A Hole in the Head, by Zachary Siegel

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September 2022 Issue [Report]

A Hole in the Head

Can a brain implant treat drug addiction?

Photo illustrations by Nicolás Ortega for Harper’s Magazine

[Report]

A Hole in the Head

Can a brain implant treat drug addiction?
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On a bright summer day in July 2021, James Fisher rested nervously, with a newly shaved head, in a hospital bed surrounded by blinding white lights and surgeons shuffling about in blue scrubs. He was being prepped for an experimental brain surgery at West Virginia University’s Rockefeller Neuroscience Institute, a hulking research facility that overlooks the rolling peaks and cliffs of coal country around Morgantown. The hours-long procedure required impeccable precision, “down to the millimeter,” Fisher’s neurosurgeon, Ali Rezai, told me.

Prior to operating, Rezai and his team of neuroscientists created a digital rendering of Fisher’s brain, a neural map that would help them place what looked like a pair of long metal chopsticks roughly six centimeters deep into his nucleus accumbens, a structure in the center of the brain. The nucleus accumbens, according to the latest research, is associated with processing reinforcement, motivation, and desire. It’s also where the most famous neurotransmitter, dopamine, gets released when we anticipate rewards from behaviors like sex, drug use, or gambling. Rezai, who thinks as much like a neural engineer as like a surgeon, described the nucleus accumbens as the brain’s Grand Central Station, a junction for “addictions and anxiety and obsessions.”

Once Fisher was anesthetized, Rezai bored two holes about the size of nickels into the top of his skull. Then he slowly inserted the long metal probes into Fisher’s brain, as if sticking a dull knife into a mold of opaque Jell-O. The probes were lined with four tiny round electrodes, each just over a millimeter in diameter, that were to deliver continuous electrical impulses to Fisher’s nucleus accumbens. The surgery is known, fittingly, as deep brain stimulation, or DBS.

The probes were connected to wires that ran under Fisher’s skin, beneath his scalp, behind his ear and down his neck, then into a pulse generator sewn into his chest below his collarbone. Imagine a pacemaker, but for the brain. Once the generator’s battery was switched on, low-voltage electricity began traveling up the wires and out of the electrodes resting in the nucleus accumbens. Rezai, the executive chair of the institute and the head of its DBS experiments, hypothesized that stimulating this region of Fisher’s brain would reduce his cravings and help him recover from a severe addiction to opioids and anti-anxiety pills that had persisted despite numerous treatments and life-threatening consequences, including multiple overdoses.

For decades, addiction and overdose deaths have been skyrocketing across the United States—and particularly in West Virginia, which has been dubbed the epicenter of the overdose crisis and consistently has one of the highest death rates in the nation. Patients like Fisher have been deemed “treatment-resistant,” meaning conventional approaches have failed to bring about lasting recovery. Medication, therapy, inpatient and outpatient care—Fisher has tried it all. Deep brain stimulation, which before this trial had never been tested in the United States to treat addiction, was a last resort.

Still supine on the operating table, Fisher was woken by a team of doctors eager to hear from him. Rezai asked, “What are you feeling?” An oxygen hose in his nose, Fisher looked up and tried to laugh. “Happier,” he said.

Last December, I pulled up outside an old brick mansion off Pleasant Street, a few blocks from the Monongahela River. After recovering from surgery, Fisher had moved to this sober house, which was owned by a company called West Virginia Sober Living. At any given time, up to sixteen other people in recovery live here. The main rule of living in a sober house, self-evident enough, is to remain abstinent from drugs and alcohol. It’s a rule that Fisher says he has dutifully followed in the roughly six months since his surgery.

The wooden floors creaked as I stepped inside. At thirty-six, Fisher was stout, with short dark hair and a salt-and-pepper soul patch. Passing him on the street, you’d never know that he is one of only four Americans who has received a brain implant for drug use. All the hardware—the battery, probes, and wires—is invisible from the outside. He greeted me with a friendly West Virginian drawl and took long drags on an e-cigarette the size of a TV remote as I asked what it was like to live a neurostimulated life.

