fatal-
ity was found by literature search (70). The ethnographic
methodology and access to the network of the providers of iboga-
ine treatment and other participants in the ibogaine subculture are
described in detail elsewhere (5,67).
All fatalities were followed up by contact with appropriate
medico-legal death investigation agencies to obtain all available
autopsy and toxicology reports, inquest testimony, and other inves-
tigative reports. In addition to documentary evidence, in most
instances, treatment providers and other first-hand observers of the
death scene were interviewed. Systematic evaluation of the litera-
ture included Medline searches from 1966 to June 2010 utilizing
PubMed and ISI Web of Knowledge with the search terms ‘‘iboga-
ine’’ combined with ‘‘death’’ or ‘‘fatality’’ in addition to searches of
periodical and nonindexed ‘‘grey’’ literature as described elsewhere
Analytical Toxicology
Various methodologies for toxicological analysis of ibogaine
(molecular weight 310.44) have been previously described, includ-
ing liquid chromatography with flourimetric detection (71), gas
chromatography mass spectrometry (GC MS) (72–76) liquid chro-
matography mass spectrometry (LC-MS) (70,75,77–80), and liquid
chromatography-tandem mass spect rometry (LC-MS MS) (81–83).
There is a potential for confusion because of the use of two differ-
ent schemes for numbering the iboga alkaloid parent ibogamine
skeleton (84), the Chemical Abstracts system, which is common in
the biological and medical literature, and the Le Men and Taylor
system, which tends to be favored by natural products and synthetic
chemists and is also frequently encountered in the biological
literature (see Fig. 1).
Ibogaine screening usually is not included in most routine foren-
sic toxicological laboratories and a suspicion of use is required for
analysis, which is typically performed by a referral laboratory. For
two fatalities in this series (cases #3 and #10 in Table 1), the
Forensic Toxicology Laboratory at the OCME performed the analy-
sis. The presence of ibogaine was confirmed by GC MS and the
concentration determined using GC with a nitrogen phosphorus
detector (69).
Cause of Death
The certified cause of death is included in Table 1, entitled
‘‘Official cause of death.’’ The certified cause of death is that which
is indicated by the official documentation, that is, autopsy report or
death certificate, by the local authority that investigated and
recorded the death. The available documentation varied greatly with
regard to investigative rigor, level of detail, and geographic location
of the official entity that issued the report. As an approach to con-
trolling for this variance, a coauthor (JRG, a board-certified foren-
sic pathologist) made a determination regarding the cause of each
official documentation, included any information that was provided
by treatment providers and other first-hand observers of the death
scene, or friends and acquaintances of the decedent. Table 1 pro-
vides the conclusions of this systematic, critical evaluation of all
available evidence in the far right-hand column entitled ‘‘Proximate
cause of death.’’
The cause of death is defined as the original, etiologically spe-
cific, underlying medical condition that initiates the lethal sequence
TABLE 1—Worldwide known fatalities outside of West Central Africa temporally associated with the ingestion of ibogaine, 1990–2008.
Age Gender,
Reason for
Ibogaine Use Country Year Circumstance
Time Interval
from Most
Ingestion of
Until Death
Ibogaine Form,
(Blood, mg L
or mg kg)
(mg L)
Other Autopsy
or Historical
Official Cause
of Death
Proximate Cause
of Death
spiritual (1)
France 1990 Witnessed
to become
4 h Ibogaine
300 mg (c.
4.5 mg kg)
Liver: 0.17
Kidney: 0.3
Negative Hypertension;
prior left
myocardial infarct,
3-vessel coronary
inverted T waves
noted on EKG
3 months prior to
Acute heart
Acute ibogaine
and hypertensive
detoxification (6)
Netherlands 1993 Died during
19 h Ibogaine HCl
29 mg kg
Cardiac: 0.74
Femoral vein:
‘‘trace’’ <0.01
Cardiac: 11.28
vein: 3.96
Charred tin foil
found in room
role of ibogaine
unknown due to
lack of information
relating levels to
toxic effects
Acute intoxication
due to the
effects of
ibogaine and
dependence (69)
USA 1999 Found dead
at home.
A syringe
found near
8–9 h Ibogaine HCl;
believed to be
16–20 mg kg
vein: 9.3
Brain: 18.6
Liver: 18.1
ecgonine: 0.6
Opiates: 0.1
adverse life
events prior to
decedent was
aware of dangers
of use of cocaine
or heroin
with ibogaine
Acute intoxication
due to the
combined effects
of opiates, cocaine,
and ibogaine
Acute intoxication
due to the
combined effects
of opiates,
cocaine, and
2000 Died in
prior to death
40 h Tabernanthe
iboga alkaloid
extract 6 g
over c.6h
0.36 Other toxicology:
Hepatitis C with
liver fibrosis,
pulmonary and
cerebral edema
Fatal reaction to
Tabernanthe iboga
Hepatitis C
Acute ibogaine
5. 35 F
Germany 2002 Found dead
in bed
of not feeling
well the
day before)
1.5 h Ibogaine HCl
500 mg
Unknown Unknown Childhood
heart surgery
coronary artery
Acute ibogaine
(unknown if
other drugs
TABLE 1—Continued.
Age Gender,
Reason for
Ibogaine Use Country Year Circumstance
Time Interval
from Most
Ingestion of
Until Death
Ibogaine Form,
(Blood, mg L
or mg kg)
(mg L)
Other Autopsy
or Historical
Official Cause
of Death
Proximate Cause
of Death
6. 32 M
by opiate abuser)
USA 2003 Found dead
in bed at his
Unknown Bag of brown
powder at scene
that tested
positive for
dried root
Cardiac: 0.95
vein: 1.5
Liver: 8.0
Urine: 26
Vitreous: 0.54
Gastric: 2.9
Bile: 0.54
History of opiate
abuse, and had
been in
at time
of death
cocaine use
Acute ibogaine
cocaine abuse
Mexico 2003 Died at
60 h Ibogaine HCl
13 mg kg
Unknown Unknown Obesity, chronic
(unclear if
autopsy was
Mexico 2004 Died at
20 h Ibogaine HCl
15 mg kg
Unknown Unknown Chronic
obesity, cardiac
Acute hemorrhagic
obesity, opiate
pain medication
in the US)
2005 Died at
2 days Ibogaine HCl
14 mg kg
Liver: 0.72
Diazepam: 0.06
Temazepam (trace)
Prior gastric
bypass surgery
with 135 lb
weight loss in
8 months
preceding death.
dependence that
was not
to treatment
Sudden cardiac
death due to
acute myocardial
infarct due to
acute coronary
chronic pain
Acute myocardial
infarct due to
coronary artery
during ibogaine
therapy for
TABLE 1—Continued.
Age Gender,
Reason for
Ibogaine Use Country Year Circumstance
Time Interval
from Most
Ingestion of
Until Death
Ibogaine Form,
(Blood, mg L
or mg kg)
(mg L)
Other Autopsy
or Historical
Official Cause
of Death
Proximate Cause
of Death
10 43 M
USA 2005 Witnessed
cardiac arrest
during self-
ibogaine treatment.
Witnessed apparent
seizure 17 h after
ibogaine ingestion
27 h Ibogaine HCl,
dose unknown
2.8 Diazepam: 0.03
benzamide: 0.85
Hepatitis B
heart disease.
