14. Interventions

Basic Treatment Course Interventions

Anxiety / Panic Attacks

Evaluate whether there are corresponding physiological symptoms, and respond accordingly. Then:

  • Work with simple breathing practices to cultivate a sense of calm.
  • Supplementation with GABA can help to calm patients that are experiencing acute anxiety. Administer 750 mg every 30-45 minutes until the the patient becomes calm.
  • Supplement with other GABAergic natural health care products such as L-glutamine, valerian, passionflower, magnesium, can help to stabilize patients that experience frequent anxiety, especially stimulant users.
  • If anxiety persists, benzodiazepines may be administered. Doses of 5 to 10 mg of oral diazepam may be used for benzo-dependent patients. For non-dependent or benzo-naïve patients, .25 to .5 mg of alprazolam is preferred. In some cases, use of alprazolam may provide more acute relief, even in benzo-dependent patients, but watch for peaks and valleys of withdrawals. Refer to previous notes about benzodiazepines (Ch. 4).

Chronic Fatigue

Refer to Depression below.

Chronic Pain

Ibogaine, in threshold doses, has been known to reduce pain. And generally patients do not experience pain during a full dose. However, it is common for pain to emerge afterwards, especially in patients who were treating chronic pain with opiates. Learning to work with pain management effectively is a critical segue to continuing care.

Long-term opioid use is known to cause hyperalgesia, an increased sensitivity to pain (Marion 2011). This may exacerbate chronic pain symptoms in people for whom it either is or is not an underlying condition. If hyperalgesia has been ruled out as a factor, a thorough assessment of pain management options should be explored in collaboration with the patient.

If patient has detoxified from opioids, but continues to experience symptoms of chronic pain, and/or requests for pain medication to be re-administered, opioids can be prescribed under appropriate medical care in minimal possible doses. Patients should counseled about the risks associated with the reduced tolerance, then be discharged and instructed to return to a pain management specialist.

In addition to other adjunct therapies (Ch. 1) effective pain relief has been found from the following:

  • Pay attention to diet and make sure that patient eats nutritious whole foods after treatment. Avoid inflammatory foods such as gluten and dairy.
  • Non-opiate, non-steroidal anti-inflammatories and analgesics, such as ketorolac 30 to 60 mg (sublingual or IV), naproxen 500 mg (oral), 3 mg diclofenac (IM).
  • Spasmolytics such as carisoprodol 250 mg to 700mg oral, tizanidine 2-4mg oral, or baclofen 20 to 40 mg.
  • As well as natural health products such as 1 to 2g curcumin extract, corydalis, 300 to 600 mg calcium/magnesium powder, or a magnesium oil or spray.
  • Analgesic heat rubs such as diclofenac gel, BenGay, or Tiger Balm.
  • .5Mhz of cranial electrotherapy stimulation for 30 minutes, twice daily.

Constipation or Impacted Bowel

It is critical that patient has at last two normal bowel movements prior to administration of ibogaine. Check that bowel sounds are positive in all four quadrants. Make sure patient hydrates, exercises, and eats foods that are high in fiber as well as vegetables and fruits such as papaya. Avoid bananas or white rice for their binding effect. A stool softener such as sennosides can be administered, but avoid other bowel preps or medications that may cause diarrhea or electrolyte loss.

Dehydration

For instructions on how to deal with dehydration during treatment or for serious episodes of acute dehydration, see Dehydration listed under Acute/Emergency Interventions later in this chapter.

If patient becomes dehydrated during the normal course of treatment, attempt to rehydrate orally. About 1 fl. oz. per kg of body weight throughout the day is recommended, or more for physically active people. All hydration done during 24 hours prior to treatment, during treatment, and for at least 72 hours after treatment, should be done with fluids that contain electrolytes such as coconut water or other electrolyte preparation, and not with plain water or other fluids. This will help to maintain electrolyte levels.

Intravenous saline fluids should be administered to pre-emptively treat dehydration in patients who experience an inability to retain fluids orally.

Depression

Depression is a common underlying condition for many people who are looking for ibogaine treatment. Because of ibogaine’s serotonergic activity, many patients experience an elevation in mood. However, occasionally, patients may regress into acute depression in the acute integration period following ibogaine administration, in which case it should be worth noting that this is often part of a healing process. Adjunct therapies to treat depression can be extremely beneficial:

  • Psychotherapeutic support should be available.
  • If appropriate, repeated lower doses of ibogaine can be administered.
  • Many other adjunct therapies have been shown to assist in treating depression (Ch. 1).