What did that first hit of electricity feel like? “It takes your breath away,” he told me. It was difficult to find the words, he explained, but the initial wave of electricity felt like an all-encompassing, energizing euphoria. What about now? “I’m more motivated,” he said, “a lot more motivated.” He can conquer tasks that used to overwhelm him, like talking to a journalist about the lowest moments of his life. Day to day, does he think about the fact that electrodes are zapping at his reward circuitry? “A lot of times, I forget I even have it.” Do people look at him any differently? “I don’t advertise it, like, ‘Hey, I got my fuckin’ brain operated on, by the way.’ ”

It’s true that Fisher wasn’t seeking publicity. I had sought him out, motivated by a mix of fascination and horror. Having reported on drug policy and treatment for several years, I had grown less interested in how and why people get addicted to drugs—everyone has their reasons, and though we often seek neat explanations for complex phenomena, tracing addiction to a sole cause (such as trauma or genetics) doesn’t seem particularly revealing. More interesting to me, and the reason I flew to Morgantown, are the many ways people find or sustain recovery. What kinds of treatments work? How do you properly address a catastrophe like the one in which the United States finds itself, where overdose deaths now kill more than a hundred thousand people each year?

Losses of this magnitude are unprecedented, and these deaths are largely preventable. They’re also routinely swept under the rug. There is no nationwide rallying cry to flatten the curve of overdose mortality, no daily public health briefings. Americans, and those born in the Eighties and Nineties in particular, are dying prematurely en masse, and this fact rarely rises to the level of the national conversation.

Neuroscientists, as is their wont, generally understand addiction as a disorder of the brain. Drugs are said to hijack neural circuits and scramble the brain’s most critical reward pathway. Years of neuroimaging studies purport to show hot spots in the brains of addicted people; experts like Nora Volkow claim this is empirical evidence of physiological abnormalities. Volkow, the director of the National Institute on Drug Abuse, the federal agency funding WVU’s phase 1 DBS trial, has called addiction “a disease of free will.” The addicted brain, after years of exposure to drugs, Volkow argues, loses capacity to make “free determinations.” Thus people like Fisher, despite their best, clear-eyed intentions to quit, return to drugs again and again. This research suggests that one should not shame or blame a person who is struggling, because they are not in complete control of their own decision-making. We don’t punish and criminalize people who are sick; yet for decades, addiction has existed in a kind of limbo between criminalization and medicalization.

“Many people with addiction feel themselves occupying a confusing middle ground between free choice and total loss of control,” Carl Erik Fisher writes in The Urge: Our History of Addiction. For Dr. Fisher, medical science and neurobiology alone cannot explain addiction’s knotty complexities, and his expansive history reveals a field that is bitterly divided over even the most fundamental assumptions. “Some insisted that addiction was primarily a brain disease,” he writes. “Others claimed that this brain-centric view blinded us to the psychological, cultural, and social dimensions, including trauma and systems of oppression.” Whether addiction is a brain disease or something else entirely, it’s undeniably affected by the environment in which it ferments and functions. Life circumstances—such as a global pandemic—that occur beyond the purview of the individual brain, and therefore beyond that of a neurosurgeon, can alter the trajectory and course of one’s addiction. Our brains respond and adapt to stressors and threats. Dr. Fisher’s view that people use drugs out of a deep sense of dislocation, alienation, and unprocessed pain corresponds with what I saw in West Virginia, where maladies of this variety are in abundant supply.

In other words, there’s a reason why overdose deaths in the Mountain State are consistently higher per capita than in most other states. James Mahoney, a neuropsychologist who directs addiction research at the WVU neuroscience institute, said that he and his team are constantly asking: “Why here?” How did West Virginia come to be the center of the overdose epidemic? “It’s so multifaceted,” Mahoney told me. “It’s not just biological, obviously. Substance use is so self-reinforcing because it works really well. It’s able to remove people mentally and psychologically from stress.” He went on to list a few of the factors at play: “economic despair, health literacy, educational attainment, all of that going back through Appalachian history.”