Acute ibogaine
with dilated
11 51 M
and alcohol
Mexico 2005 Died at ibogaine
treatment facility
24 h Ibogaine HCl
12 mg kg
Unknown Unknown Autopsy not
arrest due to
acute myocardial
infarction (death
clinical diagnosis
of attending
12 38 M
Mexico 2006 Died at ibogaine
treatment facility.
Found dead within
1 h of having last
been seen alive
12 h Ibogaine HCl
13 mg kg
Unknown Cocaine and
Autopsy was
done, but
inadequate for
determination of
a proximate
cause of death
(death certificate)
13 48 M
Unknown (70)
France 2006 Ingested root bark
of Tabernanthe
iboga followed by
vomiting and
53 h 18 ‘‘soup-spoons’’ of
a mixture of
Tabernanthe iboga
root bark and
sweetened condensed
milk over 10 h
Vena cava: 6.6
Femoral vein: 5.4
Brain: 12.5
Liver: 40.5
Vena cava: 15.5
Femoral vein: 5.6
Brain: 18.7
Liver: 50.5
tablets and
‘‘different objects
and burned-out
parts of plants
found at the
scene suggested
that some sort of
esoteric ritual
may have taken
place.’’ History
of substance
Acute ibogaine
Acute ibogaine
(unknown if
other drugs
TABLE 1—Continued.
Age Gender,
Reason for
Ibogaine Use Country Year Circumstance
Time Interval
from Most
Ingestion of
Until Death
Ibogaine Form,
(Blood, mg L
or mg kg)
(mg L)
Other Autopsy
or Historical
Official Cause
of Death
Proximate Cause
of Death
14 28 M
The Netherlands 2006 Fluctuating
level of
immersion in a
warm bath
for a 4-h period
prior to death.
Subject was
observed and at no
time was his head
underwater, ruling
out drowning
76 h Tabernanthe
iboga alkaloid
extract, 7.5
grams over
Unknown Quantitative
toxicology results
not available
but ibogaine
and cannabinoid
reportedly ‘‘low.’’
Negative for
other drugs
of abuse
and ethanol
Choroid plexus
with hypoxic
damage to
Large duodenal
ulcer with
accumulation of
blood in
Not conclusive
cause of death.
Possible causal
and or
factors were
of duodenal
ulcer, increased
pressure resulting
from obstruction
of third ventricle,
and or partial
seizures originating
from the temporal
cause not likely’’
of duodenal
15 30 M
South Africa 2006 ‘‘Gurgling sounds’’
on expiration.
Died en route to
hospital after
appearing to
respond to
8 h Ibogaine HCl
17 mg kg
(1.75 g)
Single dose
Not tested Not tested Autopsy not
secondary to drug
related illness’’
(death certificate)
16 27 M
France 2006 Discovered dead
in meditation
room at a center
spiritual use
£20 h Powdered root
bark (7.2% ibogaine,
0.6% ibogamine).
The actual
amount ingested
was not provided
in the report.
The medical
examiner estimated
13 teaspoons at
1.5-g dried
bark teaspoon
would have
been required to
achieve the
ibogaine blood
death: 0.65
blood at
8 days
death: 1.27
Peripheral blood
following death:
Methadone: 0.077
Diazepam: 0.413
Oxazepam: 0.09
Temazepam: 0.04
Ibogamine: 0.05
Peripheral blood at
autopsy 8 days
following death:
Ibogamine: 0.10
History of
on multiple
including crack
and alcohol
Drug overdose
due to ibogaine,
diazepam, and
due to the
effects of
methadone, and
TABLE 1—Continued.
Age Gender,
Reason for
Ibogaine Use Country Year Circumstance
Time Interval
from Most
Ingestion of
Until Death
Ibogaine Form,
(Blood, mg L
or mg kg)
(mg L)
Other Autopsy
or Historical
Official Cause
of Death
Proximate Cause
of Death
17 45 M
USA 2006 Found dead in
bed following
ibogaine treatment
at a private
8–12 h Ibogaine HCl
22 mg kg
1.4 Diazepam:
77 ng ml
1.2 ng ml
1.5 ng ml
urine screen
Hepatic steatosis Mixed drug
due to the
combined effects
of ibogaine,
fentanyl, and
18 33 M
crack cocaine
Mexico 2007 Died at ibogaine
treatment facility
6.5 h Ibogaine HCl
11 mg kg
Not tested Not tested.
History of
having been
caught using
crack cocaine in
the bathroom
during a prior
admission to the
Family history
of pulmonary
in patients father.
Autopsy was
done, but
inadequate for
determination of
a proximate
cause of death
clinical diagnosis
of attending
physician present
at time of death)
19 41 M
in the US)
2007 Died at
shortness of
and became
6 h Ibogaine HCl
13 mg kg
(1080 mg)
Not tested Not tested Cardiac
397 mg dL
Fatal arrhythmia
during drug
treatment with
Acute ibogaine
(unknown if
other drugs
of events (85). A competent cause of death includes the proximate
(underlying) cause, defined as that which in a natural and continu-
ous sequence, unbroken by any efficient intervening cause,
produces the fatality and without which the end result would not
have occurred. Contributing conditions were additional disorders
contributory to death but unrelated to the underlying cause of
The conclusion that death was caused by an acute intoxication
requires that three conditions be met: the toxicological results are
within the range typically encountered in such fatalities, the history
and circumstances are consistent with a fatal intoxication, and the
autopsy fails to disclose a disease or physical injury that has an
extent or severity inconsistent with continued life (86). In deaths
caused by drug intoxication with more than one drug in concentra-
tions greater than trace amounts, it is customary to include all of
the identified drugs in the cause of death.
We report a summary of 19 ibogaine-associated deaths that have
occurred worldwide between 1990 and 2008 including the probable
causes of death based on the available clinical and pathologic infor-
mation (see Table 1). There were 15 men and four women with a
mean age of 39.1 € 8.6 years ranging from 24 to 54 years. In 18
decedents, the estimated time intervals were available from the
most recent ingestion of ibogaine in any form until death, and the
mean interval was 24.6 21.8 h and ranged from 1.5 to 76 h. In
one other fatality (case #6) the time interval between death and the
time when the decedent was last noted to be alive was 20 h, the
decedent had been dead for at least several hours at the time the
body was found. The time interval from the most recent ingestion
of ibogaine until death in this instance was likely less than 76 h,
but it was not included in the calculation of the mean interval.
Fifteen individuals took ibogaine for the indication of opioid
detoxification, four of who were also dependent on alcohol, three
on cocaine, and one on methamphetamine. Two individuals used it
for a spiritual psychological purpose and had no known substance
abuse history, and two took it for unknown reasons but had a his-
tory of substance abuse. Ibogaine was given as the HCl form in 14
instances, as an alkaloid extract in two (cases #4 and #14), dried
root bark in two (cases #13 and #16), and a brown powder that
was probably either root bark or alkaloid extract in another (case
#6). In the 12 fatalities where ibogaine was given as the HCl and a
dose was reported, the mean dose was 14.3 6.1 mg kg (range
4.5–29 mg kg). In the 10 fatalities in which ibogaine blood con-
centrations were determined, the mean was 2.38 € 3.08 mg L
(range 0.24–9.3 mg L), obtained at a mean of 25.5 17.8 h fol-
lowing the ingestion of ibogaine (range 4–53 h). In addition, com-
monly abused drugs (including benzodiazepines, cocaine, opiates,
and methadone) were detected in eight of 11 decedents on whom
toxicological analysis for abused substances was performed.
