Scientists at West Virginia University Rockefeller Neuroscience Institute and School of Medicine are pioneering Deep Brain Stimulation (DBS) as a treatment for refractory addiction to opioids and other substances.
The idea of using brain surgery to treat or cure addiction is well over one hundred years old.
As recently as 1952, the Journal of the American Medical Association (JAMA) published a study on the effects of frontal lobotomy on addiction; the authors noted prior clinical findings that lobotomy attenuated opioid withdrawal and reduced or eliminated addictive usage of these drugs.
Ever the Communist pragmatists, Chinese scientists have experimented with a variety of neurosurgical procedures to treat addiction, from traditional frontal lobotomies to techniques that burned away midbrain pleasure centers to Deep Brain Stimulation (DBS) setups very similar to the one that I will be discussing today.
In fact, Chinese scientists pursued such techniques so enthusiastically that the Chinese Communist Party was forced to ban certain procedures in 2004 (article here). The issue is that the surgical protocols employed obliterated swathes of neural tissue that had broad functions in desire, reward, and pleasure, producing wide-reaching, undesirable effects on personality, especially in regard to motivation and contentment.
I don't want to insert myself into this discussion overly much, but I would like to say that - during my 20s, when I was trapped in an endless cycle of relapse, treatment, and temporary recovery, as I was putting everything I had into staying clean and yet I just - could - not - get - it, as I looked around and saw friends from treatment dying left and right of overdoses and suicides - I absolutely would have considered brain surgery as a treatment option.
I doubt that I would now, and I'm not sure that it would have been the right option for me to pursue then. However, given that severe opioid addiction has a prognosis comparable to that of the most deadly cancers, I believe that it is worth investigating even quite invasive, potentially dangerous treatments.
How It Works
The scientists at West Virginia University Rockefeller Neuroscience Institute are using a Deep Brain Stimulation setup that has previously been used to treat Parkinson's and other ailments, most notably Obsessive Compulsive Disorder (OCD).
I say "most notably" in regard to OCD because, as I have articulated elsewhere, there are striking parallels between OCD and addiction in regard to anxiety, compulsion, ritual, and reward. In fact, I often explain addiction to non-addicts who are struggling to understand it as a severe OCD in which disproportionate anxiety and discomfort is alleviated only by the ritual of using, which is repeated despite the accumulation of life-disruptive to life-threatening negative consequences.
In the specific protocol employed by WVU, small electrodes are implanted into a part of the brain known as the striatum, a group of interconnected neural networks in the midbrain, which play a role in motor function as well as emotion, habit formation, and reward.
Specifically, the DBS procedure targets the nucleus accumbens, sometimes referred to as one of the dopaminergic pleasure centers of the brain. There, pleasure from food, drugs, and sex registers and interfaces with higher-order motivation networks as well as motor networks that carry out behaviors designed to obtain more pleasure / reinforcement.
Not surprisingly, there is a good deal of fine-tuning involved. Overstimulation of the area that the electrodes are implanted into creates a manic, euphoric state that can lead to undesirable behavior. Under-stimulation, on the other hand, takes away from the efficacy of the procedure.
It's a delicate balance that is achieved by trial and error. On the basis of the results obtained so far, it seems that there is an optimal level of stimulation at which cravings, anxiety, and depression are greatly reduced, but the subject still feels "normal" rather than artificially elevated.
Risks and Prerequisites
There are very real risks to such an invasive procedure.
It seems that there is about a one percent chance of serious adverse outcomes, including death during surgery, stroke, bleeding in the brain, infection, and other permanently debilitating complications.
This is in line with the risks of the average neurosurgery, and it is very high relative to the risks of most surgical and nonsurgical treatments. (The infamous Brazilian Butt Lift, decried as the deadliest procedure in plastic surgery, has a fatality rate of between 1/2351 and 1/6241 [although the rate of serious complications other than death isn't factored into these figures]).