Jon E. Zibbell, a behavioral scientist who studies illicit drug use and infectious disease, put it more bluntly. “Appalachia has been really screwed over by both government and industry,” he said, meaning the mining industry, the lumber industry, and more recently the pharmaceutical industry. “It’s like [Senator] Joe Manchin, pushing back against the Build Back Better bill, a bill designed for his state, to help rural areas rebuild.” Manchin reportedly blocked the more generous aspects of Biden’s Build Back Better agenda because he thought poor parents would spend the federal government’s largesse on drugs instead of helping their families. (A spokesperson for Manchin told me that the senator “continues to support policies that reward hardworking families.”)

The sparse rurality of West Virginia also can’t be overlooked. “There is no longer a syringe program between Morgantown and Huntington,” said Judith Feinberg, who studies harm-reduction strategies at WVU. “That’s a really big distance.” As a result, Feinberg went on, parts of West Virginia are seeing HIV and hepatitis C outbreaks linked to injection drug use. On top of that, “The state has only nine methadone clinics,” Feinberg said. “You see how limited treatment is?” In West Virginia, there are now more deaths than births per year.

Fisher was the third of four participants in WVU’s attempt to address the state’s addiction problem through brain surgery. It had taken Rezai, Mahoney, and more than twenty of their colleagues four painstaking years to get to this point. A study of just four people, of course, cannot establish proof that deep brain stimulation is an effective treatment for addiction. Rather, this preliminary phase aims to evaluate whether it is safe and feasible when used on people with opioid-use disorders, the first in a long series of steps that could lead to approval by the Food and Drug Administration. If the results from phase 1 show that DBS is safe and tolerable, the next step will consist of a randomized, controlled proof-of-concept study in which approximately sixteen people will receive brain implants. And if that succeeds, DBS will be tested in a much larger trial featuring more than fifty participants.

DBS may indeed prove to be safe and feasible—but its practicality is another matter. Batteries unexpectedly die, hardware erodes. Say DBS does help people conquer severe addictions: Where will researchers go from there? Will brain implants be tested on more and more mental disorders? Will we all, one day, walk around with some implant or another, narrowing what remains of the gap between mind and machine?

For the past decade, James Fisher has been stuck in a miserable, chaotic loop. He has wrecked a jeep, suffered withdrawal-induced seizures, and survived multiple overdoses. His cocktail of choice, a mix of opioids and anti-anxiety drugs like Xanax, is notoriously deadly. Both classes of drugs are central nervous system depressants—downers supplemented with downers. From 2019 to 2020, overdoses involving illegal benzodiazepines increased 520 percent, according to the Centers for Disease Control and Prevention. In that same time span, overdoses involving prescription benzodiazepines like Xanax jumped by 22 percent. In over 90 percent of these overdoses, an opioid like heroin or fentanyl was also found in the person’s system.

Dying of an overdose was no abstraction to Fisher. That fear alone might explain why he would take the risk of undergoing an experimental brain surgery. But Fisher wasn’t the first to take the leap. He had heard about the remarkable recovery of the study’s first patient, Gerod Buckhalter, who became something of a celebrity in Morgantown. In November 2019, Buckhalter was the first American to receive a brain implant for his addiction. News of Buckhalter’s brain being “rewired” by “microchips’’ made national headlines. cyborg technology aims to reduce the opioid epidemic one chip at a time, hailed USA Today. addiction treatment had failed. could brain surgery save him? asked the Washington Post.

While the high-tech approach generated hype in the press, Fisher took note of Buckhalter’s success. “I could remember every day waking up sick, and that feeling of just pure depression and absolutely hating life,” Buckhalter told me, sitting at the kitchen table in the same Morgantown mansion in which Fisher lived, and where he works. Before he became addicted to opioids, Buckhalter was a star football player in high school. In his early twenties, he went to work in a coal mine where he said he made “great money.” Of course, the money financed his addiction, which following high school had escalated from pills to heroin. Things got so bad, he said, that he was unemployed for three years, a period he largely spent lying in bed trying to blot out all sense of consciousness.