Twelve of the decedents had medical comorbidities including
liver disease, peptic ulcer disease, brain neoplasm, hypertensive and
atherosclerotic cardiovascular disease, and obesity. Among the three
decedents in which no other drugs of abuse were detected in post-
mortem toxicology analysis, one had advanced heart disease and
another had liver fibrosis. Full toxicology and autopsy results were
not available in eight and five decedents, respectively.
In this series, 19 deaths occurred between 1990 and 2008, with
an interval of 76 h or fewer between the most recent ingestion of
ibogaine and death. In 14 instances, an autopsy was performed that
allowed the determination of the proximate cause of death. The
lack of clinical and pharmaceutical controls in settings in which ib-
ogaine has been given, and the limited data regarding toxic concen-
trations of ibogaine in humans make the determination of the
causes of these deaths difficult. Nonetheless, advanced comorbidi-
ties and contributing conditions appear to include preexisting medi-
cal, particularly cardiovascular disease, and drug use around the
time of treatment.
This series of fatalities is consecutive in the sense that it repre-
sents a systematic application of an intensive methodology for iden-
tifying cases over the time interval spanned by this study. It is
possible that additional fatalities may have occurred which were
missed by death investigation agencies and this study. In the United
States, this could relate to the surreptitiousness regarding the use of
ibogaine because of its status as a schedule I substance, and indi-
viduals aware that ibogaine was used in temporal association with
a fatal outcome might be reluctant to disclose that history. Without
investigative information about the recent use of ibogaine, special-
ized analysis for ibogaine may not be performed. Under these cir-
cumstances, the cause of death of an individual treated with
ibogaine for a substance use indication could be certified as a typi-
cal multidrug intoxication, particularly in view of the likelihood of
detecting other drugs of abuse in these deaths. In most of the
world, however, ibogaine is not illegal. In this series, outside of the
United States, ibogaine was not illegal at the time of occurrence of
the fatality in any country in which the fatality occurred.
In at least five instances, providers contacted the first author
immediately regarding the death, and in a number of others,
another individual close to the provider relayed the information,
usually with the providers consent. Their motivation to disclose
this information included the wish to understand the causality of
the death and prevent a future occurrence, abreaction regarding a
traumatic event, and anxiety regarding legal liability. In a country
in which ibogaine is not illegal, however, concealing its use is not
necessarily perceived to be, or actually safer than disclosing it.
Regardless of their distress regarding a death, experienced treatment
providers such as those in Mexico or the Netherlands were aware
that they did not face significant legal consequences. In a prior
study by the first author of this article that surveyed the settings
and extent of ibogaine use (5), it was estimated that 20–30% of the
actual total number of ibogaine treatments had been missed by that
study. Six of the series of 19 fatalities in this article occurred in
settings and circumstances that are likely to have otherwise been
hidden from the medical ethnographic study mentioned previously
(5). While it is likely that some deaths temporally related to the
use of ibogaine escaped inclusion in this series, it is also possible
that treatments that are associated with a fatal outcome may come
to attention relatively more frequently than those that are not.
For the purpose of this discussion, the terms ‘‘proximate cause’’
and ‘‘contributing condition’’ are used as they are defined previ-
ously in the methods section and appear in the extreme right-hand
column of Table 1. A striking factor in this series of deaths is the
identification of a comorbidity or intoxication (in addition to iboga-
ine) that could adequately explain or contribute to the death in 12
of 14 decedents that have adequate postmortem data. There are
multiple possible pathways by which ibogaine may cause or con-
tribute to death in these instances and include toxicological interac-
tions with substances of abuse and direct cardiac effects.
Cardiac disease was a contributing condition or proximate cause
in six deaths, suggesting cardiac mechanisms are an important
mediator of fatal outcomes. Although preclinical toxicological test-
ing by NIDA did not indicate prolongation of the QT interval (87),
it has been observed during ibogaine treatments with continuous
EKG monitoring (88). Blockade of the potassium voltage-gated ion
channel encoded by the human ether-a-go-go-related gene (hERG)
is regarded as the most common cause of drug-related QT prolon-
gation (89,90), which is associated with torsades de pointes (TdP),
a morphologically distinctive polymorphic ventricular tachycardia.
The effect of ibogaine differs from that of the hERG channel
antagonist WAY-123.398 in studies of chromaffin cells (91–93);
however, ibogaine is an hERG channel antagonist in the low
micromolar range in human embryonic kidney tsA-201 cells (94).
Ibogaine has low micromolar affinity for sodium channels
(2,95,96), which might also possibly relate to cardiac risk in view
of the possible association of sodium channel blockade with slow-
ing of intraventricular conduction and the subsequent development
of a re-entrant circuit resulting in ventricular tachyarrhythmia
(89,97), and there is evidence for altered sodium channel function-
ing in some drug-induced forms of long QT syndrome (98–101).
QT prolongation is also regarded as a general correlate of car-
diac instability that is associated with arrhythmias other than TdP
(89,102,103), and with multiple risk factors relevant to the present
study including bradycardia, coronary artery disease, dilated cardio-
myopathy, recent myocardial infarction, ventricular hypertrophy,
and liver disease (89,104). Bradycardia has been reported in
humans in association with the ingestion of ibogaine in medical
(88,105) and nonmedical (106) settings, and in some preclinical
studies (33,36,107,108). The frequently altered nutritional status of
substance abusers puts them at risk of hypomagnesemia and hypo-
kalemia (90), which are associated with QT prolongation, as are
bulimia and anorexia (109). Methadone is associated with QT pro-
longation, particularly in the presence of other drugs (110). Alcohol
or cocaine use is associated with prolongation of the QT interval
both acutely (111,112) and during withdrawal (113–115). In
patients with alcohol dependence, QT prolongation has been
observed to persist for 7 days after the last intake of alcohol (116),
and withdrawal seizures contribute further independent and additive
risk (114). Epileptic seizures, even in the absence of substance use
or withdrawal, are an independent risk factor for QT prolongation
A case report of QT prolongation and ventricular arrhythmia in
association with the ingestion of T. iboga alkaloid extract (118)
illustrates the variety of potential arrhythmogenic factors in the
clinically uncontrolled settings in which ibogaine has been used.
The patient survived in that case, which is not included in this pres-
ent series. The patient had taken ‘‘Indra,’’ an apocryphal brand of
alkaloid extract that subsumes multiple sources of diverse origin,
composition, and conditions of storage (67). Multiple confounding
risk factors for QT prolongation and ventricular arrhythmia were
present. The patient had presented with a witnessed generalized
tonic-clonic seizure (GTCS) in the setting of acute alcohol with-
drawal with hypomagnesemia and hypokalemia. Although the
report made no mention of toxicological testing for illicit drugs, the
patient had a prior history of cocaine abuse and a history of buli-
mia and had been purging prior to admission.
Bradycardia is a functional effect of potential medical signifi-
cance that could possibly involve muscarinic cholinergic transmis-
sion. Ibogaine binds with reported affinities in the 10–30 lM range
to M1 and M2 muscarinic cholinergic receptors and is generally
assumed to act as an agonist (1,2); however, functional studies have
not been performed. Although ibogaine is concentrated in brain tis-
sue relative to serum in the animal model (119) and in the two
cases reported here that reported on brain levels (cases #3 and
#13), an older literature (120,121), as well as more recent data
(122), indicates that the inhibition of acetylcholinesterase by
ibogaine in vitro is negligible over the range of ibogaine concentra-
tionsobservedinbothbloodandbrain in this series. It is unclear
whether the apparent association of ibogaine with bradycardia could
possibly be related to orthosteric agonist actions at muscarinic cho-
linergic receptors, or to effects involving sodium channels (123) or
other signal transduction pathways.