This means that only the most refractory, life-threatening cases of addiction are suitable for treatment with DBS in its current form. It's also important to keep in mind that even opioid addicts who successfully achieve long-term recovery often do so only after completing inpatient and outpatient treatment multiple times, so it's crucial to differentiate addicts for whom existing pharmacologic and psychological treatments simply do not work from addicts for whom existing treatments have not worked yet.
It's not just the life-threatening complications that merit consideration, either. The brain's pleasure and reward pathways are intricate, complicated systems; they evolved over millions upon millions of years to modulate our behavior in nuanced, intertwined ways.
Tampering with them ventures into Brave New World territory in which we are modifying systems with profound ramifications regarding our motivations, relationships, and spiritual life - and we absolutely don't have a firm handle on the potential, permanent side effects on personality and behavior.
There's also a bit of a paradox involved in terms of which addicts need the procedure versus who will qualify for it. The nature of intractable addiction means that jobs and apartments are lost, relationships decline, support dissipates - in every direction, bridges are burnt; things fall apart.
Unfortunately, such a significant neurosurgery, which necessitates regular, long-term follow-up appointments, demands safe, stable housing where the patient can recuperate. He or she also requires transportation to and from the many follow-up appointments. Moreover, the patient must have the financial security to take extended time off of work without disrupting any of the aforementioned supports.
In short, very few addicts who will benefit from the procedure have stable enough lives to qualify for it. Perhaps someday this can be resolved by developing a type of "halfway house" program for addicts who need the procedure but who don't have the housing and transportation stability necessary to qualify for it.
Outcomes
The results, while far from uniform, have been promising.
In a paper published in the Journal of Neurosurgery in 2023, the results of the small initial cohort were summarized as follows:
"Four male participants were enrolled and all tolerated DBS surgery well with no serious adverse events (AEs) and no device- or stimulation-related AEs. Two participants sustained complete substance abstinence for > 1150 and > 520 days, respectively, with significant post-DBS reductions in substance craving, anxiety, and depression. One participant experienced post-DBS drug use recurrences with reduced frequency and severity. The DBS system was explanted in one participant due to noncompliance with treatment requirements and the study protocol. FDG-PET neuroimaging revealed increased glucose metabolism in the frontal regions for the participants with sustained abstinence only."
I've italicized the final line because it indicates that - for the patients for whom the surgery worked in stopping substance use - brain physiology seems to have shifted in a way that might indicate recovery of executive function that is lost in advanced addiction, which underlies the addict's inability to make logical decisions.
The distribution of outcomes in the West Virginia University study seems consistent with those reported by a Chinese research group using a similar DBS protocol, which reported that - out of a cohort of eight patients with opioid addiction who underwent the procedure - five of them remained abstinent for at least three years of follow-up, two relapsed after six months, and one patient died of an overdose three months after surgery.
Case Studies
So, the DBS treatment didn't work for everyone.
And I should emphasize that this trial, which involves the first utilization of DBS for the purpose of addiction treatment in the United States, began in 2019 with a very small initial cohort and hasn't yet progressed to a broader, Phase II clinical trial (at least, I can't find evidence that it has done so; see note at end of article).
Still, the results of the DBS treatment for the patients that it worked for have been astounding.
As Gerod Buckhalter, the study's first patient, reported in a 2020 Vice interview, immediately after the procedure to implant the electrodes, he felt "really, really, really, really good." As the level of stimulation was fine-tuned and his brain adjusted to the hardware over the following days and weeks, Buckhalter reported a return to a baseline state that he hadn't experienced since before his addiction - free of depression and anxiety, just "normal."
*I've searched for an update on Buckhalter's outcome. He participated in a flurry of interviews in 2019 through 2022 after he had the DBS procedure, but I haven't been able to find any more recent documentation about how he's doing. However, the 2021 Vice interview mentioned that he was working with other patients in the WVU program, and the 2022 CNN interview reported that he had been stable for 2.5 years.