More than two years after his surgery, the thirty-five-year-old was on his longest run of sobriety since he started using oxycodone in high school, right as pill mills flooded Appalachia with a deluge of powerful painkillers. From 2006 to 2012, 780 million hydrocodone and oxycodone pills were delivered to West Virginia alone, a state with a population under two million. Far more potent synthetic substances, like fentanyl and methamphetamine, have since largely replaced them, causing overdose deaths to reach extraordinary levels. Nearly half of adults in the United States now say they have a family member or a close friend who is addicted to drugs.

“Each time I’d relapse,” Fisher told me, “my family would be on me like, ‘Why don’t you get that surgery?’ And I’d be like no, no, no, I’m not gonna do that.” It was out of desperation that Fisher finally changed his mind. “I knew Gerod was still sober. Man, it’s gotta be doing something,” he remembers thinking. The WVU study happened to be looking for patients just like Fisher, whose addiction trajectories seemed grim enough to outweigh the risks and strangeness of invasive brain surgery.

The first time I met Rezai at the neuroscience institute in Morgantown, he had just finished a brain implant procedure on a patient with Parkinson’s disease. As soon as the battery was switched on and the brain received its first electrical impulses, the patient’s debilitating tremors and shaking improved. In such cases, it’s clear that the stimulation, in some sense, has worked. Testing the effects of DBS in patients who struggle with drug addiction, meanwhile, is a much thornier endeavor.

“With addiction, with human emotions and behaviors, you must tread on that territory very carefully,” Rezai told me. I couldn’t help but wonder whether he was referring to the dark history of so-called psycho-surgery: a surgeon scrambling someone’s prefrontal lobe with an ice pick, permanently altering their sense of personhood.

Rezai is widely considered a pioneer in brain-implant surgery, and he has performed more than twenty-five hundred implant procedures in his twenty-five-year career, mostly operating on the well-mapped thalamus of patients with Parkinson’s. In 1997, the Food and Drug Administration approved the use of DBS in patients with Parkinson’s and essential tremor, and later for those with dystonia. Around the world, more than two hundred thousand people have received DBS implants, mostly for movement disorders. Testing DBS on psychiatric disorders is a more recent development, and has generated mixed results. And several of the studies have gone awry.

In one case, a large clinical trial testing DBS on patients with depression blew up before it could be completed. The device company supplying the hardware, St. Jude Medical, withdrew its support after a “futility analysis” showed that not enough patients were improving. For obsessive-compulsive disorder, DBS is approved only through the FDA’s humanitarian device exemption, which stipulates that a medical device can be marketed without robust evidence of effectiveness. DBS remains an option for people with severe depression or OCD, but it’s rarely pursued.

DBS was originally invented to treat chronic pain. But given that pain is subjective and difficult to quantify, DBS was never granted FDA approval for that purpose; its effect couldn’t be properly demonstrated. For both pain and depression, brain implants remain under review. Now, in an ironic twist, the technology invented to treat pain is being tested on opioid addiction, which took off in the United States, in part, thanks to pharmaceutical companies that aggressively, and in some cases fraudulently, marketed opioids to treat all types of pain.

“Most contemporary accounts of DBS therapy give the impression that it is the inevitable consequence of scientific discovery and medical progress,” John Gardner, a sociologist, wrote in the journal Social Studies of Science. “The history of DBS is, in fact, complex.” Gardner’s history shows that DBS continues to be tested by medical device companies seeking new use cases—that is, new markets—for their own technologies, despite the treatment’s spotty track record. What’s driving this expanding search? When I reached Gardner by phone in Australia, he told me that our “neuro-obsessed” culture offered fertile ground for testing brain-stimulation technology, as “we like to think of behaviors and social problems in terms of their neural correlates.” Gardner points to a murky nexus of “entrepreneurial” neurosurgeons aligned with medical device companies that lobby government agencies responsible for deciding whether all this hardware is safe to put inside human beings.

