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Versalovic E, Klein E, Goering S, Ngo Q, Gliske K, Boulicault M, Sullivan LS, Thomas MJ, Widge AS. Deep Brain Stimulation for Substance Use Disorders? An Exploratory Qualitative Study of Perspectives of People Currently in Treatment. J Addict Med 2023; 17:e246-e254. [PMID: 37579102 PMCID: PMC10417220 DOI: 10.1097/adm.0000000000001150] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2022] [Accepted: 01/05/2023] [Indexed: 03/06/2023]
Abstract
OBJECTIVE Although previous studies have discussed the promise of deep brain stimulation (DBS) as a possible treatment for substance use disorders (SUDs) and collected researcher perspectives on possible ethical issues surrounding it, none have consulted people with SUDs themselves. We addressed this gap by interviewing people with SUDs. METHODS Participants viewed a short video introducing DBS, followed by a 1.5-hour semistructured interview on their experiences with SUDs and their perspective on DBS as a possible treatment option. Interviews were analyzed by multiple coders who iteratively identified salient themes. RESULTS We interviewed 20 people in 12-step-based, inpatient treatment programs (10 [50%] White/Caucasian, 7 Black/African American [35%], 2 Asian [10%], 1 Hispanic/Latino [5%], and 1 [5%] Alaska Native/American Indian; 9 women [45%], 11 men [55%]). Interviewees described a variety of barriers they currently faced through the course of their disease that mirrored barriers often associated with DBS (stigma, invasiveness, maintenance burdens, privacy risks) and thus made them more open to the possibility of DBS as a future treatment option. CONCLUSIONS Individuals with SUDs gave relatively less weight to surgical risks and clinical burdens associated with DBS than previous surveys of provider attitudes anticipated. These differences derived largely from their experiences living with an often-fatal disease and encountering limitations of current treatment options. These findings support the study of DBS as a treatment option for SUDs, with extensive input from people with SUDs and advocates.
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Cabrera LY, Courchesne C, Bittlinger M, Müller S, Martinez R, Racine E, Illes J. Authentic Self and Last Resort: International Perceptions of Psychiatric Neurosurgery. Cult Med Psychiatry 2021; 45:141-161. [PMID: 32562138 DOI: 10.1007/s11013-020-09679-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Psychiatric neurosurgery has resurfaced over the past two decades for the treatment of severe mental health disorders, with improved precision and safety over older interventions alongside the development of novel ones. Little is known, however, about current public opinions, expectations, hopes, and concerns over this evolution in neurotechnology, particularly given the controversial history of psychosurgery. To fill this knowledge gap, we conducted a study with eight focus groups in Vancouver and Montreal (Canada; n = 14), Berlin (Germany; n = 22), and Madrid (Spain; n = 12). Focus group texts were transcribed and analyzed using qualitative content analysis in the language local to each city, guided by the theoretical framework of pragmatic neuroethics. Findings indicate that participants across all cities hold concerns about the last resort nature of psychiatric neurosurgery and the potential impact on the authentic self of patients who undergo these procedures. The views captured serve to advance discussion on the appropriate timing for psychiatric neurosurgery, promote sound health policy for the allocation of this resource, and foster scientific literacy about advances for mental health internationally.
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Affiliation(s)
- L Y Cabrera
- Center for Ethics & Humanities in the Life Sciences, Department of Translational Neuroscience, Michigan State University, East Fee Hall, 965 Wilson Road, Rm C211, East Lansing, MI, 48824, USA.
| | - C Courchesne
- The University of British Columbia, Vancouver, Canada
| | - M Bittlinger
- Division of Mind and Brain Research, Department of Psychiatry and Psychotherapy, CCM, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health, Berlin, Germany
| | - S Müller
- Division of Mind and Brain Research, Department of Psychiatry and Psychotherapy, CCM, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health, Berlin, Germany
| | - R Martinez
- Functional Neurosurgery and Radiosurgery Unit, Ruber International Hospital, Madrid, Spain
| | - E Racine
- Institut de Recherches Cliniques de Montréal (IRCM), Department of Medicine and Department of Social and Preventive Medicine, Université de Montréal, Montreal, Canada.,Department of Neurology and Neurosurgery and Biomedical Ethics Unit, McGill University, Montreal, Canada
| | - J Illes
- Department of Medicine, The University of British Columbia, 2211 Wesbrook Mall, Koerner S124, Vancouver, BC, V6T 2B5, Canada.
