Editor’s Note: This story was reported in collaboration with the Global Health Reporting Center.
Morgantown, West Virginia
When her son bounced up the steep stone steps and through the door of the house he shared with his mother and father, Gina Buckhalter was wary. It was no secret that Gerod was a heavy drug user, addicted to opioids for more than half 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 recalls. “And I literally wanted to pass out on the floor.”
“They” were a research team at the Rockefeller Neuroscience Institute, based at the University of West Virginia, about 10 miles away, across the state line from the Buckhalter home in Dilliner, Pennsylvania. Buckhalter was already a patient at the institute, where he was being treated by Dr. James Mahoney, a specialist in substance abuse.
Over the years, Buckhalter had tried time and again to get sober, but his longest stretch of success was just three months. Most only lasted a few days.
His troubles had begun early. Buckhalter grew up in Dilliner, a nervous, anxious child who was also a basketball and football star, fielding Division I scholarship offers in 10th grade. The local paper named him “Mr. Everything.”
By Buckhalter’s senior year, that dream was gone. A shoulder injury at age 15 led to a prescription for opioid painkillers. His doctors prescribed the pills for six weeks. After that, Buckhalter found them on his own.
By his 20s, Buckhalter was using heroin, and drugs were all he could think about. By the time Mahoney proposed surgery, Buckhalter was at the end of his rope.
“Immediately, I said, ‘Yes, let’s do it.’ Immediately. Because that’s how desperate I was,” Buckhalter told CNN 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 an addiction 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 Rockefeller’s director, drilled a hole in Buckhalter’s skull. I have inserted an electrical probe, a fine piece of wire barely a millimeter wide. Then, with the probe in place, the real work began.
As Buckhalter lay sedated but awake, Rezai showed him a series of images on a monitor: piles of drugs and other pictures meant to induce the cravings and anxiety that had haunted Buckhatler for 17 years. Based on Buckhalter’s responses, Rezai adjusted the probe – a little to the left, now a little higher up — to make sure it sat in the correct position. The team hoped the electrical signal would restore healthy function to damaged brain areas and free Buckhalter from the nonstop craving 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 ailments, including severe epilepsy and obsessive-compulsive disorder.
But substance abuse disorder presents a more complex set of emotional and behavioral challenges. Dr. Nora Volkow, the director of the National Institute on Drug Abuse, says deep brain stimulation was first tried on a handful of drug users in China, but little was known about the long-term outcome.
To Buckhalter and Rezai, it was worth the gamble. “There are people dying, 100,000 a year,” Rezai said. “These individuals were at risk of dying from another overdose. And for those end-stage severe cases, DBS becomes an option.”
Dilliner and Morgantown are in the heart of coal country, a region that’s been hit especially 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 growing. Between June 2020 and June 2021, annual overdose deaths jumped nearly 32% in West Virginia, compared with a 21% increase in the US overall. The latest provisional 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 from drug overdoses from June 2020 to June 2021, according to the CDC. Synthetic opioids, like fentanyl, were involved in nearly two-thirds of those deaths.
Counseling and anti-addiction medications help many people, but Rezai says that some need additional help to break the cycle of drug dependence.
As he explains it, the brain of a heavy drug user physically changes over time. One change takes place in the nucleus accumbens, which helps regulate the function of a neurotransmitter called dopamine, vital to what’s known as the brain’s reward system. This is the brain circuitry that leads us to eat, fall in love or perform a rewarding task – indeed, anything that requires even a hint of motivation. Motivation, reward, satisfaction. For some people, that includes drug use.
“When you first take drugs, you get the dopamine high,” Rezai said. “But the more drug you take, there’s less and less.” In susceptible individuals, the result is intense craving and obsessive behavior. “The nucleus [accumbens] becomes overactive, to seek the dopamine.”
By placing an electrical probe in the nucleus accumbens, Rezai hopes to restore normal function. The wire also stimulates a second region of the brain, the frontal cortex, which is vital to 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 are receiving transcranial magnetic stimulation, in which current is delivered through a device held to the outside of the head. The technique has been FDA-approved since 2008 to treat major clinical depression and since 2018 for obsessive-compulsive disorder. A handful of pilot studies found that it might reduce cravings for alcohol, nicotine, opiates or cocaine, according to Mahoney, Buckhalter’s doctor.
Another experimental approach is focused ultrasound. Using either 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 an addiction treatment, however, is still theoretical.
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-streaming,” Rezai said. “With biofeedback, we’re starting to model these digital biomarkers for addiction and craving and anxiety.”
Though the models are 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 electrical current from the probe for better effect.
For Buckhalter, it’s worked. The guy who never made it past three months sober has now been drug-free for 2½ years. Deep brain stimulation is part of it, but he also takes a medication called suboxone, goes to counseling and holds down a steady job at a sober living home – support he says has been critical: “When it comes to staying sober, It’s just as important as the surgery.”
Of the three other people in the study, one had success much like Buckhalter, but another relapsed and had his probe removed. For the most recent patient, it’s too soon to tell. Rezai says a larger study, with more than a dozen people, is in the works.
Amid the flood of overdose deaths, a study with just four people might seem like spitting in the ocean. A $50,000 surgical procedure doesn’t take the place of a supportive family or ensure that people have food to eat and a safe place to sleep. And it doesn’t begin to grapple with the question of whether fatal overdoses could be curbed by changing drug laws that push users to black-market fentanyl.
But Volkow, of the National Institute on Drug Abuse, argues that basic medical research can still play an important role.”Whether or not this goes into the clinic in a meaningful way, it can translate into methods that are less costly and less invasive, ” she said. “There is tremendous promise in neuromodulation.”
She also says it isn’t an either/or proposition. Surgical procedures “are not the panacea for the overdose crisis, but studies like [DBS] help us understand what is driving drug-taking and inspire the development of new treatments for addiction.”
For Rex Buckhalter, Gerod’s father, “It just feels good to wake up and not have to worry about him.”