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Alternative Treatments for Substance Use Disorder

Science fiction has long looked ahead to theoretical future uses and misuses of science, including for countering the effects on the brain of mental illness and drug addiction.

In 1955, Damon Knight’s novel Hell’s Pavement, imagined a future in which the authorities implant an “analogue” of an authority figure from someone’s past into their brain to preempt antisocial behavior, such as drinking excessively until you start a drunken brawl in a bar … or exposing the government’s analogue program to a reporter.

In 1962, Anthony Burgess’ cautionary tale A Clockwork Orange examined the immorality of using behavior modification to control violent, antisocial behavior, such as youthful “ultraviolence”, both because it could be used as thought control by an authoritarian government and—more importantly to Burgess—because it deprived man of his God-given free will.

And in 1972, Michael Crichton’s The Terminal Man turned to the use of electrodes implanted in the brain to prevent violent seizures caused by a head injury that sparked violent outbursts.

That last one is no longer science fiction and hasn’t been for about 50 years. In the 1970s I saw a patient in a hospital who was being treated with electrodes implanted in the brain, hooked up to a monitoring computer. I thought this treatment was horrific, and I was amazed that the research seemed to be going forward with no public discussion or even knowledge.”

That’s why Crichton decided to write the novel: “to make such procedures better known”. When he wrote this blurb for his official website many years later, Crichton said, “This particular kind of surgery is no longer done much”.

The normally prescient author spoke too soon. The Associated Press (AP) reported last month that doctors in Shanghai are experimenting with implanting electrodes into the brains of people with substance use disorders. Sometimes referred to as a “brain pacemaker” (as in Crichton’s novel), deep brain stimulation (DBS) has been used to treat movement disorders such as Parkinson’s disease, as well as epilepsy, depression, and obsessive-compulsive disorder. (Not that they always succeed; depression trials earlier this decade failed to produce positive results.)

Now it’s being used to treat methamphetamine addiction in Shanghai. The first US trial for opioid addiction, funded by the National Institute on Drug Abuse (NIDA), could begin this month at the West Virginia University Rockefeller Neuroscience Institute.

The problem with all these techniques is that they don’t cure the underlying condition, only prevent the manifestation of the symptoms. Is that enough? Is it acceptable? Should such methods be used to stop or at least slow down the opioid epidemic?

In Crichton’s novel, the patient’s condition is complicated by how the implant affects and changes his brainhis brain likes the shocks, so causes the episodes to recur more oftenand that he is actually mentally ill. He believes that machines are going to take over the world, and now one is literally controlling his brain.

The same problem applies to other treatments for addiction. Medication-assisted treatment (MAT) with buprenorphine (Suboxone), methadone, and naltrexone (Vivitrol) may control or prevent drug-induced euphoria but have no effect on the reasons why the client started using drugs in the first place. Cognitive behavioral therapy (CBT) is still required.

Such an extreme treatment as DBS is not, should not, and probably never will be the first resort. It’s invasive, expensive (the cost of implantation is about $100,000), and has no long-term history of success.

However, Shanghai’s Patient Number One was desperate. He lost his family due to his addiction and an estimated $150,000. He felt that he didn’t have the will power to quit on his own and was desperate to try anything.

DBS may at least be better than an earlier surgical technique, brain lesioning, which AP wrote: “left a trail of patients with mood disorders, lost memories and altered sex drives.”

It will take years and many studies before DBS for addiction is available and affordable. Don’t wait. Other treatments are available now. CBT and MAT are a powerful combination.