Iboga Compared

People arrive at this comparison for one of two reasons. Either nothing else has worked, or what is working is something they want to stop. Both are reasonable positions, and both deserve the real numbers rather than a verdict.

The first thing to say is the thing least often said.

The table

The number that matters most

If you take one figure from this page, it is not about ibogaine.

Pooling 36 cohort studies covering 749,634 people, a 2021 analysis found that all-cause mortality during opioid agonist treatment was around half what it was out of treatment, at a rate ratio of 0.47 with a confidence interval from 0.42 to 0.53. The same held for suicide, drug-related death, alcohol-related death, cardiovascular death and cancer.

Then it measured what happens when people stop.

Six times, in the first month. That is the window any detoxification opens, whatever the method used to open it, and it is why leaving an agonist to try something unproven is a different kind of decision from adding something to an existing regimen.

The effect is not a historical artefact of a gentler drug supply. A cohort of 55,347 people in British Columbia found that as fentanyl saturated the supply, the relative risk of dying while off treatment rose from 2.1 to 3.4 times. The cost of a gap in treatment is higher now than when the older studies were assembled.

Detoxification, as a category, has been measured

This is the finding most directly relevant to what an ibogaine clinic sells, and it does not concern ibogaine at all.

A study of 40,885 people compared six real-world treatment pathways. Only buprenorphine and methadone reduced overdose, cutting it to roughly a quarter of baseline risk at three months and 41 per cent at twelve.

Inpatient detoxification and residential treatment showed no such reduction.

Ibogaine is not those things and the study did not test it. But the structure of what is being sold, an intensive supervised episode ending in abstinence, is the structure that did not reduce overdose in this data. That is worth knowing before paying for one.

Note also who funded it: six of the eight authors declare employment or funding from the insurer whose claims data this is, and a seventh is affiliated to it. It is disclosed in the paper.

Where the comparison is fairer than people expect

Two honesty points cut the other way.

Methadone is also cardiotoxic. Its US label carries a boxed warning naming QT prolongation and torsade de pointes, the same mechanism that kills people on ibogaine, and noting that cases have occurred at ordinary maintenance doses. The difference is not that one drug affects the heart and the other does not. It is that methadone’s risk is characterised, dose-known, monitored under a regulatory framework, and outweighed by a measured mortality benefit across three quarters of a million people. Ibogaine’s is characterised too, and there is nothing on the other side of the scale yet.

Starting methadone carries its own spike. Mortality in the first four weeks of methadone runs about twice that of the rest of treatment. Buprenorphine does not show that pattern. Neither fact is usually mentioned by people advocating for agonist treatment, and both belong here.

Methadone retains people better than buprenorphine. Across 32 randomised trials covering 5,808 people and 69 observational studies, retention at six months favoured methadone consistently. On most other outcomes the two differ little, and the authors’ own recommendation is that the choice follow the patient’s preference.

The other two comparisons

Ketamine and psilocybin come up constantly, and the honest position on both is narrower than their reputations.

Neither is approved for any substance use disorder, anywhere. Esketamine’s approval covers treatment-resistant depression and depression with acute suicidality, and every intravenous ketamine clinic treating addiction is operating off-label. Psilocybin has no marketing approval in any jurisdiction, and no phase 3 trial has published a result for any indication.

The single meta-analysis of ketamine for substance use disorder found the benefit at under a month and not at one to six months. Ibogaine and ketamine sets out that record. Ibogaine and psilocybin does the same for the other.

What to do with all this

The comparison does not resolve into a recommendation, and this site does not make treatment recommendations. Three things follow from the evidence.

The treatments with the strongest mortality evidence are the ones people are often trying to leave. That tension is real and it is not resolved by pretending the evidence is weaker than it is.

The gap in the ibogaine column is a gap in knowledge, not a proof of failure. Nobody can give you the odds, and what the trials found explains why.

And the highest-risk moment in this whole picture is not the dosing session. It is the weeks afterwards, when tolerance has fallen. When it does not work covers what happened to the people who were followed.