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Addiction and Voluntariness: Five “Challenges” to Address in Moving the Discussion Forward. Camb Q Healthc Ethics 2019; 28:677-694. [DOI: 10.1017/s0963180119000628] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Abstract:The question as to whether people with an addiction have control (and to what extent) over their addiction, and voluntarily decide to use substances is an ongoing source of controversy in the context of research on addiction, health policy and clinical practice. We describe and discuss a set of five challenges for further research into voluntariness (definition[s], measurement and study tools, first person perspectives, contextual understandings, and connections to broader frameworks) based on our own research experiences and those of others.
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Park RJ, Singh I, Pike AC, Tan JOA. Deep Brain Stimulation in Anorexia Nervosa: Hope for the Hopeless or Exploitation of the Vulnerable? The Oxford Neuroethics Gold Standard Framework. Front Psychiatry 2017; 8:44. [PMID: 28373849 PMCID: PMC5357647 DOI: 10.3389/fpsyt.2017.00044] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2016] [Accepted: 03/03/2017] [Indexed: 01/13/2023] Open
Abstract
Neurosurgical interventions for psychiatric disorders have a long and troubled history (1, 2) but have become much more refined in the last few decades due to the rapid development of neuroimaging and robotic technologies (2). These advances have enabled the design of less invasive techniques, which are more focused, such as deep brain stimulation (DBS) (3). DBS involves electrode insertion into specific neural targets implicated in pathological behavior, which are then repeatedly stimulated at adjustable frequencies. DBS has been used for Parkinson's disease and movement disorders since the 1960s (4-6) and over the last decade has been applied to treatment-refractory psychiatric disorders, with some evidence of benefit in obsessive-compulsive disorder (OCD), major depressive disorder, and addictions (7). Recent consensus guidelines on best practice in psychiatric neurosurgery (8) stress, however, that DBS for psychiatric disorders remains at an experimental and exploratory stage. The ethics of DBS-in particular for psychiatric conditions-is debated (1, 8-10). Much of this discourse surrounds the philosophical implications of competence, authenticity, personality, or identity change following neurosurgical interventions, but there is a paucity of applied guidance on neuroethical best practice in psychiatric DBS, and health-care professionals have expressed that they require more (11). This paper aims to redress this balance by providing a practical, applied neuroethical gold standard framework to guide research ethics committees, researchers, and institutional sponsors. We will describe this as applied to our protocol for a particular research trial of DBS in severe and enduring anorexia nervosa (SE-AN) (https://clinicaltrials.gov/ct2/show/NCT01924598, unique identifier NCT01924598), but believe it may have wider application to DBS in other psychiatric disorders.
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Affiliation(s)
- Rebecca J. Park
- OxBREaD Research Group, Department of Psychiatry, University of Oxford, Oxford, UK
| | - Ilina Singh
- Neuroscience Ethics and Society Research Group, Department of Psychiatry, University of Oxford, Oxford, UK
- Oxford Uehiro Centre for Practical Ethics, University of Oxford, Oxford, UK
| | - Alexandra C. Pike
- OxBREaD Research Group, Department of Psychiatry, University of Oxford, Oxford, UK
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Woopen C, Pauls KAM, Koy A, Moro E, Timmermann L. Early application of deep brain stimulation: Clinical and ethical aspects. Prog Neurobiol 2013; 110:74-88. [DOI: 10.1016/j.pneurobio.2013.04.002] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2012] [Revised: 04/10/2013] [Accepted: 04/16/2013] [Indexed: 11/25/2022]
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Pisapia JM, Halpern CH, Muller UJ, Vinai P, Wolf JA, Whiting DM, Wadden TA, Baltuch GH, Caplan AL. Ethical Considerations in Deep Brain Stimulation for the Treatment of Addiction and Overeating Associated With Obesity. AJOB Neurosci 2013; 4:35-46. [PMID: 29152408 PMCID: PMC5687095 DOI: 10.1080/21507740.2013.770420] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
The success of deep brain stimulation (DBS) for movement disorders and the improved understanding of the neurobiologic and neuroanatomic bases of psychiatric diseases have led to proposals to expand current DBS applications. Recent preclinical and clinical work with Alzheimer's disease and obsessive-compulsive disorder, for example, supports the safety of stimulating regions in the hypothalamus and nucleus accumbens in humans. These regions are known to be involved in addiction and overeating associated with obesity. However, the use of DBS targeting these areas as a treatment modality raises common ethical considerations, which include informed consent, coercion, enhancement, threat to personhood, and manipulation of the reward center. Pilot studies for both of these conditions are currently investigational. If these studies show promise, then there is a need to address the ethical concerns related to the initiation of clinical trials including the reliability of preclinical evidence, patient selection, study design, compensation for participation and injury, cost-effectiveness, and the need for long-term follow-up. Multidisciplinary teams are necessary for the ethical execution of such studies. In addition to establishing safety and efficacy, the consideration of these ethical issues is vital to the adoption of DBS as a treatment for these conditions. We offer suggestions about the pursuit of future clinical trials of DBS for the treatment of addiction and overeating associated with obesity and provide a framework for addressing ethical concerns related to treatment.