The biggest and most profitable of the device companies, Medtronic, trademarked the term “deep brain stimulation” decades ago while marketing its device as a treatment for pain, says Gardner, who notes that DBS has been a genuine medical breakthrough for movement disorders. But medical breakthroughs must also be profitable. “DBS for [Parkinson’s], then, has proven highly lucrative for Medtronic,” Gardner wrote. “The company is attempting to replicate some of this success by developing DBS as a treatment for other conditions.” This includes addiction. Medtronic is listed as a “collaborator” on WVU’s phase 1 trial. A spokesperson for Medtronic told me that this role means the company provides the hardware for the trial and not much else. This year, incidentally, Medtronic posted $435 million in second-quarter earnings from its neuromodulation division, which sells the DBS hardware.

Before green-lighting the WVU trial, Volkow told me she had traveled to China and interviewed a handful of patients who received brain implants for opioid addiction. Given China’s draconian drug laws, scientists have raised ethical concerns about whether patients consented to the surgery. Their concern was merited: Before China tested DBS for opioid addiction, surgeons there performed an irreversible surgery that involved burning brain cells in thousands of patients. Known as ablation, the surgery involved applying heat to a specific set of cells, potentially cutting off the patient’s ability to feel motivation or pleasure. Following an international outcry, China’s Ministry of Health supposedly put a stop to the procedure in 2004. DBS arrived as an alternative.

The research on DBS in China is mostly made up of individual case studies rather than rigorous trials. In a three-year follow-up study of eight DBS patients in China, five remained abstinent, two relapsed after six months, and one was “lost to follow-up.” The researchers noted vaguely that “adverse events” were rare. In a separate study, a patient died of a heroin overdose shortly after being implanted, and the researchers blamed the patient’s “antisocial personality disorder.”

In 1990, the year Rezai graduated from medical school at the University of Southern California, President George H. W. Bush announced the “Decade of the Brain,” ushering in an era of techno-optimism for diseases and conditions deemed intractable or incurable, like Alzheimer’s and Parkinson’s. But Bush’s speech went further than degenerative brain diseases. “Research may also prove valuable in our war on drugs,” Bush proclaimed, “as studies provide greater insight into how people become addicted to drugs and how drugs affect the brain.” For the next thirty years, the U.S. government’s national research apparatus would steer billions of dollars toward neuroscience research in the field of addiction. Unraveling this complex phenomenon would, in theory, lead to more effective treatments. Psychiatrists like Carl Erik Fisher say the government’s focus on neuroanatomy and neurobiology has warped the research agenda, steering precious resources away from social, epidemiological, and behavioral treatments that might offer more direct benefits for patients than, say, mapping the architecture of their brains.

In his office overlooking the university’s sprawling medical campus and the tree-lined hills of Morgantown, Rezai spoke of the overdose crisis with a stern sense of urgency. “Addiction is not going away,” he said. “The problem is going to get worse. And up till now, our best efforts and billions spent are not really helping. So we need to come up with better solutions.” Among the high-tech solutions being tested at WVU to treat addiction: virtual-reality goggles, wearable devices that track sleep patterns and heart rates, as well as less invasive forms of neuromodulation, like transcranial magnetic stimulation and focused ultrasound therapy, which like DBS use energy to stimulate brain circuits distorted by addiction.

I noticed that Fisher and Buckhalter each wore a smart ring that tracked their vital signs and sleep patterns. “I guess what they’re trying to do with it is map your heart and stuff before a relapse,” Fisher told me. “Like if a relapse happens, they go back and look at the stuff.” Within all that data, there might be some biomarker or signal that a relapse was coming. The DBS device is also recording electrical signals in their brain, which can be downloaded and analyzed. Both men are walking, talking data emitters.

At one point during my tour of the neuroscience institute, Rezai invited me into a windowless room where I donned a pair of VR goggles that placed me in what looked like a college kid’s messy apartment. I saw old boxes of pizza and drug paraphernalia strewn about the room, as well as crushed beer cans and lines of white powder splayed on a wooden coffee table. “There’s a Mountain Dew,” Rezai said, chuckling.