Pulmonary thromboembolism (PE) was the reported cause of
death in three deaths (cases #7, #12, and #18) all of which
occurred in Mexico. Two were not under direct observation at the
time of the death. In all three of these cases, autopsy reports were
inadequate as a basis for the determination of a proximate cause of
death due the lack of evidence of systematic examination of the
lungs and pulmonary vasculature. In Mexico, the death certificate
provides the clinical conclusion reached by the physician who pro-
nounced the death. In case #18, the attending physician patient
observed the patient directly and based the clinical diagnostic
impression of PE on acute dyspnea, tachypnea, and desaturation
indicated by pulse oximetry. Although an adequate autopsy is lack-
ing, the clinical picture mentioned previously is frequently seen
with PE (124), and in instances where there is verification by a
subsequent autopsy, the prospective clinical diagnosis of PE is less
commonly falsely positive than falsely negative (125). The dece-
dent had a family history of PE, and if he did indeed die from
venous thrombotic disease, the family history suggests a possible
etiological contribution because of genetic risk (126). Other possi-
ble risk factors for PE include travel to the treatment location (127)
and or inactivity and immobility during the treatment (128). Intra-
venous drug use is a risk factor for deep venous thrombosis
(129–131), and hence for PE, and appears to be associated with
injection per se, independent of the use of opioids versus other
substances (132).
In this series, there appeared to be no clinical or postmortem evi-
dence suggestive of a characteristic syndrome of neurotoxicity. Ib-
agonist activity potentiates excitatory transmission in
the olivocerebellar projection, where the redundancy of inputs to
cerebellar Purkinje cells renders them vulnerable to excitotoxic
injury (133,134). This is believed to be the mechanism of degener-
ation of cerebellar Purkinje cells observed in rats given substan-
tially larger dosages of ibogaine than those used to study drug self-
administration and withdrawal (135). Subsequent research found no
evidence of neurotoxicity in the primate (65) or mouse (136) at
dosages that produced cerebellar degeneration in the rat, or in the
rat at dosages used in studies of drug self-administration and with-
drawal (137). Neuropathological examination revealed no evidence
of degenerative changes in a woman who had received four sepa-
rate doses of ibogaine ranging between 10 and 30 mg kg over a
15-month interval prior to her death due to a mesenteric artery
thrombosis with small bowel infarction 25 days after her last inges-
tion of ibogaine (65).
In one fatality in this series, a GTCS occurred (case #10), which
might have been due to alcohol or benzodiazepine withdrawal. In
another death (case #14), a brain neoplasm might have explained
the possibility of complex partial seizures mentioned in the autopsy
report. The neurodegeneration observed in the rat following high
dosages of ibogaine has mainly involved the cerebellum (134,135),
which is an unlikely location for a seizure focus in humans. Sei-
zures originating from the cerebellum in humans appear to be lim-
ited to rare instances in which a focus is located in a tumor mass
distinct from normal cerebellar tissue, most commonly a gangliogli-
oma (138). Furthermore, cerebellar stimulation is viewed as a pos-
sible antiepileptic treatment (139), and ibogaine has been observed
to protect against convulsions in animal models (140–142), which
has been attributed to NMDA antagonist activity. Ibogaine causes
serotonin release in selected brain regions in the animal model
(49), and seizures are sometimes seen in serotonin syndrome (143),
but characteristic features of serotonin syndrome such as hyperther-
mia or rigidity were not present and a clinical picture suggestive of
serotonin syndrome does not appear to have been evident in this
The apparent potentiation of both the analgesic (22,38,39,43–47)
and toxic (33,37–39) effects of opioids by ibogaine may be medi-
ated by enhanced transduction of signaling via opioid receptors
(40), which might have been a factor in deaths involving the use
of opioids in temporal proximity to the ingestion of ibogaine. In
one fatality (case #2), it appeared that the decedent smoked heroin
following ibogaine treatment and shortly before death (6). Toxico-
logical analysis detected a low morphine concentration that none-
theless was in the range measured in human subjects within
30 min after inhalation of volatilized heroin (144), similar to the
the dragon’’ (145), and suggests possible potentiation of opioid tox-
icity by ibogaine in this death. Ibogaine increases cocaine-induced
stereotypic motor behavior in the animal model (146), suggesting
that ibogaine might also potentiate the toxicity of stimulants as
well as opioids.
Postmortem toxicological analysis detected commonly abused
drugs in eight of the 11 cases in which toxicological analysis was
performed in this series. When considering a drug intoxication
death because of multiple substances, it usually is not possible to
differentiate the individual roles and complex interactions of these
substances in causing the death. These deaths typically are certified
as intoxications because of the combined effects of all substances
detected. Therefore, it is not possible to determine whether the
deaths in which drugs of abuse were detected were because of ib-
ogaine alone, to one or more of the drugs of abuse, or a combina-
tion. There is also a general effect of the number of abused
substances, with a larger number associated with a greater risk of
death independent of the identity of specific substances involved
(147). The unexplained variance of lethal outcome as a function of
dose further adds to the difficulty of the determination of causality
for ibogaine and drugs of abuse. For example, morphine concentra-
tions associated with heroin overdose overlap substantially with
concentrations obtained from living current heroin users (148),
which may relate to the wide ranges of tolerance among opioid-
dependent individuals, and within the same individual at different
time points.
Systemic disease is a confounding factor that contributes to the
mortality associated with substance use and further complicates the
identification of the cause of death.Theriskofdeathmayrepresent
a complex interaction involving a substance of abuse against a
backdrop of systemic medical illness related to addiction. For
example, the risk of death from opioid overdose is associated with
cardiac hypertrophy and atherosclerotic disease (149), which were
contributing conditions in this case series and which in turn are
associated with a history of methamphetamine and cocaine use
(150,151). The role of advanced preexisting medical comorbidities
in this series of fatalities appears to be an instance of a more gen-
eral association between systemic disease and risk of fatal overdose
The reported elimination half-life of ibogaine in humans is on
the order of 4–7 h (7,70), and that of noribogaine is apparently
longer (7,35). Ibogaine is relatively lipophilic and accumulates pref-
erentially in tissues containing a high density of lipids, such as
brain or fat (119). Ibogaine undergoes demethylation to noribogaine
via cytochrome P450 2D6 (CYP2D6) (152), which is expressed in
the brain (153), where noribogaine may be ‘‘trapped’’ because it is
more polar than ibogaine and may cross the blood–brain barrier
more slowly. Postmortem redistributionofdrugsanddrugmetabo-
lites may occur due to passive drug release from drug reservoirs,
cell autolysis, and putrefaction (154,155). In the three instances in
which peripheral and cardiac concentrations of ibogaine were
reported (cases #2, #6, and #13), the concentrations from the femo-
ral and cardiac or vena cava sites were similar. However, the two
that reported noribogaine concentrations (cases #2 and #13) demon-
strated evidence for postmortem redistribution of noribogaine with
ratios of c. 3:1 between cardiac and peripheral blood. The one
instance that reported ibogaine concentrations at two time points
(case #16) indicated 0.65 mg L in blood at autopsy and 1.27 mg L
days following death.
