Rewiring the Will: The Ethics of Deep Brain Stimulation for Treatment-Resistant Addiction

Sometimes individuals will reach a point in their ailments where typical medicine and interventions have no effect. For patients with severe, treatment-resistant substance use disorder (SUD), that can happen after years of failed rehabilitation and medication trials. There are over 75,000 drug overdose deaths in the United States every year, and despite advances in behavioral and pharmacological treatments, over 50% of those receiving treatment for opioid use disorder experience relapse [1]. Considering this issue, deep brain stimulation (DBS) is now a part of the conversation as an intervention for the most critical cases. The procedure has been used to treat Parkinson's disease, but its application to addiction is an entirely other matter. 

What DBS Can Do

DBS is an adjustable, reversible, and non-destructive neurosurgical intervention using implanted electrodes to deliver electrical pulses to areas in the brain [2]. In treating addiction, the primary target of DBS has been the nucleus accumbens (NAc), a subcortical structure involved in reward processing. DBS has shown promising treatment effects in regards to the plastic changes in the NAc that are common characteristics of addiction [3]. The rationale behind performing this procedure is that if drug-seeking is a result of disrupted reward circuitry, then modulating that circuitry could interrupt the cycle of craving and relapse.

Early clinical results have shown some promise. A review of 26 human DBS studies between 2007 and 2023 found that DBS primarily targeting the NAc presented encouraging levels of efficacy in reducing cravings and consumption [2]. While some DBS trials were followed by remission in subjects, 73.2% of patients still reported drug relapses [2]. A 2023 trial found that DBS of the NAc and ventral capsule was safe, feasible, and had the potential to reduce substance use, craving, and emotional symptoms in those with opioid use disorder [1]. While results are not definitive, DBS has demonstrated some favorable outcomes. However, before we continue to move forward with it, this technology deserves a closer look at its ethics. 

The Autonomy Paradox

The central tension in applying DBS to addiction treatment involves autonomy. In general, the definition of autonomy is twofold: it involves the willingness to consent to medical procedures and the ability to lead an independent life without a sense of alienation of self [4]. These two aspects can go in opposite directions, as a patient can consent to a procedure and still experience a sort of alienation of self as part of the outcome.

Broadly, one of the main issues with human trials is this principle of autonomy, as patients with addictive disorders may not have the capacity to fully and knowledgeably consent to such a process. The science of addiction demonstrates how severe SUD impairs the prefrontal systems responsible for deliberative reasoning, especially in the moments when it matters the most [5]. As a result, assessing consent in this population requires an in-depth examination and vetting of their decision making.

On the other hand, refusing DBS because of diminished capacity is another ethical contradiction. As Caplan observed in coerced addiction treatment, there is a paradox in denying autonomy to restore it [6]. If addiction is damaging to an individual’s agency, then pushing to withhold a potential intervention in the name of protecting that agency becomes a circular argument. To solve quandaries like this one, a test like the MacArthur Competence Assessment Tool for Clinical Research can be useful [7]. Measures like this that assess one’s decision-making capacity provide an alternative path that takes into account the complicated relationship between addiction and autonomy. 

Questions of Identity

DBS for addiction raises further questions about what happens to the notion of self when brain circuitry is surgically altered. Some studies posit that DBS significantly alters a patient's personality and identity [8]. It is possible, however, that these discussions have misinterpreted psychosocial reintegration difficulties as DBS-related personality changes [8]. Essentially, the concern may be overstated, but it cannot be dismissed. There is as yet no decisive data supporting whether or not patients undergoing neuromodulation experience a change in their sense of self, as some reports indicate that patients can struggle to evaluate if their "improved" self post-DBS feels authentic or artificially induced [8].

For addiction specifically, this problem has an additional dimension. Conventional recovery from SUD is often perceived by patients as a hard-won transformation. The struggle against addiction becomes part of an individual’s narrative. What happens to that narrative when the craving simply disappears because of an external device? 

A Framework for Proceeding Carefully

Consensus statements on DBS underscore the significance of a multidisciplinary team approach  with those from different fields, including psychiatry, neurology, neurosurgery, and surgery, to collaborate in assessing and treating patients. Additionally, an ethical committee should oversee the interventions for further improvement of patient outcomes [9]. Robust longitudinal follow-ups and standardized criteria for treatment resistance need to be implemented before DBS can become the convention for addiction treatment. 

While DBS offers transformative potential, its application must be guided by ethics and patient-centered care. The population experiencing active addiction is vulnerable, and Deep Brain Stimulation is a very invasive procedure. This combination demands unique care and attention to detail to allow DBS to continue progressing as a viable treatment pathway for those with substance use disorders. 

Reviewed By: Laila Khan-Farooqi

Designed By: Selena Xiao

References

[1] Rezai, A. R., Mahoney, J. J., Ranjan, M., Haut, M. W., Zheng, W., Lander, L. R., ... & Hodder, S. L. (2023). Safety and feasibility clinical trial of nucleus accumbens deep brain stimulation for treatment-refractory opioid use disorder. Journal of Neurosurgery, 140(1), 231–239.

[2] Luigjes, J., van den Brink, W., Feenstra, M. (2012). Deep brain stimulation in addiction: a review of potential brain targets. Mol Psychiatry 17, 572–583.

[3] Chang, R., Peng, J., Chen, Y., Liao, H., Zhao, S., Zou, J., & Tan, S. (2022). Deep Brain Stimulation in Drug Addiction Treatment: Research Progress and Perspective. Frontiers in psychiatry, 13, 858638. 

[4] Lee, K. E., Bhati, M. T., & Halpern, C. H. (2016). A Commentary on Attitudes Towards Deep Brain Stimulation for Addiction. Journal of neurology & neuromedicine, 1(8), 1–3. 

[5] Yuen, J., Kouzani, A. Z., Berk, M., Tye, S. J., Rusheen, A. E., Blaha, C. D., Bennet, K. E., Lee, K. H., Shin, H., Kim, J. H., & Oh, Y. (2022). Deep Brain Stimulation for Addictive Disorders-Where Are We Now?. Neurotherapeutics : the journal of the American Society for Experimental NeuroTherapeutics, 19(4), 1193–1215. 

[6] Caplan, A. (2008). Denying autonomy in order to create it: The paradox of forcing treatment upon addicts. Addiction, 103(12), 1919–1921.

[7] Lo, C., Mane, M., Kim, J. H., Berk, M., Sharp, R. R., Lee, K. H., & Yuen, J. (2023). Treating addiction with deep brain stimulation: Ethical and legal considerations. The International journal on drug policy, 113, 103964. 

[8] Shaw, J., Pyreddy, S., Rosendahl, C., Lai, C., Ton, E., & Carter, R. (2025). Current Neuroethical Perspectives on Deep Brain Stimulation and Neuromodulation for Neuropsychiatric Disorders: A Scoping Review of the Past 10 Years. Diseases (Basel, Switzerland), 13(8), 262. 

[9] Iqbal, J., Mansour, M. N. M., Saboor, H. A., Suyambu, J., Lak, M. A., Zeeshan, M. H., Hafeez, M. H., Arain, M., Mehmood, M., Mehmood, D., & Ashraf, M. (2023). Role of deep brain stimulation (DBS) in addiction disorders. Surgical neurology international, 14, 434.