Many Americans are aware of the United States’ current overdose and addiction epidemic. For patients, families, friends, and loved ones, the tragic health and behavioral effects of substance use disorders (SUDs) are readily recognizable at a level of intimate, granular detail. Among individuals who have used substances, not all have SUDS, but many have spent money on illicit substances. SUD-related discussions frequently focus on survival or addiction, sometimes looking past another elephant in the room: finance. A recent RAND report for the Office of National Drug Control Policy (ONDCP) sheds an important light on how much money we pay for illegal drugs by highlighting Americans’ expenditures on methamphetamine, marijuana, heroin, and cocaine.
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What is TMS and can it help treat withdrawal, addiction, and patients with SUDs like it can treat depression and OCD?
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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Experts say it’s happened before.
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At the center of America’s deadly opioid epidemic, non-pharmaceutical fentanyl appears to be finding its way into illegal stimulants that are sold on the street, such as cocaine. Adulteration with fentanyl is considered a key reason why cocaine’s death toll is escalating. Cocaine and fentanyl are proving to be a lethal combination - cocaine-related death rates have increased according to national survey data. This has important emergency response and harm reduction implications as well—naloxone might reverse such overdoses if administered in time. A recent study by Nolan et. al. assessed the role of opioids, particularly fentanyl, in the increase in cocaine-involved overdose deaths from 2015 to 2016 and found these substances to account for most of this increase.