The available data do not provide a basis for a reliable estimate
of toxic concentrations of ibogaine. In humans administered fixed
oral doses of ibogaine of 10 mgkg, mean peak blood levels were
0.74 € 0.08 and 0.90 € 0.17 mg L in extensive and poor CYP2D6
metabolizers, respectively (7). In series of cases reported here, the
mean dosage was 14.3 € 6.1 mg kg (range 4.5–29 mg kg), and
the mean blood level was 2.38 € 3.08 mgL. The presence of coin-
toxicants and comorbidities, difference in dosages used, and the
higher variance in dosages and blood levels in the present series
does not provide for a meaningful comparison regarding a lethal
dosage or level in humans.
In the rat, the animal model that is predominantly used in
research on ibogaine, the dose that is usually used in models of
drug self-administration and opioid withdrawal is 40 mgkg admin-
istered intraperitoneally (i.p.) (1,2). This dose is approximately one-
third of the LD
of ibogaine administered i.p. (33), which in turn
is approximately one-half to one-third of the LD
by the intraga-
stric route of administration (33,156). The animal data indicate a
significant effect of abused substances on toxicity associated with
ibogaine (33,37–39), and taken together with the clinical evidence
for the effect systemic disease on fatal overdose (149) suggests that
interactions involving cointoxicants and medical comorbidities pre-
clude a reasonable estimate regarding a lethal dosage or level of ib-
ogaine in humans.
Cointoxicants or contributing medical comorbidities were not
reported in only two fatalities for which there were an adequate
postmortem examination and toxicological analysis (cases #4 and
#13). These two deaths involved the ingestion of crude alkaloid
extract in one case, and root bark in the other. The overall compo-
sition, age, and origin of these sources of ibogaine are unknown.
The iboga alkaloid content of T. iboga root bark extracts depends,
among other factors, on the extraction method. The total alkaloid
content of the root bark is c. 2–8% of the dry weight of the root
bark, about half of which is iboga alkaloids, 80% of which is ib-
ogaine (157,158). Utilization of water-soluble extractants yields an
extract with an alkaloid fraction composed of c. 40% ibogaine,
10% related iboga alkaloids, and 50% other alkaloids, whereas uti-
lization of an organic solvent such as acetone or methanol yields
a total alkaloid fraction with relatively less non-iboga alkaloid con-
tent (157). Other iboga alkaloids that co-occur with ibogaine in
T. iboga root bark include ibogamine, ibogaine, tabernanthine, and
voacangine (157–159) (see Fig. 1). The overall iboga alkaloid
composition of T. iboga alkaloid extracts may range from c. 15%
to 50% (157) (C. Jenks, personal communication). Sources of ib-
ogaine HCl are restricted and tend to be known to providers,
and certificates of analysis have generally been available and
corroborated when verified by independent laboratories, which up
to the present time has distinguished ibogaine from the counterfeit-
ing and adulteration seen with commonly abused ‘‘street’’ drugs
Inexperience and lack of information regarding the use of ethno-
pharmacological forms of ibogaine may itself constitute a salient
domain of risk, independent of the uncertain composition of alka-
loid extracts and the undefined potential toxicity of the alkaloids
that co-occur with ibogaine in T. iboga root bark. For example,
one decedent (case #13) (70) may have ingested an amount of
dried T. iboga root bark in excess of that which would typically be
given in a full Bwiti initiation ceremony (5). The blood ibogaine
concentration in this case was the second highest in the series, even
though it was measured an estimated 53 h after ingestion, and does
not take into account the likely presence of other alkaloids. This
case additionally suggests that the bioavailability of the alkaloid
content of dried root bark may be high.
The incidence of fatalities may have decreased in the recent past.
As indicated in Table 1, in 2008, there were no known fatalities,
and in 2007, there were 2. In contrast, there were a total of nine
fatalities that occurred in 2005 and 2006. It is unlikely that this
reflects a decline in the number of individuals treated, which
appears to be continuing the trend of growth evident over the last
decade (5). Greater recognition of medical risk on the part of treat-
ment providers may have been a factor in the apparent reduction in
the incidence of fatalities. Pretreatment screening including basic
blood chemistries and EKG, the exclusion of patients with signifi-
cant medical, particularly cardiac illness, and the recognition of the
need to stabilize physical dependence on alcohol and benzodiaze-
pines prior to ibogaine treatment has gradually become more
widely accepted norms in the settings of ibogaine use (161). This
might to a significant extent reflect the collective, cumulative expe-
rience of the fatal outcomes presented here.
In conclusion, in this series of 19 cases, advanced preexisting
medical comorbidities, which were mainly cardiovascular, and or
one or more commonly abused substances explained or contributed
to the death in 12 of the 14 cases for which adequate postmortem
data were available. Significant factors in this series appear to
include preexisting medical, particularly cardiovascular disease,
possible PE, drug use during treatment, seizures associated with
withdrawal from alcohol and benzodiazepines, and the uninformed
use of ethnopharmacological forms of ibogaine.
We gratefully acknowledge the valuable assistance of How-
ard Lotsof in identifying cases and providing documents.
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... Individuals in this review received between 0.28 mg/kg (Glue, Lockhart, et al., 2015) and up to 55 mg/kg of ibogaine (Noller et al., 2018). Severe adverse events and fatal outcomes associated with the ingestion of iboga/ibogaine have appeared in the literature (dos Santos et al., 2016;Schep et al., 2016;Alper et al., 2012;Corkery, 2018;Grogan et al., 2019;Steinberg & Deyell, 2018). Among the 24 studies included here, we identified two reported fatalities (Alper et al., 1999;Noller et al., 2018). ...
... In addition to the two fatalities among the included literature, we identified another 56 deaths or emergencies associated with ibogaine use that did not meet inclusion criteria for this review. After cross-checking for duplicates in previously published systematic analyses of cases (Alper et al., 2012;Corkery, 2018;Koenig & Hilber, 2015;Litjens & Brunt, 2016) we found a total of 58 ibogaine-associated emergencies (n = 20) and deaths (n = 38). In 34.5% of these cases concomitant drug use was documented and in 70.7% ibogaine was administered with the intention of treating OUD. ...
... In 34.5% of these cases concomitant drug use was documented and in 70.7% ibogaine was administered with the intention of treating OUD. Most of the ibogaine-related adverse events were accompanied by cardiac arrhythmias as published previously (Alper et al., 2012;Corkery, 2018;Koenig & Hilber, 2015;Litjens & Brunt, 2016). However, in one obj. ...
Background Iboga and its primary alkaloids, ibogaine and noribogaine, have been of interest to researchers and practitioners, mainly due to their putative efficacy in treating substance use disorders (SUDs). For many SUDs, still no effective pharmacotherapies exist. Distinct psychoactive and somatic effects of the iboga alkaloids set them apart from classic hallucinogens like LSD, mescaline, and psilocybin. Aims The study team performed this systematic review focusing on clinical data and therapeutic interventions involving ibogaine and noribogaine. Methods The team conducted a search for all publications up to December 7, 2020, using PubMed and Embase following PRISMA guidelines. Results In total, we identified 743 records. In this review, we consider 24 studies, which included 705 individuals receiving ibogaine or noribogaine. This review includes two randomized, double-blind, controlled clinical trials, one double-blind controlled clinical trial, 17 open-label studies or case series (including observational or retrospective studies), three case reports, and one retrospective survey. The published data suggest that ibogaine is an effective therapeutic intervention within the context of SUDs, reducing withdrawal symptoms and craving. Data also point toward a beneficial impact on depressive and trauma-related psychological symptoms. However, studies have reported severe medical complications and deaths, which seem to be associated with neuro- and cardiotoxic effects of ibogaine. Two of these fatalities were described in the 24 studies included in this review. Conclusion Treatment of SUDs and persisting comorbidities requires innovative treatment approaches. Rapid-onset therapies such as the application of ibogaine may offer novel treatment opportunities for specific individuals. Rigorous study designs within medical settings are necessary to warrant safe application, monitoring, and, possibly, medical intervention.