Alongside DBS, virtual reality is one of the many technologies used at the Morgantown lab to try and grasp how addiction works at the physiological level. A type of exposure therapy, virtual reality has been used to help combat veterans struggling with post-traumatic stress disorder relive the horrors of war in a controlled clinical setting. VR simulations for addiction attempt something similar. Instead of a Humvee, the scene is a seedy apartment.

“We immerse somebody with addiction into a virtual environment, and then we’re testing the networks in the brain,” Rezai said. If somebody’s drug of choice was alcohol, Rezai explained, they could be transported to a bar where they’d hear the unmistakable sound of ice clinking against a glass. Any changes in a person’s heart or respiratory rate, eye movements, skin tone, or sweat glands could be an indication of the virtual experience triggering a reaction, maybe even a craving.

In this case, the test subject was me. Almost ten years ago, I turned twenty-three inside a treatment facility in Minnesota, where I was treated for an opioid addiction that had spiraled out of control. By now, the story of how I got addicted is boilerplate for a millennial: Pharmaceutical opioids like OxyContin were in abundant supply by the time I graduated from high school in Chicago’s north suburbs. I had experimented with the usual drugs that teenagers in affluent communities tend to, like Adderall and marijuana. It wasn’t until I tried an opioid at age seventeen that the proverbial clouds parted. The harsh, judgmental, self-effacing critic in my head finally quieted, and in the absence of that unrelenting mental cacophony, I was left with a feeling of soothing warmth and clarity like I had never felt before. It wasn’t that I loved the high, per se—I remember thinking, this must be what it’s like to feel normal.

Before flying out to West Virginia, I had mentioned to Rezai that I had my own experience with addiction, hence my sincere interest in his lab’s research. With the VR headset on, I looked up, down, and from side to side. The simulated drug den certainly resembled the dingy apartments I inhabited while using—there was a familiar sort of austerity that tends to accompany opioid addiction. I never needed much to be comfortable, mostly because opioids make you comfortable wherever you are, in whatever condition. That’s more or less the point.

They also produce an insatiable sweet tooth. I thought the VR drug den could use some candy for verisimilitude. While using, I ripped through endless lime-green bags of Sour Skittles. To this day I associate Skittles with an opioid high. As for my physiological response: Did my palms get sweaty? Did my heart start racing? Did I get butterflies? No. The effect was uninspiring, like being dropped in a particularly hedonistic version of The Sims.

Environmental cues don’t quite trigger me the way they used to, which I’d like to think is a result of all the work I’ve done to address my addiction over the years. The sight of Sour Skittles is more of a reminder than a trigger. My triggers today seem to be internally generated. Opioids relieved me of profound psychic pain by creating, eventually, a different variety of profound psychic pain. It would take much more than cold pizza and Mountain Dew in a grimy apartment to make a return to that place seem attractive.

Most people seeking treatment are unlikely to receive anything like the approach championed by the neuroscience institute. Popular treatment facilities in the United States market their services as if they were an all-inclusive vacation package, enticing wealthy clientele with “therapeutic experiences” at serene locales, offering equine and surf therapy. Rehabs are advertised as retreats: a thirty-day stay at a Four Seasons and interminable hours of group therapy that can cost upwards of $1,000 per day.

Simulated drug dens, wearable devices, biofeedback, and neuromodulation are the sorts of unusual approaches that drew me to the Rockefeller Neuroscience Institute. Rezai was the first neurosurgeon to successfully reanimate paralyzed limbs by connecting the brain to a computer interface. It’s that feat, a cure for paralysis, that Elon Musk hopes his neurotechnology company Neuralink can accomplish. Applying his knack for engineering and the latest technology to the seemingly intractable problem of addiction, Rezai may yet deliver a breakthrough in a field where treatments still rely on prayer and belief in a higher power. What if that higher power was, well, electricity?