Gastrointestinal Conditions

Many people who are seeking ibogaine treatment experience various gastrointestinal conditions. Some providers have reported a decrease in vomiting, gut infections, and related problems (such as not being able to continue administration) through the use of probiotic preparations, and natural and pharmaceutical prophylactic anti-nausea (ginger, diphenhydramine, etc.).

Insomnia

Inability to sleep should be considered a normal response for the first 24 to 35 hours after treatment. Outside of this window however, without proper rest and recovery, it can be very difficult to integrate the ibogaine experience. Prolonged insomnia may precipitate anxiety, mania or acute confusional states.

  • Supplementation with natural health products such as melatonin, GABA, valerian, tryptophan, 5-HTP, etc. can help to balance sleep patterns.
  • Diphenhydramine can be administered to facilitate sleep, as can judicious uses of zolpidem, eszopiclone and zaleplon.
  • If insomnia persists, doses of 5 to 10 mg of oral diazepam may be administered (Ch. 4), but not recommended for longer than 1 to 3 days.

Acute/Emergency Interventions

Acute Alcohol Withdrawal

As an aid in symptomatic relief of acute agitation, tremor, impending or acute delirium tremens and hallucinosis, administer 10mg diazepam IV (preferred) or IM (via shoulder), then 5mg to 10mg in 3 to 4 hours, if necessary.

If signs of delirium tremens persist after the first dose of diazepam, continue to administer and consider calling EMS for transfer to a hospital.

Acute Confusional State

Although very rare, acute confusional states (ACS) have been known to occur after ibogaine administration, especially after long sessions involving relatively high doses. This is characterized by a noticeable psychic break from reality, during which the patient may be fully alert and communicative. This has been known to persist for periods as short as 15 minutes, but sometimes longer than 24 hours. Extreme cases have been reported of up to 14 days. In each of these reported cases patient eventually returned to their normal state.

Avoid using antipsychotic medications to try to stop a bad trip. Halperidol or thorazine will not function as they do to interrupt other psychoactive substances, and can precipitate a very difficult psychological experience that can last for 2-5 days.

Benzodiazepines may be implicated in causing or exacerbating the ACS. However, if this is not considered a factor, benzodiazepines (for example: 5 to 10 mg of diazepam for long-acting effects, or .25 to .5 mg of alprazolam for more acute short acting effects) may be administered very carefully in order to assist in sleep and relaxation.

The transpersonal school of psychotherapy considers that an abrupt chemical intervention may interfere with a natural psychological breakthrough or resolution that may be beneficial to the individual. Several patients have noted that in retrospect the experience was personally valuable. There are no reported cases of permanent psychosis that have ever resulted from experiencing an extended ACS.

The most important factor is to maintain a physically safe space. Patient should be under constant supervision for the complete duration, and should not be discharged until they are able to care for themselves. If care provides are not, or becomes unable, to provide this level of care, then a decision should be made in conjunction with the patient’s emergency contact person about how to proceed, and into which professional services the patient should be discharged.

Allergic Reactions

In the case of mild alergic reaction, 50mg of diphenhydramine can be administered (IM).

For more serious reactions such as facial swelling, IM methylprednisolone is preferable.

For anaphylactic reactions (throat closing) an epinephrine auto-injector should be administered. Patient should be connected to a cardiac monitor, airway should be monitored closely. Call EMS.

Arrhythmias

If extrasystoles are detected, follow ACLS protocols. Be prepared and monitor closely for advanced arrhythmias.

Note that T-wave changes, including flattened T-wave, are normal alterations under the effects of ibogaine. Although this would normally require ACLS intervention, monitor and treat in the event of other arrhythmias.

For ventricular arrhythmias including ventricular tachycardia, ventricular fibrillation, and torsades de pointes, check pulse. If no pulse, defibrillate when indicated. Call EMS and proceed with ACLS protocols.

Note that amiodarone, included in the ACLS guidelines for cardiac arrhythmias, is known to prolong the QT interval and should not be used if ibogaine has been administered.

Asthma Attack

Emergency steroid inhaler should be administered to prevent airway from closing. Cease further administration of ibogaine. Monitor oxygen levels, pulse and blood pressure closely. Continue to check in if they are short of breath.