... In this regard, two systematic reviews evaluated reports of fatalities or serious adverse events related to iboga/ibogaine use (Alper et al. 2012;Koenig and Hilber 2015), while a third review also analyzed the anti-addictive potential of ibogaine (dos Santos et al. 2016). Alper et al. (2012) collected the ibogaine-associated fatalities (n = 19) reported between 1990 and 2008, while Koenig and Hilber (Koenig and Hilber, 2015) collected the fatalities (n = 3) and serious adverse events (n = 8) associated with ibogaine reported between the years 2009-2014. ...
... In this regard, two systematic reviews evaluated reports of fatalities or serious adverse events related to iboga/ibogaine use (Alper et al. 2012;Koenig and Hilber 2015), while a third review also analyzed the anti-addictive potential of ibogaine (dos Santos et al. 2016). Alper et al. (2012) collected the ibogaine-associated fatalities (n = 19) reported between 1990 and 2008, while Koenig and Hilber (Koenig and Hilber, 2015) collected the fatalities (n = 3) and serious adverse events (n = 8) associated with ibogaine reported between the years 2009-2014. All the cases came from case reports in which ibogaine were used in non-controlled settings, including private residences or private ibogaine clinics. ...
... All the cases came from case reports in which ibogaine were used in non-controlled settings, including private residences or private ibogaine clinics. Cases reported by Alper et al. (2012) consisted of 15 men and 4 women aged 24 to 54 years (mean 39.1 years). There were 8 men and 3 women aged 25 to 63 years (mean 38 years) in cases collected by Koenig and Hilber (2015). ...
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Context Ibogaine is the main alkaloid of the African shrub Tabernanthe iboga. It produces hallucinogenic and psychostimulant effects, but it is currently known for the anti-addictive properties. Despite the potential therapeutic effects, several cases of fatalities and serious adverse events related to ibogaine/noribogaine use can be found in the literature. Most studies consist in case reports or were conducted under non-controlled settings, so causation cannot be clearly established. Objectives To update (2015–2020) the literature on the adverse events and fatalities associated with ibogaine/noribogaine administration. Methods Systematic review following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). Results Eighteen studies were included in the final selection. Highly heterogeneous results were found in terms of kind of product used or the known dosages. The adverse events were classified in acute effects (< 24 h), mainly cardiac (the most common was QTc prolongation), gastrointestinal, neurological, and clinical alterations, and long-lasting effects (> 24 h), mainly persistent cardiac alterations, psychiatric, and neurological signs. Conclusions There is a high need of phase I clinical trials that can describe the safety of different dosages of ibogaine with standardized products. Further research should perform clinical profiling of vulnerable populations, and design effective screening methods and clinical procedures.
... While it is touted for its potent addiction interrupting properties, especially with opioids, several cardiac-related deaths have been reported with ibogaine use. It appears that the presence or absence of withdrawal symptoms secondary to substance use disorders, individual pharmacokinetics (CYP2D6 phenotype), dose of ibogaine administered, concurrent drug use, and preexisting medical conditions may all substantially influence the safety of ibogaine (Alper, Stajic, & Gill, 2012). Therefore, while psychological risk precautions are similar to other psychedelic-assisted psychotherapy modalities, additional medical precautions are warranted to reduce physiological risks associated with ibogaine use. ...
... Several case reports have documented severe neurological adverse effects such as muscle spasms, tonic-clonic seizures, decorticate posturing, and coma with permanent cognitive deficits after ibogaine use (Alper et al., 2012;Litjens & Brunt, 2016). ...
... Cardiotoxicity is a well-documented and severe adverse effect associated with the use of ibogaine or iboga. Ibogaine binds to the hERG potassium channel on cardiac myocytes, which can prolong the QTc interval and increases the risk of monomorphic ventricular tachyarrhythmias such as torsades de pointes (TdP) (Alper et al., 2012(Alper et al., , 2016. In a dose-response study of noribogaine in opioid-dependent persons (n = 27), there was a dose-dependent effect on the QTc interval with average increases of ~16, 28, and 42 milliseconds (msec) in the 60, 120, and 180 mg dose groups, respectively. ...
In an attempt to comprehensively review the adverse effects of psychedelics, toxicology literature associated with unsafe recreational environments was also selectively reviewed for reports of adverse effects that may be generalizable to a therapeutic setting, but more robust evidence from clinical trial research is emphasized in this chapter.
... When consuming, users experience stimulating and aphrodisiac properties, trance, energization and increased alertness [94,163]. The consumption of this substance also causes hallucinations that, in contrast to common hallucinogens, are more intense and realistic when experienced with closed eyes [162]. Despite the structure of ibogaine being similar to other hallucinogens, this compound has a different mode of action [162]. ...
... The consumption of this substance also causes hallucinations that, in contrast to common hallucinogens, are more intense and realistic when experienced with closed eyes [162]. Despite the structure of ibogaine being similar to other hallucinogens, this compound has a different mode of action [162]. So far, its mechanism of action is not fully known, but it is known that it is able to act as an agonist of σ2 receptors and an antagonist of nicotinic α3β4 acetylcholine receptors and as an antagonist at N-methyl-d-aspartatetype (NMDA) glutamate receptors [164,165]. ...
... Throughout history, the extract of T. iboga has been used for other purposes, namely for fatigue and depression [166]. Currently, ibogaine is used in opioid detoxification [94,162]. Thus, this compound is legal in most countries, however, in Switzerland, Belgium, Australia, Sweden, France, Denmark and the United States of America, it is illegal [162]. ...
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The consumption of new psychoactive substances (NPSs) has been increasing, and this problem affects several countries worldwide. There is a class of NPSs of natural origin, consisting of plants and fungi, which have a wide range of alkaloids, responsible for causing relaxing, stimulating or hallucinogenic effects. The consumption of some of these substances is prompted by religious beliefs and cultural reasons, making the legislation very variable or even ambiguous. However, the abusive consumption of these substances can present an enormous risk to the health of the individuals, since their metabolism and effects are not yet fully known. Additionally, NPSs are widely spread over the internet, and their appearance is very fast, which requires the development of sophisticated analytical methodologies, capable of detecting these compounds. Thus, the objective of this work is to review the toxicological aspects, traditional use/therapeutic potential and the analytical methods developed in biological matrices in twelve plant specimens (Areca catechu, Argyreia nervosa, Ayahuasca, Catha edulis, Datura stramonium, Lophophora williamsii, Mandragora officinarum, Mitragyna speciosa, Piper methysticum Forst, Psilocybe, Salvia divinorum and Tabernanthe iboga).
... Regardless, these days iboga extract is widely misused as an alternative remedy in anti-addiction medical settings. Its unregulated use in opioid withdrawal is associated with serious side effects and sudden deaths [1,3]. ...
... In most of ibogaine-related deaths, the results of toxicological analysis showed the presence of a spectrum of common drugs of abuse, in addition to ibogaine. Bearing this in mind, in these cases the cause of death will certainly be certified as a typical multidrug intoxication [3]. ...
