Addiction Policy Forum Blog

7 min read

What is TMS and can it help treat withdrawal, addiction, and patients with SUDs like it can treat depression and OCD?

By Mark Gold, MD on September 19, 2019

In April, The Atlantic published a piece about a young woman who became a viral internet sensation after she was photographed wearing a futuristic-looking hat or device on her head.1 Some online commentators dubbed the large, grey headwear, connected by a strap under the chin, “the depression helmet.” What the commentators did not understand is that such devices are part of a safe, effective, FDA-approved treatment for depression: transcranial magnetic stimulation, or TMS. At the University of Florida, in 2008, I was part of a team that purchased one of the first TMS machines sold after FDA approval. We bought other machines and did TMS research as well. Since that time, the technique has been used successfully to treat depression around the world. It was also approved in 2013 for the treatment of pain associated with certain migraine headaches, and more recently approved for the treatment of Obsessive-Compulsive Disease.2

At least 100 randomized clinical trials have been completed in an attempt to find a MAT which might treat cocaine use disorder, employing over 50 chemical compound medications. With very little progress made from early work3, none have been shown to be particularly useful4, until the current day and TMS. Treatment must reverse more than acute or even chronic dopamine neuron effects of cocaine. The TMS research group at the National Institute of Drug Abuse (NIDA) in Baltimore works on TMS research, dopamine plasticity, cocaine and SUD-related dopamine changes. TMS offers us a chance to intervene against cocaine and other substance’s ability to change the firing rates and key brain circuits that ultimately reduce dopamine release. The TMS research group is working to define how SUDs change the brain, intrinsic and synaptic plasticity control dopamine neurons, and what might be done to return the brain to pre-drug functionality.5

NIDA TMS researchers were featured in a cover story on the science of addiction in National Geographic.6 This article describes how a psychiatrist in Italy, who has treated addiction for 30 years,  became interested in TMS and began using it for treatment. It also details the successful use of traditional TMS treatment on a chronic relapsing patient, treated as if he had a naturally occurring depression. The psychiatrist, patient, and NIDA researchers are all interviewed for the story. TMS is not shock therapy; it delivers electromagnetic pulses to the brain in dopamine rich areas, resulting in painless, rapid magnetic pulses delivered through a pad or cap or hat. It is called non-invasive, and clearly has the ability to use  magnetic stimulation to drive the brain’s circuitry with electric currents. TMS can increase and decrease cortical excitability, through high and low frequency wave generation.  Scientists are very excited about this as TMS may help rebuild neural connections, or possibly regenerate dopamine systems damaged by substance use. The psychiatrist featured in the National Geographic article, Luigi Gallimberti, MD, has subsequently used TMS to treat other addictions. 

Medication assisted therapies are approved and used for detoxification, maintenance, and relapse prevention. Unfortunately, these do not address many of the changes produced by cocaine and other drugs. Even patients following these treatment plans and taking medications often feel a lack of energy, diminished pleasure, and declining enthusiasm, and drop out of treatment. TMS might not help people to stop using drugs, but it could be beneficial in helping with addiction and post-addiction related depression and anhedonia.7 TMS researchers have become part of a promising frontier for combating craving, addiction, relapse, and co-occurring depression. Greeting with laughter images of TMS devices, caps, and hats is a perfectly unhelpful reaction in the middle of a major opioid crisis.

FDA approval for treating depression through TMS piqued interest in applying the technique to substance use disorders, since depression is often a major part of SUDs, and a cause of relapses and overdoses, as a recent consensus review on the current state of non-invasive brain stimulation science pointed out. Neuroscience research has helped establish connections between substance-using behavior and particular neural circuits, which prompted additional interest in using TMS and related techniques to treat substance use disorders. TMS is no longer an experiment. With time, SUD researchers have compiled more studies on non-invasive brain stimulation, symptoms, and outcomes, leading to new reviews on relative effectiveness and future development prospects.


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6 min read

Now What? THC Exposure and the Adolescent Brain

By Mark Gold, MD on August 29, 2019

As more states move to decriminalize or legalize marijuana and THC-related products, researching potential harms associated with cannabis use is an even more important field of study. In certain cases, such as marijuana-related medications, there is sound evidence. Usually, the manufacturer of a drug has to do clinical trials, called FDA trials, to demonstrate dose, safety, and efficacy for a particular problem or illness. The FDA did approve the first drug comprised of an active ingredient derived from marijuana to treat rare, severe forms of epilepsy. This was a well-conceived and logical trial and process. It resulted in the approval of Epidiolex (cannabidiol, or CBD) oral solution for the treatment of seizures associated with two rare and severe forms of epilepsy, Lennox-Gastaut syndrome and Dravet syndrome, in patients two years of age and older. This was the first FDA-approved drug that contains a purified drug substance derived from marijuana. It was also the first FDA approval of a drug for the treatment of patients with Dravet syndrome. Notably, however, the FDA did not approve a crude plant or marijuana, but CBD. CBD does not cause intoxication or euphoria, the “high” that comes from marijuana’s tetrahydrocannabinol (THC). In this case, we know that the medication is safe, we know its formulation and composition, and we know the dose. We also know that before this treatment, there were no good alternatives.

According to pediatricians and research scientists, there’s no scientific evidence supporting the acceptability of adolescent marijuana use, and products sold in dispensaries pose considerable risks to children and teens.1 The situation with cannabis, vaping THC, and other preparations is considerably different from that of an FDA-approved medication. In these cases, sadly, we are doing the research after the fact. We know that laws are meant to prevent children from using and smoking marijuana, but the public appears confused about safety warnings when children and adolescents seem like they are safely given cannabis for seizures. Recent data shows that use is increasing among young people. A SAMHSA report found that marijuana is teens’ most widely used illicit drug.2 Frequent marijuana use, in both youth (aged 12-17 years) and young adults, appears to be associated with risk for opioid use, heavy alcohol use, and major depressive episodes. Youth have access to the legal cannabis and related product markets, as well as the thriving illicit marketplace for drugs. Health problems linked to vaping may be in the headlines, as many of those with reported lung damage have vaped THC, but it is not the only problem facing teen users.3 

What does the latest research tell us about the effects of cannabis on the adolescent brain, and do we know enough to make recommendations? 

Science has not shown that cannabis is performance-enhancing like amphetamines, psychostimulants, or medications like methylphenidate given to people with learning problems. Research has clearly shown that adult cannabis use can affect a person’s memory, performance and ability to learn. Recently, Gorey et. al. conducted a systematic review of 21 human and animal studies to investigate whether age influenced the effects of cannabis on the brain, and found preliminary evidence that suggested it does. Further understanding the differences between how cannabis affects the adult brain versus the adolescent one could help us create better messaging and education for youth about how cannabis could affect them.  

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