"Before, you know, I just didn’t do anything... Nothing brought joy to my life," Buckhalter explained, adding that now, he takes pleasure in ordinary activities once again.
“Once in a great while, I’ll have a few cravings. They don’t last very long and they’re not so strong that I contemplate acting on them…before I couldn’t process thinking of the consequences,” he adds, noting that his impulsivity has been greatly diminished post-procedure, as well.
Intriguingly, Buckhalter found that his fear of public speaking and some other assorted anxieties have dissipated as well.
One parameter that bears further investigation is how opioid maintenance treatment with buprenorphine and methadone interfaces with DBS as a treatment for addiction. Buckhalter is still on Suboxone (buprenorphine); the procedure was mainly undertaken to control his rampant use of benzodiazepines.
It's unclear based on the studies I've read how many of the patients in whom DBS is used for opioid addiction are on maintenance prior to and following the procedure, and this is far from a trivial or tangential consideration. It's likely that the efficacy of the treatment is substantially impacted by the concomitant use or non-use of maintenance, and it will be difficult to gauge whether the procedure has other desirable effects - such as attenuation of withdrawal symptoms and opioid cravings - in patients who remain on opioid maintenance.
James Fisher, the study's third patient, who was also addicted to both benzos and opioids, has reported similarly extraordinary results.
"It's like night and day," Fisher explained in a 2021 interview with NBC News. Fisher said that he felt "fantastic" and that his depression, anxiety, and irritability had been replaced by a calm contentment that felt "like a warm blanket."
Although the interview was conducted only three months after he underwent the procedure, Fisher reported no cravings to use drugs.*
*Another interesting case is that of Canadian AIDS researcher Frank Plummer, who was such a severe alcoholic that he continued drinking following a liver transplant. Plummer had the DBS surgery in 2018, after which he reported great subjective improvement in his inner state as well as the ability to moderate his drinking for over a year. However, Plummer died in January 2020 of cardiac arrest, so the longer-term efficacy and side effects of the procedure in his case cannot be assessed.
One concern that I have that I haven't seen mentioned in the literature is that the procedure could actually worsen outcomes for patients for whom it isn't effective in reducing cravings, impulsivity, and using behaviors. By blocking or mitigating some of the usual neurochemical reward for getting high, for example, it could potentially push addicts into using dangerous amounts, leading to overdose.
Larger-scale studies are needed, of course, and with them, we hope, will come the ability to differentiate which subpopulations of addicts will benefit from the DBS treatment.
For now - against a ghastly backdrop of over one hundred thousand drug overdoses per year in the United States - I can only feel grateful that such dedicated researchers are expanding the scientific boundaries of treating addiction.
Given the low efficacy of existing treatment options, such investigations are progress, indeed.
And who knows? Maybe someday while they're tinkering with someone's nucleus accumbens - a process that patients are awake for, by the way - these scientists will stumble upon a truly revolutionary discovery.
Quick Note: I haven't been able to find conclusive confirmation of the current status of the West Virginia University DBS study. After quite extensive media coverage surrounding the first cohort of cases in 2019-2021, the available information quickly fell off. I was able to find a couple of papers published as late as 2023 summarizing the results of the first cohort, but nowhere have I seen mention that the study has progressed to the second phase, which involves more extensive clinical trials.
A 2023 summary of research at the WVU Rockefeller Neuroscience Institute mentions that the DBS study is no longer seeking participants, which possibly indicates a disruption in funding and / or more serious problems with the project. It's possible that COVID played a role in delaying the timetable, too, but my overall impression is that the project began with quite a bit of media fanfare, then ran out of steam due to cost, feasibility, limited efficacy, and other issues.
More recently, WVU is also pioneering a first-in-the-world treatment that uses ultrasound waves focused on the nucleus accumbens to reduce cravings (article here).
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