... Another important issue concerning sudden ibogainerelated deaths is the lack of dosage regulation that could be used in cases of ibogaine consumption and its toxic effects. Namely, the relevant scientific data suggest that, although blood concentrations of ibogaine ranged between 0.24 and 9.3mg/L, in all cases sudden death was associated with much lower ibogaine concentrations, predominantly related to withdrawal therapy [3]. ...
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Ibogaine is a psychotropic indole alkaloid extracted from the roots of the Tabernanthe iboga shrub from the Apocynaceae family. Depending on the taken dose, it can lead to stimulant effects, euphoria, visual and auditory hallucinations, along with auditory, olfactory, and gustatory synesthesia. In addition to its historical usage in spiritual rituals of African tribes, these days iboga extract presents a prohibited, alternative drug widely used as a part of addiction treatment. Ibogaine used in opioid withdrawal is associated with serious side effects and sudden deaths. Besides its main use as an anti-addiction medication in alternative medicine, in moderate doses (from 100mg to 1g) ibogaine most commonly causes a “trance-like state”. In this paper, we report the case of a heroin addict who died suddenly 5-12 hours after oral ingestion of powder labeled Tabernanthe iboga which had been bought online and used in the process of detoxification during an addiction treatment. The man was found dead in a rented apartment, where he was undergoing the addiction treatment. External examination revealed no lesions other than nonspecific injuries on the legs. The autopsy showed congestion of internal organs and pulmonary edema. Histopathological analysis of the heart showed neither macroscopic nor microscopic abnormalities. The concentration of ibogaine was 3.26mg/L. Moreover, systematic toxicological analyses of biological samples showed the presence of morphine and codeine. These data suggest that death, which occurred unnaturally after initiation of the “treatment”, was probably the result of the cardiovascular effects caused by the ibogaine powder. The presented case highlights the worldwide problem of various products being widely available over the internet and the danger associated with consumption thereof.
... Regarding the toxicity profile of bioactive constituents of Tabernaemontana species such as ibogaine, including deaths associated with their ingestion, it is likely that this has hampered subsequent clinical research on the anti-addictive properties of ibogaine (Brown, 2013). Some clinical and postmortem evidence did not suggest a characteristic syndrome of neurotoxicity (Alper et al., 2012). ...
... A forensic analysis of ibogaine fatality revealed the presence of other drugs in the body, such as methadone and diazepam, in which concentrations of ibogaine measured in the peripheral and subclavian blood, urine, and gastric fluid samples taken during the autopsy were 0.65, 1.27, 1.7, and 53.5 μg/mL, respectively (Alper et al., 1994). Other apparent risk J o u r n a l P r e -p r o o f factors include seizures associated with withdrawal from alcohol and benzodiazepines and the uninformed use of ethnopharmacological forms of ibogaine (Alper et al., 2012). Intoxication with the herbal substance ibogaine alone in a 22-year-old white man after taking a cumulative dose of 38 g (taken in two doses) resulted in visual memories, nausea and vomiting with a generalized tonic-clonic seizure (Breuer et al., 2015). ...
Several Apocynaceae species, most notably Tabernanthe iboga, Voacanga africana and many Tabernaemontana species, produce ibogan-type alkaloids. Although a large amount of information exists about the Tabernaemontana genus, knowledge concerning chemistry and biological activity remains lacking for several species, especially related to their effects on the central nervous system (CNS). The aim of this study was to evaluate the effect of Tabernaemontana arborea Rose ex J.D.Sm. (T. arborea) hydroalcoholic extract (30, 56.2 and 100 mg/kg, i.p.) and two of its main alkaloids (ibogaine and voacangine, 30 mg/kg, i.p.) on electroencephalographic (EEG) activity alone and in the presence of the chemical convulsant agent pentylenetetrazole (PTZ, 85 mg/kg, i.p.) in mice. EEG spectral power analysis showed that T. arborea extract (56.2 and 100 mg/kg) and ibogaine (30 mg/kg, i.p.) promoted a significant increase in the relative power of the delta band and a significant reduction in alpha band values, denoting a CNS depressant effect. Voacangine (30 mg/kg, i.p.) provoked an EEG flattening pattern. The PTZ-induced seizures were not modified in the presence of T. arborea, ibogaine, or voacangine. However, sudden death was observed in mice treated with T. arborea extract at 100 mg/kg, i.p., combined with PTZ. Because T. arborea extract (100 mg/kg, i.p.) and ibogaine (30 mg/kg, i.p.), but not voacangine (30 mg/kg, i.p.), induced paroxysmal activity in the EEG, both were explored in the presence of a serotonin 5-HT1A receptor antagonist (WAY100635, 1 mg/kg, i.p.). The antagonist abolished the paroxysmal activity provoked by T. arborea (100 mg/kg, i.p.) but not that observed with ibogaine, corroborating the participation of serotonin neurotransmission in the T. arborea effects. In conclusion, high doses of the T. arborea extract induced abnormal EEG activity due in part to the presence of ibogaine and involving serotonin 5-HT1A receptor participation. Nevertheless, other possible constituents and mechanisms might participate in this complex excitatory activity that would be interesting to explore in future studies.
... The transport of all test compounds was within the linear range al., 2012; Steinberg and Deyell, 2018;Vlaanderen et al., 2014). Since in most case reports ibogaine administered to the patients was internet-purchased with unknown purity, the reported doses were converted to effective doses by multiplying with the lower (15%) and upper value (50%) of purity reported in Alper et al. (2012). The predicted dose-response curve of noribogaine for the validation was made using the body weight 81.9 kg, which was the average body weight of subjects as reported in Glue et al. (2016). ...
... In the current paper, the electrophysiological cardiotoxicity of ibogaine and noribogaine was assessed using hiPSC-CMs on a MEA platform, which has been used previously for detecting drug-induced QTc prolongation and proarrhythmia (Shi et al., 2020a,b;Satsuka and Kanda, 2020). The results reveal that ibogaine and noribogaine prolong the FPDc in a concentration-dependent manner, which could be explained by their inhibitory (Alper et al., 2012). Dots in (b) represent the in vivo dose-response data for noribogaine reported in Glue et al. (2016). ...
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The development of non-animal based New Approach Methodologies (NAMs) for chemical risk assessment and safety evaluation is urgently needed. The aim of the present study was to investigate the applicability of an in vitro in silico approach to predict human cardiotoxicity of the herbal alkaloid ibogaine and its metabolite noribogaine, being promising anti-addiction drugs. PBK models were developed using in silico-derived parameters and biokinetic data obtained from in vitro liver microsomal incubations and Caco-2 transport studies. Human induced pluripotent stem cell-derived cardiomyocytes combined with the multi-electrode array (MEA) assay were used to determine in vitro concentration-dependent cardiotoxicity reflected by prolongation of field potential duration, which was subsequently translated to in vivo dose-dependent QTc prolongation using PBK model based reverse dosimetry. Results showed that the predictions matched well with available in vivo kinetic data and QTc data for ibogaine and noribogaine available in literature, indicating a good performance of the NAM. Benchmark dose analysis of the predicted dose response curves adequately predicted the onset of in vivo cardiotoxicity detected by QTc prolongation upon oral exposure to ibogaine and noribogaine. The present study provides an additional proof of principle of using PBK modeling-based reverse dosimetry as a NAM to predict human cardiotoxicity.
... Toxicity. According to a review by Alper, Staajic, and Gill (2012), data for 19 published human fatalities associated with the use of ibogaine contribute to concerns about its clinical use. Ibogaine presents complex pharmacokinetics, rendering it safest when administered under medical supervision following robust screening. ...