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Hall W, Carter A. Anticipating possible policy uses of addiction neuroscience research. DRUGS-EDUCATION PREVENTION AND POLICY 2013. [DOI: 10.3109/09687637.2013.779426] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Bell E, Racine E. Ethics guidance for neurological and psychiatric deep brain stimulation. HANDBOOK OF CLINICAL NEUROLOGY 2013; 116:313-25. [DOI: 10.1016/b978-0-444-53497-2.00026-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
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Lee NM, Carter A, Owen N, Hall WD. The neurobiology of overeating. Treating overweight individuals should make use of neuroscience research, but not at the expense of population approaches to diet and lifestyle. EMBO Rep 2012; 13:785-90. [PMID: 22898978 DOI: 10.1038/embor.2012.115] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Affiliation(s)
- Natalia M Lee
- The University of Queensland, UQ Centre for Clinical Research, Herston, Queensland, Australia
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Stephen JH, Halpern CH, Barrios CJ, Balmuri U, Pisapia JM, Wolf JA, Kampman KM, Baltuch GH, Caplan AL, Stein SC. Deep brain stimulation compared with methadone maintenance for the treatment of heroin dependence: a threshold and cost-effectiveness analysis. Addiction 2012; 107:624-34. [PMID: 21919988 DOI: 10.1111/j.1360-0443.2011.03656.x] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
AIMS To determine the success threshold at which a theoretical course of deep brain stimulation (DBS) would provide the same quality of life (QoL) and cost-effectiveness for heroin dependence as methadone maintenance treatment (MMT). DESIGN We constructed a decision analysis model to calculate QoL after 6 months of MMT and compared it to a theoretical course of DBS. We also performed a cost-effectiveness analysis using societal costs of heroin dependence, MMT and DBS. SETTING Systematic literature review and meta-analysis. PARTICIPANTS Patients (n = 1191) from 15 trials administering 6 months of MMT and patients (n = 2937) from 45 trials of DBS for movement disorders. MEASUREMENTS Data on QoL before and after MMT, retention in MMT at 6 months, as well as complications of DBS and their impact on QoL in movement disorders. FINDINGS We found a QoL of 0.633 (perfect health = 1) in heroin addicts initiating MMT. Sixty-six per cent of patients completed MMT, but only 47% of them had opiate-free urine samples, resulting in an average QoL of 0.7148 (0.3574 quality-adjusted life years (QALYs) over 6 months). A trial of DBS is less expensive ($81,000) than untreated (or relapsed) heroin dependence ($100,000), but more expensive than MMT ($58,000). A theoretical course of DBS would need a success rate of 36.5% to match MMT, but a success rate of 49% to be cost-effective. CONCLUSIONS The success rate, defined as the percentage of patients remaining heroin-free after 6 months of treatment, at which deep brain stimulation would be similarly cost-effective in treating opiate addiction to methadone maintenance treatment, is estimated at 49%.
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Affiliation(s)
- James H Stephen
- Department of Neurosurgery, Centers for Functional and Restorative Neurosurgery, Hospital of the University of Pennsylvania, Philadelphia, PA 19104, USA
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Ethical Aspects of Neuromodulation. INTERNATIONAL REVIEW OF NEUROBIOLOGY 2012. [DOI: 10.1016/b978-0-12-404706-8.00016-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/04/2023]
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