The strangeness and intensity of the DBS surgery is belied by the pilot study’s straightforward hypothesis: Stimulation of the nucleus accumbens in the deep brain will, in theory, give people with severe addictions more control over their impulses, decisions, and behaviors, which are governed and executed by structures in the frontal lobe. If addiction diminishes our agency, narrowing our horizon of choice, then DBS seeks to expand that horizon and restore a sense of self-control.

Discussing the phase 1 trial, Volkow, of NIDA, chose her words carefully. A scientist at her core, Volkow commands the biggest addiction research budget in the world. She’s wary of jumping ahead of the data. “Oh, and she also is the great-granddaughter of Russian revolutionary Leon Trotsky,” the Washington Post pointed out in a profile that described her thinking on addiction as “electric.”

“There is a signal there that appears to indicate that for some patients DBS may be helpful,” Volkow told me. “Time will tell. We have such very limited information.” Despite the small sample size, Volkow said that the results of WVU’s trial are “definitely interesting.”

Fisher and Buckhalter have had, by all accounts, extremely positive outcomes. Not only do their experiences demonstrate that DBS is safe and tolerable, but they also show that the stimulation may be having beneficial effects on their moods and cravings. Their addictions were severe and life-threatening, and they had not responded to several prior treatment attempts. With a neurostimulator implanted, they appear to be thriving.

“You know, sometimes I wonder how it works,” Buckhalter told me back in the kitchen of the sober house, which was connected to another room in which I could see a group of guys crowded around a big-screen TV. Last summer, Buckhalter got a chance to really understand what the stimulation was doing for him. The research team brought him into the institute to run some scans on his brain. While he was there the researchers turned off the stimulator—after it had been running for over a year and a half. Was the stimulation really helping him? Was it a placebo?

“I was getting very irritable, like, noticeably very irritable and agitated,” Buckhalter said, as though he were in withdrawal from the voltage. “Then they turned it back on after being off for three days. I felt a calmness coming over me. There was a great feeling of euphoria.” He felt so buzzed after it was switched on that he didn’t sleep that night. It turns out Fisher was right to look at Buckhalter and think the stimulation was doing something. Exactly what, though, is still hard to say. The experience of the two other patients in the trial complicates things.

Patients 2 and 4, whose identities have not been disclosed to the public, had a rockier experience after the implantation process. I was told by the university that they did not consent to interviews, and the information that was shared was anonymized, to respect their wish for privacy. Patient 2, a young man in his early twenties, relapsed shortly after the surgery, and exited the trial before I arrived in Morgantown. But a relapse, in isolation, need not spell doom. As with most illnesses, relapse is part of the treatment process, and is “quite the norm, and thus expected,” especially in severe cases of addiction, Mahoney told me.

When DBS was tested on patients with treatment-resistant depression, the researchers were not expecting symptoms to vanish with the flip of a switch. The desired outcome was merely less severe depression. So it wasn’t the relapse that caused all the trouble. Rather, “it was how he responded following the relapse,” Mahoney said. After he went dark and missed his follow-up appointments, the researchers decided to surgically remove all of Patient 2’s hardware. “In a study of this magnitude, we can’t have them just go off the grid for weeks at a time and not contact us,” Mahoney said. “If we don’t know where they are, we can’t confirm that they’re safe.” Such a situation would threaten the integrity of the trial.

Patient 4, a man in his forties, received his implant in late November 2021. Like Buckhalter and Fisher, he had a long history of severe substance use and had attempted treatment numerous times. Patient 4 made a full recovery from the surgery and appeared to be doing well until a relapse in January. Unlike Patient 2, Patient 4 has, so far, remained engaged and enrolled in the study. Again, a relapse does not necessarily end things, nor should it. For years, especially in America, total abstinence has been the only acceptable outcome for addiction treatment, a situation which Volkow told me is simply unrealistic.

