When her son bounced up the steep stone steps and through the door of the home he shared with his mother and father, Gina Buckhalter was suspicious. It was no secret that Gerod was a heavy drug user, addicted to opioids for more than half of his 33 years.
Gina was used to surprises, but this day brought a big one. “He said, ‘They actually approached me about having brain surgery for addiction,'” she recalled. “And I literally wanted to pass out on the floor.”
“They” were a research team from the Rockefeller Neuroscience Institute, based at the University of West Virginia, about 10 miles away, across the border from the Buckhalter house in Dilliner, Pennsylvania. Buckhalter was already a patient at the institute, where he was being treated by Dr. James Mahoney, an addiction specialist.
Over the years, Buckhalter had tried many times to get sober, but his longest streak of success lasted just three months. Most only lasted a few days.
His troubles had started early. Buckhalter grew up Dilliner, a nervous and anxious kid who was also a basketball and football star, offering Division I scholarship offers in the 10th grade. The local newspaper named him “Monsieur Tout”.
By Buckhalter’s senior year, that dream was gone. A shoulder injury at age 15 led to a prescription for opioid painkillers. Her doctors prescribed the pills for six weeks. After that, Buckhalter found them on his own.
By age 20, Buckhalter was using heroin and drugs were all he could think of. By the time Mahoney offered surgery, Buckhalter was at his wit’s end.
“Immediately I said, ‘Yeah, let’s do it.’ Immediately. Because that’s how desperate I was,” Buckhalter told CNN’s chief medical correspondent, Dr. Sanjay Gupta.
Soon, Buckhalter became the first patient in a four-person research study testing the safety and feasibility of deep brain stimulation, or DBS, as a drug treatment. The study is funded by a $750,000 grant from the National Institute on Drug Abuse.
Early in the morning of November 1, 2019, Dr. Ali Rezai, a neurosurgeon and director of Rockefeller, drilled a hole in Buckhalter’s skull. He inserted an electrical probe, a thin piece of wire barely a millimeter wide. Then, with the probe in place, the real work began.
While Buckhalter was sedated but awake, Rezai showed him a series of images on a monitor: piles of drugs and other images meant to induce the cravings and anxiety that had haunted Buckhatler for 17 years. Based on Buckhalter’s answers, Rezai adjusted the probe – a little to the left, now a little higher – to make sure it was in the right position. The team hoped the electrical signal would restore healthy function to damaged brain areas and free Buckhalter from the incessant urge that held him prisoner.
Deep brain stimulation is widely used to treat Parkinson’s disease and is approved by the US Food and Drug Administration to treat a range of other conditions, including severe epilepsy and obsessive-compulsive disorder.
But substance use disorder presents a more complex set of emotional and behavioral challenges. Dr Nora Volkow, director of the National Institute on Drug Abuse, says deep brain stimulation was first tried on a handful of drug addicts in China, but little was known about the results. long term.
For Buckhalter and Rezai, it was worth it. “There are people dying, 100,000 a year,” Rezai said. “These people were at risk of dying from another overdose. And for those severe terminal cases, DBS becomes an option.”
Dilliner and Morgantown are in the heart of coal country, an area that has been hit particularly hard by the overdose crisis. Overdose death rates in West Virginia have been more than double the national rate for at least six years, and the gap is widening. Between June 2020 and June 2021, annual overdose deaths jumped nearly 32% in West Virginia, compared to a 21% increase in the United States as a whole. The latest interim data from the US Centers for Disease Control and Prevention shows that overdose death rates are now about three times higher in West Virginia than the national rate.
In the United States, more than 100,000 people died of drug overdoses from June 2020 to June 2021, according to the CDC. Synthetic opioids, such as fentanyl, were implicated in nearly two-thirds of those deaths.
Addiction counseling and medication help many people, but Rezai says some need extra help to break the cycle of drug addiction.
As he explains, the brain of a heavy drug user changes physically over time. A change is taking place in the nucleus accumbens, which helps regulate the function of a neurotransmitter called dopamine, vital to what’s called the brain’s reward system. It’s the circuitry in the brain that leads us to eat, fall in love, or perform a rewarding task — in fact, anything that requires even a hint of motivation. Motivation, reward, satisfaction. For some people, this includes drug use.
“When you first take drugs, you get high dopamine,” Rezai said. “But the more drugs you take, there are less and less of them.” In sensitive individuals, the result is intense craving and obsessive behavior. “The core [accumbens] becomes hyperactive, to seek dopamine.”
By placing an electrical probe into the nucleus accumbens, Rezai hopes to restore normal functioning. The wire also stimulates a second region of the brain, the frontal cortex, which is vital for higher thought and decision-making, and which Rezai says is also damaged by heavy drug use.
Deep brain stimulation is just one approach to reversing these changes. Other research subjects receive transcranial magnetic stimulation, in which the current is delivered by a device held outside the head. The technique has been approved by the FDA since 2008 to treat major clinical depression and since 2018 for obsessive-compulsive disorder. According to Mahoney, Buckhalter’s doctor, a handful of pilot studies have found it may reduce cravings for alcohol, nicotine, opiates or cocaine.
Another experimental approach is focused ultrasound. Using high or low frequency energy waves, the technique can reach brain structures much deeper than those accessible by transcranial magnetic stimulation. It’s like deep brain stimulation, but without the risk of surgery. Its use as a treatment for addiction remains theoretical, however.
In the deep brain stimulation study, once the probe is implanted, subjects, including Buckhalter, can allow researchers to record their brain activity in real time. “It’s live,” Rezai said. “With biofeedback, we’re starting to model these digital biomarkers of addiction, craving, and anxiety.”
Although the models are still in their infancy, the goal is to find indicators that can warn doctors and patients that a relapse is near. Doctors can then remotely adjust the strength and placement of the probe’s electrical current for best effect.
For Buckhalter, it worked. The guy who never made it past three months sobriety has now been drug-free for two and a half years. Deep brain stimulation is one of them, but he also takes a drug called suboxone, sees counselors and has a steady job in a sober house. as important as surgery.”
Of the other three people in the study, one had success much like Buckhalter, but another relapsed and had her tube removed. For the most recent patient, it’s too early to tell. Rezai says a larger study, with more than a dozen people, is underway.
Amid the flood of overdose deaths, a study with just four people might seem to be spitting into the ocean. A $50,000 surgery does not replace the support of a family or guarantee that people have food to eat and a safe place to sleep. And it doesn’t begin to address the question of whether fatal overdoses could be curbed by changing drug laws that push fentanyl users onto the black market.
But Volkow of the National Institute on Drug Abuse argues that basic medical research can still play an important role. ” she said. “Neuromodulation is extremely promising.”
She also says it’s not an either/or proposition. Surgical procedures “are not the panacea for the overdose crisis, but studies like [DBS] help us understand what drives drug use and inspire the development of new addiction treatments.”
For Rex Buckhalter, Gerod’s father, “It feels good to wake up and not have to worry about him.”