... Ibogaine presents complex pharmacokinetics, rendering it safest when administered under medical supervision following robust screening. Reports of ibogaine fatalities often lack information on the quantities of ibogaine or noribogaine present in the blood during autopsy (for review, see Alper et al., 2012). In some instances, such as the New Zealand study where ibogaine was administered to humans under medical supervision, one person died (Noller et al., 2017). ...
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Ibogaine is a psychoactive alkaloid contained in the West African plant Tabernanthe iboga . Although preliminary, evidence suggests that ibogaine could be effective in the treatment of certain substance use disorders, specifically opioid use disorder. This narrative review concentrated on the pharmacological, cultural and psychological aspects of ibogaine that contribute to its reputed effectiveness with a specific focus on the ibogaine state of consciousness. Although the exact pharmacological mechanisms for ibogaine are still speculative, the literature highlighted its role as an NMDA antagonist in the effective treatment of substance use disorders. The cultural aspects associated with the use of ibogaine pose questions around the worldview of participants as experienced in the traditional and western contexts, which future research should clarify. From a psychological perspective, the theory that the ibogaine state of consciousness resembles REM sleep is questionable due to evidence that indicated ibogaine supressed REM sleep, and contradictory evidence in relation to learning and memory. The suggested classification of the ibogaine experience as oneirophrenic also seems inadequate as it only describes the first phase of the ibogaine experience. The ibogaine experience does however present characteristics consistent with holotropic states of consciousness, and future research could focus on exploring and potentially classifying the state of consciousness induced by ibogaine as holotropic.
... Concerns about the safety of ibogaine use have also been reported. Studies have shown ibogaine to be associated with torsades des pointes (TdP) after ingestion of ibogaine [8,9]. In-vitro studies show that ibogaine prolongs repolarization of cardiomyocytes through human Ether-ago-go-related gene (hERG) channel inhibition [10,11]. ...
... The SARA indexes severity of ataxia, often related to cerebellar pathologies. It has eight items (maximum score): gait [8], stance [6], sitting [4], speech [6], finger-chase test [4], nose-finger test [4], fast alternating movements [4] and a heel-shin test [4], with a total maximum score of 40. The heel-shin test was performed while standing. ...
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Background and aims Ibogaine is an indole alkaloid used in rituals of the Bwiti tribes of Africa. It is also used in non‐medical settings to treat addiction. However, ibogaine has been linked to several deaths, mostly due to cardiac events called torsades des pointes preceded by QTc prolongation as well as other safety concerns. This study aimed to evaluate the cardiac, cerebellar and psychomimetic safety of ibogaine in patients with opioid use disorder. Design A descriptive open‐label observational study. Setting Department of psychiatry in university medical center, The Netherlands. Participants Patients with opioid use disorder (n=14) on opioid maintenance treatment with a lasting wish for abstinence, who failed to reach abstinence with standard care. Intervention and measurements After conversion to morphine‐sulphate, a single dose of ibogaine‐HCl 10mg/kg was administered and patients were monitored at regular intervals for at least 24 hours assessing QTc, blood pressure and heart rate, Scale for the Assessment and Rating of Ataxia (SARA, to assess cerebellar side effects) and the Delirium Observation Scale (DOS, to assess psychomimetic effects). Findings The maximum QTc prolongation was on average 100ms (range 40‐168ms). Fifty percent of subjects reached a QTc of over 500ms during the observation period. In six out 14 subjects prolongation above 450ms lasted beyond 24 hours after ingestion of ibogaine. No torsades des pointes were observed. Severe transient ataxia with inability to walk without support was seen in all patients. Withdrawal and psychomimetic effects were mostly well‐tolerated and manageable (11/14 did not return to morphine within 24 hours, DOS scores remained below threshold). Conclusions An open‐label observation study found that ibogaine treatment of patients with opioid use disorder can induce a clinically relevant but reversible QTc prolongation, bradycardia, and severe ataxia.
... [111][112][113][114] Ibogaine has also been implicated in fatal cases of cardiomyopathy, QT prolongation, and ventricular arrhythmias, and cardiac hypertrophy, mostly in patients with preexisting cardiac issues, which has limited its use in the United States in the treatment of opioid use disorder. 115,116 Additional fatal cases of cardiotoxicity have been identified following the ingestion of MDMA in patients both with and without preexisting cardiac conditions. Chronic cardiac toxicity associated with hallucinogen use may include cardiomyopathy. ...
Hallucinogens constitute a unique class of substances that cause changes in the user's thoughts, perceptions, and mood through various mechanisms of action. Although the serotonergic hallucinogens such as lysergic acid diethylamide, psilocybin, and N,N‐dimethyltryptamine have been termed the classical hallucinogens, many hallucinogens elicit their actions through other mechanisms such as N‐methyl‐D‐aspartate receptor antagonism, opioid receptor agonism, or inhibition of the reuptake of monoamines including serotonin, norepinephrine, and dopamine. The aim of this article is to compare the pharmacologic similarities and differences among substances within the hallucinogen class and their impact on physical and psychiatric effects. Potential toxicities, including life‐threatening and long‐term effects, will be reviewed.
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Ibogaine is a naturally occurring psychoactive indole alkaloid that is used to treat substance-related disorders in a global medical subculture, and is of interest as an ethnopharmacological prototype for experimental investigation and possible rational pharmaceutical development. The subculture is also significant for risks due to the lack of clinical and pharmaceutical standards. This study describes the ibogaine medical subculture and presents quantitative data regarding treatment and the purpose for which individuals have taken ibogaine. All identified ibogaine "scenes" (defined as a provider in an associated setting) apart from the Bwiti religion in Africa were studied with intensive interviewing, review of the grey literature including the Internet, and the systematic collection of quantitative data. Analysis of ethnographic data yielded a typology of ibogaine scenes, "medical model", "lay provider/treatment guide", "activist/self-help", and "religious/spiritual". An estimated 3414 individuals had taken ibogaine as of February 2006, a fourfold increase relative to 5 years earlier, with 68% of the total having taken it for the treatment of a substance-related disorder, and 53% specifically for opioid withdrawal. Opioid withdrawal is the most common reason for which individuals took ibogaine. The focus on opioid withdrawal in the ibogaine subculture distinguishes ibogaine from other agents commonly termed "psychedelics", and is consistent with experimental research and case series evidence indicating a significant pharmacologically mediated effect of ibogaine in opioid withdrawal.
Pulmonary thromboembolisin (PE) is found commonly in forensic pathology practice, as it typically causes sudden death. It is attributed to a wide variety of predominantly acquired etiologies. Although likely etiologically multifactorial, some common proximate causes include: surgery, pregnancy, injury, inactivity of any cause, cancer, obesity, or serum hyperviscosity. On occasion, no apparent predisposing condition is identified. In these instances, occult hereditary thrombophilias may play a causal role. Deaths referred to the Office of Chief Medical Examiner (OCME) of New York City between December, 2000 and September, 2003 and due to PE were retrospectively reviewed. Molecular analysis (FRET) was performed on selected cases for three common hereditary thrombophilias: mutations in factor V Leiden (FVL), prothrombin G20210A (PT), and methy lenetetrahydrofolate reductase (MTHFR). During the study period, 124 of 15,280 deaths were primarily attributable to PE. Of those, 34 were selected for molecular analysis. One or more mutations were detected in 35% of those, five of which were clearly causally related to death. Given the potential benefits to surviving family members, our data indicate that postmortem molecular testing for the common hereditary thrombophilias is warranted in at least selected cases.