“There are several options for optimization,” Mahoney told me regarding Patient 4. In DBS parlance, voltage is considered “the dose,” and there are numerous adjustments that can be made, such as increasing or decreasing the level of stimulation by changing the frequency or intensity of the electrical current, which the researchers can do remotely using software. Buckhalter once needed an “adjustment” after noticing he felt compulsive. He told me he started spending a lot of money really quickly, and using unusual amounts of nicotine. Realizing he was not quite himself, he called Mahoney, and the research team modified the stimulation. Hypomania, a condition in which one feels unnaturally energetic, is a known side effect of DBS. Buckhalter’s ecstatic state is yet another example of the effect the stimulation can have on a person. The stimulation, for better or worse, appears capable of changing how the brain works, and therefore changing what people think and what they do.

Just as addiction itself can have many causes, there’s rarely a single reason for a relapse. It’s entirely possible Patient 2 and Patient 4 relapsed for reasons that had nothing to do with the stimulation. But this logic cuts both ways—it’s impossible to attribute Buckhalter’s and Fisher’s successes to brain stimulation alone.

The neuroscience of addiction and recovery is rapidly evolving. Rezai and his team decided to stimulate the nucleus accumbens on the basis of prior case studies, but newer research published in Nature has focused on different brain circuits entirely. The study analyzed patients struggling with addiction who seemed cured by the experience of having a stroke. “The spots that came out of our analysis were the very anterior insula and then an area called the paracingulate gyrus,” said Michael D. Fox, the director of the Center for Brain Circuit Therapeutics at Harvard Medical School. These areas of the brain are thought to play a core role in producing the sensation of human subjectivity and sentience. “People have done cingulotomies, lesions to the anterior cingulate, to try and treat addiction,” Fox said. “We think they might have been onto something.”

The research team at the Rockefeller Institute stressed that brain stimulation should be considered an adjunct to other addiction treatments. Both Fisher and Buckhalter remain on a medication called Suboxone, which contains a mixture of buprenorphine and naloxone. The former is itself an opioid and, though it is far weaker than heroin or fentanyl, it helps curb cravings. Fisher also takes Lexapro and Abilify for depression, and Remeron for insomnia. Between medication, therapy, family support, and stable employment, the brave four who entered the study received the Rolls-Royce of addiction treatments.

Yet that two of the research subjects still struggled to get better proves how vexing treating addiction can be. Perhaps out of survivor’s guilt, I’m drawn to the question of why some of us survive and others do not, why some recover and others cannot. There is a seeming arbitrariness to it all that sometimes gets to me. If drilling holes and implanting electrodes that stimulate the brain actually works, what does that tell us about the nature of addiction and how to treat it?

I remained skeptical that severe addictions could be made to disappear by turning on a battery. Addiction is too entangled with the way we live. Deep brain stimulation, the researchers and research subjects agreed, is no panacea. And it’s certainly not going to solve West Virginia’s overdose crisis “one chip at a time,” as some press coverage has suggested. “It’s unrealistic to think that you’re going to do neurosurgery to every person that has an addiction,” Volkow told me. “That’s not going to happen.” Many effective solutions for opioid addiction already exist, Volkow said, it’s just that they’re not being properly administered, especially in rural states that lack vital health care infrastructure. It’s easy for someone like me in Chicago to get therapy and medication. But many people have no such access or safety net.

While I don’t think about my addiction most days, I also don’t really consider myself to be “cured.” I’m not even sure addiction is something that needs curing. “By accepting that addiction has been and will continue to be a part of human life, we can abandon dreams of eradicating it,” Carl Erik Fisher writes in The Urge. “The primary goal should not be victory or cure, but alleviating harm and helping people to live with and beyond their suffering.” Addiction might be more a symptom than a disease, a powerful compulsion generated by a matrix of pain and conflict deep within us. Part of my healing process involved imagining a new future for myself. I learned to live with the pain rather than crush and snort it away.

“Even with the implant, it comes down to how bad you want it, you know?” Buckhalter said. “If you’re kind of half-in, half-out, you’re probably gonna get half-ass results.” James Fisher agreed. “It’s just a tool, man,” he told me. “I still gotta work a program.”

 is a writer living in Chicago.


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