Addiction treatment had failed. Could brain surgery save him? - The Washington Post

— After nearly two decades of hardcore drug addiction — after overdoses and rehabs and relapses, homelessness and dead friends and ruined lives — Gerod Buckhalter had one choice left, and he knew it.

He could go on the same way and die young in someone’s home or a parking lot, another casualty in a drug epidemic that has claimed nearly 850,000 people like him.

Or he could let a surgeon cut two nickel-size holes in his skull and plunge metal-tipped electrodes into his brain.

More than 600 days after he underwent the experimental surgery, Buckhalter has not touched drugs again — an outcome so outlandishly successful that neither he nor his doctors dared hope it could happen.

He is the only person in the United States to ever have substance use disorder relieved by deep brain stimulation.

The procedure has reversed Parkinson’s disease, epilepsy and a few other intractable conditions, but had never been attempted for drug addiction here.

The device, known as a deep brain stimulator, also is recording the electrical activity in Buckhalter’s brain — another innovation that researchers hope will help locate a biomarker for addiction and allow earlier intervention with other people.

Buckhalter, 35, is a walking, talking laboratory for the outer edge of drug addiction therapy, a living experiment in what may be possible someday.

He still experiences cravings, depression and the anxiety that drove his drug use.

A second patient in the same experiment soon stopped participating and had the brain device removed.

Surgeons implant device in the brain of a man with intractable drug addiction.

“This is not a magical cure,” said Ali Rezai, director of the Rockefeller Neuroscience Institute at West Virginia University, who performed Buckhalter’s surgery.

He did not experience childhood trauma often linked to later drug use, although his mother said he was at times unusually anxious.

It is a story doctors and drug counselors have heard countless times since the opioid epidemic began just before the turn of the century.

“The clouds lift and the sun comes out,” said James Berry, an addiction psychiatrist at West Virginia University and a member of Buckhalter’s treatment team.

Medical authorities and drug companies were both applying pressure to treat pain aggressively.

They also had to have failed all other interventions; had to be physically healthy enough to withstand brain surgery; and needed strong family support, a place to land afterward.

The doctors were, after all, proposing experimental brain surgery.

Deep brain stimulation is one aspect of a therapeutic approach known as neuromodulation, a term that means trying to alter nerve activity in ways that will counter disease.

The FDA has approved deep brain stimulation for a variety of conditions, including depression, obsessive-compulsive disorder and epilepsy, but the most dramatic results have been achieved in movement disorders, especially Parkinson’s.

But after Rezai implanted stimulators in the brains of three women to combat morbid obesity, one asked for the device to be removed and another died by suicide 27 months later.

In theory, sending electrical signals to the correct part of the brain could have multiple benefits for addiction: It would stimulate the release of natural dopamine, reducing cravings for drugs.

And it might reverse physical changes to the brain caused by years of drug use.

Buckhalter was awake for most of the seven-hour surgery, helping doctors by responding as they probed for the precise spots in his brain for the implant.

Rezai then snaked the wires inside Buckhalter’s neck to the stimulator, a pacemaker-sized device implanted below his left clavicle.

There is a visible lump when Buckhalter lowers the collar of his shirt, but otherwise, he said, he is largely unaware of the device.

The platinum-iridium alloy tips of the device each have four separate contacts, allowing doctors to fire electric pulses at different depths in the nucleus accumbens.

Three months ago, the doctors replaced the first stimulator with a newly designed one that captures the electrical signals in Buckhalter’s brain.

The researchers are comparing that data with Buckhalter’s subjective descriptions of his feelings and maps of his real-time brain activity that they are creating using functional MRI.

While he was in the MRI tunnel, they exposed him to photo cues of drug use — pills, Xanax, someone snorting white powder — as well as images of benign objects such as rocks and a wrench to chart the differences in brain activity.

Brain stimulation for addiction, even if successful in a clinical trial, will never become widespread, said Darin Dougherty, director of the division of neurotherapeutics at Massachusetts General Hospital.

“It will always be a niche, but an important one,” he said.

And boy, we’ll take it.” (In China, he said, the operation is done much more frequently, but there has been no controlled trial to gauge its effectiveness.).

Halpern, an associate professor of neurosurgery at Stanford University Medical Center who is conducting similar surgery in an attempt to treat binge eating, said Rezai’s work is groundbreaking.

“They are conducting pioneering work in humans inspired by years of data that has been collected from international centers, from animal and human imaging studies,” he said.

The Rockefeller doctors said that patient failed to engage with the process after the surgery, skipping counseling and other meetings before dropping out.

But in an experiment so new, Malenka said, it is also possible that his brain circuitry was different or the placement of the electrodes was off by a fraction of a millimeter.

“You have a big bowl of Jell-O and it’s opaque, and you have to take a chopstick and you have to place it so the tip of the chopstick is into the exact center of that bowl of Jell-O within two millimeters, without visualizing it,” he said of the surgery.

And it’s not going to work for everybody,” Rezai said.

“I have a living problem and that’s the biggest thing,” he said