Steroid medications, which are commonly prescribed for asthma, treatments are known to prolong the QT interval.

Bradycardia

If patient’s pulse is sustained

If bradycardia is symptomatic:

  • Check level of consciousness, BP and pulse oximetry, skin temperature. Give supplemental oxygen if pulse oxygen saturation is
  • Administer a total of 1 L of Hartmann’s Solution or Lactated Ringers IV.
  • Consider giving atropine 0.25-0.5 mg IV every 3-5 min (max dose = 3 mg).
  • Considering calling EMS.
  • If patient does not respond to atropine and is still in symptomatic bradycardia call EMS and continue ACLS protocols.

If bradycardia is not symptomatic and patient is fully responsive, check to see if pulse responds to stimuli like touching their feet, having them sitting up, or walking around the room.

Dehydration

If patient becomes dehydrated due to vomiting or other reasons, or the patient’s tongue is white, administer a total of 1 L of Hartmann’s Solution or Lactated Ringers intravenously. Monitor vital signs more regularly.

Disordered Breathing (can sound like snoring)

Check airway, vital signs and oxygen saturation (see below). This may be a sign that blood is not circulating properly. Check for cardiac arrhythmia (see above).

Feeling Faint

If patient feels faint, check vitals and inquire about other symptoms. Encourage hydration. Sugarcane juice or other source of glucose may help if low blood sugar is a factor.

Headaches

Headaches should be treated with non-steroidal anti-anti-inflammatories such as aspirin and ketorolac. Check for dehydration and hydrate.

Hypotension

If hypotension is due to bradycardia, treat bradycardia.

If not, is it symptomatic? Is it due to hypovolemia? If yes, push oral fluids or administer a total of 1 L of Hartmann’s Solution or Lactated Ringers IV. Monitor vital signs as needed for response. If 1 Liter of IV fluid treatment is ineffective, consider calling EMS.

Opioid Overdose

Call EMS. Begin assisted breathing, and continue until EMS arrives or patient completely stabilizes.

Administer 0.4-2 mg of naloxone IV (preferred), IM (via shoulder), or subcutaneously administered immediately and repeat every 2-3 min. If no response is observed after 10 mg of naloxone hydrochloride have been administered, the diagnosis of opioid induced or partial opioid induced toxicity should be questioned.

It is important to note that naloxone can cause tachycardia, and precipitates withdrawal in opioid dependent patients. Monitor closely after administration.

If necessary, wait to stabilize until possible interactions between ibogaine and stabilizing medication are minimized. Then stabilize the patient (see end of this chapter) and observe closely until able to discharge.

Oxygen Saturation below 92%

Concerns should be raised when oxygen levels drop below 95%. Below 92%, consider supplemental oxygen 2 L per nasal cannula, titrate up as needed to keep oxygen in preferred range. If oxygen saturation cannot be maintained on 1-6 L per minute refer to ACLS protocols or transfer patient to the hospital.

Prolonged QTc interval

If patient registers a dangerously prolonged QTc interval of >500 milliseconds, then patient should be transferred immediately to a hospital for cardiac monitoring and treatment.

Shortness of Breath

If patient experiences shortness of breath, check oxygen saturation (see below).

Status Epilepticus & Recurrent Convulsive Seizures

Call EMS. Administer 5-10 mg of diazepam initially I.V. (preferred) or I.M. (via shoulder). This injection may be repeated if necessary at 10 to 15 minute intervals up to a maximum dose of 30 mg. Be alert that administering IV benzodiazepines may lead to respiratory arrest.

Vomiting

If patient vomits, check the vomit to see if any part of the medicine that has been administered was regurgitated. It may be the case that the capsule has started to decompose. Factor this into considerations about dosing. Monitor vitals more closely and look for signs of dehydration.

If vomiting persists, administer 50mg diphenhydramine (IM) every 6 hours or as needed. Refer to previous notes about anti-nausea medication (Ch. 14).

Reporting Adverse Events

GITA maintains an online Adverse Event Report form that is relevant for all situations that result in hospitalization or fatality. Information submitted is used in order to help keep these guidelines up to date.

Prematurely Terminating Ibogaine Administration

If during the course of interventions ibogaine administration has to be terminated, but the patient is experiencing ongoing withdrawal symptoms (verify using SOWS and OOWS measures), then administer small doses of morphine until withdrawal symptoms have abated, monitor closely, and reassess treatment plan.

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