Editor’s Note: Addiction is rife with misinformation, shame and stigma. “Drug use disorder” is less stigmatising terminology than “drug abuse.” The widespread use of less stigmatising language can help ensure people seek and obtain the treatment they need. In this article we have chosen to use less stigmatising terminology and will do so in further work on this topic.
Drug Use Disorders Are a Public Health Crisis
It is no secret that drug use disorders—and opioid use disorder in particular—are a global public health crisis. Over 35 million people worldwide suffer from drug use disorders. Opioid use disorder is particularly damaging; in 2019, opioid use disorder caused almost 100,000 deaths via overdose and resulted in almost 18 million years of healthy life lost worldwide. In the US alone, 50,000 people died from opioid overdose last year (more than double the number who died in 2010) and opioid use has devastated entire communities. The social isolation, financial hardship, and anxieties brought on by the Covid-19 pandemic have only exacerbated the problem.
It is also not a secret that the healthcare industry has long struggled to treat—let alone cure—substance use disorders. We know there are some effective treatments, such as medication for opioid use disorder (MOUD) coupled with psychosocial treatment and support. These medications work by reducing withdrawal symptoms and opioid cravings. However, there are some limitations—methadone, for example, must be taken every day, sometimes for decades if not forever. Extended-release naltrexone and buprenorphine can be delivered as a monthly injection, alleviating some of these issues, but also require years of commitment and have potential side effects.
Psychedelics and Psychedelic-Assisted Therapy Can Help
Since the link between common prescription of opioids for standard pain management and dangerous levels of misuse is widely acknowledged, we’ve seen progress in areas such as safer prescribing practices and carefully managed alternative pain treatments. A novel form of ketamine therapy uses a wearable patch to deliver clinician-specified doses subcutaneously to make this therapy more widely accessible while still safe and clinician-controlled. The wearable’s controlled dosing—it delivers doses based on the levels of the drug detected in the blood (akin to how an insulin pump works)—also has the benefit of decreasing the potential for misuse, since ketamine’s history of recreational use shows it can be addictive.
Psychedelic-assisted therapy also has the potential to treat substance use disorder. A small randomised control trial published in August 2022 showed psilocybin administered in combination with therapy can decrease heavy drinking in alcohol-dependent patients. A recent review of data from the US National Survey on Drug Use and Health found an association between past use of psilocybin and reduced risk of opioid use disorder. These findings, while cause for optimism, must be reproduced and the studies analysed for rigour. Even though the science is nascent, psilocybin will be available for supervised use at wellness centres in the state of Oregon next year and potentially in the state of Colorado in 2024, pending a vote on a ballot measure later this fall.
Even more promising are observational studies showing that a single application of ibogaine can help patients reduce or cease opioid use. Ibogaine is one of several bioactive alkaloids found in the rootstock of the iboga plant, a perennial shrub native to Central Africa.
More Research Is Needed
Despite powerful anecdotal evidence of ibogaine’s efficacy at treating addiction, there is a dearth of clinical evidence (although some clinical studies are ongoing, for example in Spain) and the drug remains illegal in most of the world. In part, this is because it is dangerous—its uncontrolled ingestion can cause cardiac arrest, among other side effects ranging from severe to unpleasant. However, ibogaine’s potential as a treatment for addiction is one worth paying attention to, especially when advances in biotech mean we can explore exploiting the benefits while minimising the side effects. There are some promising developments already underway in this area: Canada-based biotech company Mindcure is developing a synthetic ibogaine for use in clinical trials and researchers at the University of California, Davis, have developed an non-hallucinogenic analogue without the dangerous side effects.
This approach—of using tech to harness the potentials of badly needed new treatments for life-destroying drug use disorders—has positive co-benefits. For example, synthetic ibogaine reduces wildlife destruction. Elephants love iboga, often leaving trails of half-eaten fruit in their wake. Iboga is known as “the blood diamond” of the psychedelics world because poachers follow these trails, shoot the elephants, dig up the iboga bushes, and sell both the iboga root and ivory tusks. While synthetic ibogaine reduces some of this pressure, it also takes Central Africans out of the profit equation while simultaneously benefiting from the cultural knowledge of Bwiti religious practitioners who have used iboga for years. A combination of regenerative local cultivation and reciprocity initiatives (in which exogenous producers such as biotech companies compensate Central Africans) can address these connected issues while the promising science of ibogaine progresses.
Psychedelic-assisted therapy could potentially treat opioid use addiction as well as the pain for which opioids are commonly prescribed. Novel wearables can increase accessibility of these treatments while decreasing the potential for misuse. But clinical trials so far are small or non-existent. More research must be done and it is down to governments to put the right enabling environments in place to do this.