Rather than medication ‘we need to inject technology into this’

By taking away cravings — one of the biggest distractions in recovery — people may be more able to manage the daily stress.

On a smoke break, Joe Hilton, 37, who has struggled with addiction to illicit drugs for most of his life, is staying at West Virginia University’s Centre for Hope and Healing. Picture: Alyssa Schukar for The Wall Street Journal

Joe Hilton was inside an MRI machine, wearing a $US1m ($1.56m) helmet and goggles showing him pictures of heroin being cooked in a spoon and injected into an arm.

Doctors behind a glass partition used the MRI images to ensure ultrasound waves from the helmet were correctly aimed at a target in Hilton’s brain a couple of millimetres in size. Then, more than 1000 probes pulsed ultrasound waves to this area, known as the brain’s reward centre.

After the treatment Hilton, 39, tried to mentally connect with the pictures of a drug he had used for more than two decades. Instead of causing him to sweat and shake with cravings as he had minutes earlier, the pictures felt meaningless. Inside the MRI machine, he pressed a button on a joystick to let the doctors know his cravings had dropped to near zero.

“It just wasn’t there, the feeling,” he said later in a hospital room.

In Appalachia, in the heart of one of the earliest and deadliest waves of the American opioid crisis, doctors at West Virginia University’s Rockefeller Neuroscience Institute are conducting a radical experiment. Using focused ultrasound waves, they are resetting cells inside the brain’s reward centre, known as the nucleus accumbens. They hope the procedure can treat addictions ranging from drugs such as opioids and methamphetamine to gambling and eating.

While neuroscientists have long defined addiction as a brain disease, tools to fight the American drug crisis behind 100,000 overdose deaths a year in that country have changed little in decades. In Australia, one person dies because of drug overdose every four hours.

Most treatment involves medications such as methadone and buprenorphine to replace other opioids, or naltrexone to block the part of the brain that feels pleasure from alcohol or opioids. For many addictions, counselling and abstinence-based 12-step programs remain the go-to treatment.

At RNI’s 30-patient residential treatment program, more than two-thirds of patients relapse within the first few weeks. Many illicit drugs, including meth and cannabis, don’t have any prescription medications to treat the addiction.

Now, the institute’s trial using ultrasound is a peek at a future that treats the physical brain, rather than using medication or behavioural approaches to alter outcomes. “We need to inject technology into this,” said Ali Rezai, a neurosurgeon and executive chair at the institute.

Dr Ali Rezai, executive chair of the Rockefeller Neuroscience Institute, helps Joe Hilton get into place for a clinical trial in which ultrasound is used to modulate the brain’s impulses that stimulate desire. Picture: Alyssa Schukar for The Wall Street Journal

The RNI team is also studying a pill that monitors vital signs and releases overdose reversal medication automatically in people who overdose. In another trial, the team is monitoring the heart rates, emotions, sleep cycles and cravings of thousands of drug users who are helping to train artificial intelligence to predict a relapse before it occurs, so recovery coaches can intervene.

Neuroscientists are finding that in people struggling with addiction, the nucleus accumbens, which sits deep in the brain near the midline above the ears, creates unusual traffic to the prefrontal cortex, which is responsible for decision-making and problem-solving, and helps regulate emotions.

The RNI trial uses ultrasound waves to vibrate cell membranes in this area to disrupt those connections and reset them.

Rezai says it is much like resetting traffic patterns on a highway. “There’s a lot of traffic going on between the addiction centre of the brain and the rest of the brain. Over time, that traffic is gone,” he says. “The addiction centre isn’t in charge anymore.”

The hope is that by taking away cravings – one of the biggest distractions in recovery – people will have an easier time focusing on learning to manage the daily stressors of life that often lead to continued addiction.

To Hilton, the treatment felt like quieting a chattering room.

Joe Hilton is one of 30 patients with substance-use disorders undergoing the clinical trials at the Rockefeller Neuroscience Institute at West Virginia University. Picture: Alyssa Schukar for The Wall Street Journal Slug:

He was the third patient to participate in an ongoing blinded, randomised clinical trial for the procedure, with support from the National Institutes of Health. This 30-patient trial follows promising results from an earlier trial of 20 patients who were aware of the treatment protocol they received. Patients who had spent much of their lives using drugs saw their cravings drop to near zero. About three-quarters of participants remained substance-free several months later.

Overall, $US5m from NIH, WVU and donors has helped fund the ultrasound research. Weill Cornell Medicine and the University of Maryland are working with RNI to begin similar trials in coming months with funding in part from the Florida Brain State Program, a consortium made up of the state of Florida, the State University System of Florida and Insightec, the manufacturer of the focused ultrasound equipment.

Hilton says he grew up in a home where drugs and alcohol were around all the time. His early memories from his Ohio childhood are of constant bonfire parties, funny smells coming from the backyard and people going in and out of the bathroom wiping their noses and sniffling.

“I pretty much was screwed from birth,” he says.

Hilton was using heroin, marijuana and cocaine by the time he was a teenager. At 30 years old, Hilton moved with his girlfriend, pregnant with their child, to another state hoping to get away from heroin. They married when their daughter was three. His wife became sober but Hilton had found methamphetamine.

Hilton says he tried getting off drugs many times for the sake of his wife and daughter. Over the years, he spent time in multiple treatment centres and hundreds of 12-step meetings. He had more than a dozen overdoses and spent time in prison because of drug-related offences. Eventually his wife left him and child protective services denied him access to his daughter. But none of that was enough to stop his use of drugs.

“My drug of choice is more. More of anything,” he says.

In July, as he awaited his procedure, head shaved, doctors scurried around him, getting ready to direct powerful ultrasound waves at his brain. He said nothing could be scarier than what he had already been through with his drug addiction. “I’m excited to feel what normal feels like. What it’s like to not think about wanting drugs all the time,” Hilton says.

Dr Rezai and his team help Hilton get ready. Picture: Alyssa Schukar for The Wall Street Journal

Despite researchers’ hopes for the treatment, they caution that it isn’t a miracle cure.

“If you take away the craving, but you don’t remove the stressors and you don’t replace the craving with more adaptive coping mechanisms, eventually you’re going to revert back,” says James Mahoney, clinical neuropsychologist at RNI.

Terry “TJ” Sanders, 49, was in the first round of patients who received the ultrasound procedure. Recently, he returned to RNI asking if he could have the treatment again. He had relapsed after five months.

At first, Sanders says, the procedure gave him time for a voice of reason to set in so he wouldn’t resort to drugs. Then his financial situation deteriorated. The recent death of his wife added stress. He started losing that pause, he says. “I went back to survival.”

In early October, Sanders underwent the procedure again. He has since used fentanyl once. Aside from that, he hasn’t returned to using drugs and alcohol, according to his doctors.

Rezai tracks Hilton’s cravings for drugs as well as his emotions during the clinical trial.

Hilton’s wife, Maggie Bracken, 35, says she has seen a dramatic change in her husband. “Instead of getting frustrated and relapsing, he is more willing to talk it out and figure it out,” she says.

The two have reunited and are working together through child protective services to return Hilton’s rights to his daughter, so the family can live together. He is attending 12-step meetings five days a week, taking addiction treatment medication and visiting a therapist weekly.

On October 7, Hilton learned that what he had received 12 weeks before was the actual ultrasound treatment and not a placebo. The next day, he talked over a video call from his job at a pizza restaurant. “My drive to want drugs is damn near depleted,” he says. “I never thought I’d say that in my life.”

THE WALL STREET JOURNAL