RTMS and Addressing Current Challenges in Alcohol and Substance Use Disorder Management

It has been four years since my research team has conducted our retrospective rTMS research on addiction among our group of patients suffering from comorbid depression [1]. Since then, it has been a considerably challenging time for the vast majority of us both working in the clinical field, but equally for our patients and for the public around the world, especially in the aftermath of Covid-19 pandemic. In a scientific brief released by the WHO, global prevalence of anxiety and depression increased by a massive 25% in the first year of the COVID-19 pandemic [2]. Alcohol and drug misuse have been no exception to this trend; with a 23% increase in alcohol abuse and a 16% increase in drug abuse since the onset of COVID-19 for people who had consumed those substances before the pandemic [3]. The scale of the problem appears, understandably, even bigger for people in self-isolation reporting a 26% higher consumption than they would normally use [3]. 

It is therefore worth reflecting on main highlights from the research we conducted during the early stage of the Covid-19 pandemic, and try to put these finding in perspective with the latest challenges, and expectation of our services worldwide nowadays. In our retrospective observational study, we looked into the findings of rTMS offered to 55 of our patients with Substance Use Disorders (SUDs) and comorbid Major Depressive Disorder (MDD) who were eligible for rTMS. Craving was measured using the Brief Substance Craving Scale (BSCS). Severity of MDD was measured using the Clinical Global Impression-Severity (CGI-S) scale. This was observed for patients who received rTMS between June 2019 and September 2020 at Erada Center, which is a Government of Dubai tertiary psychiatric service founded in 2016, and is 1 of only 2 specialized substance misuse rehabilitation centers in the entire UAE. Erada center is the only dedicated addiction rehabilitation service in Dubai, serving approximately 3.4 million people [4]. 

Patients who met criteria for and consented to receiving rTMS were contracted for treatment with 5 weekly sessions of high-frequency rTMS for 4 to 6 weeks (a total of 20 to 30 treatments). For the demographics of our population, the mean age was 29.25 years, with a Standard Deviation (SD) of 7.62. Mean age at first use of the substance was 22 years (SD of 6.6). The primary/ main substance of misuse for our patients was Opiates (47% of our cohort), amphetamines (35%), THC (7%), Alcohol (6%) and other substances (gabapentin, organic solvents, GHB) in the rest 6% of our patients. Mean duration of inpatient admission was 24 days (SD: 12.4), with the mean number of rTMS sessions received being 11 (SD: 7.5). 

Mean days of abstinence in the community post-rTMS was 140 days (SD: 157.6). 

We found a statistically significant difference between baseline and post-treatment scores in patients receiving rTMS on both CGI-S scores and BSCS scores. We also found that the number of rTMS sessions significantly predicted increased days of abstinence in the community. Our study found that for each additional rTMS treatment session, there was an associated excess of 10 more days of abstinence in the community. This relationship was found to be both statistically significant and sustainable even after adjustment for potential confounders. 

The above results seem to suggest a clear signal of the positive impact of rTMS on reducing depression and craving among SUD clients, and extending the duration of abstinence in a cohort of patients where Opiates and Methamphetamines were the main substances of use. A question could rise to mind if this association could be the result of simply alleviating depression. However, and in studies where rTMS showed reduction in craving in SUDs, participants were both with and without MDD, so it’s unlikely the results attained were solely to do with alleviating depression [5]. Besides, the effect of rTMS on reducing craving for SUDs has been observed in a number of meta-analyses [6,7], and which concluded that excitatory rTMS of the left DLPFC significantly reduced craving compared with sham stimulation, which supports our finding. 

As promising as the above results, we, however, have acknowledged in our research paper the limitations of study; including its retrospective observational design, the lack of a sham control arm, our sample including only male participants and only inpatients, which limits it generalizability to females with SUD and outpatient SUD populations. Hence, our study provides an invitation for further research into that area which may well prove pivotal in helping treatment for SUDs, especially for drugs where no Medication Assisted Treatments are available yet. 

Fast forward to the here and now; one of the latest releases from the WHO highlights that 2.6 million deaths per year were attributable to alcohol consumption, accounting for 4.7% of all deaths, and 0.6 million deaths were due to psychoactive drug use. Males notably were the prominent sect of this population; accounting for 2 million of the alcohol related deaths, and 0.4 million of drug-attributable deaths [8]. These figures highlight the scale of the problem with alcohol and SUD worldwide, and the treatment gap for SUD worldwide among the 145 countries reporting data into this report. The same release called for stronger commitment for achieving the UN Sustainable Development Goal (SDG) 3.5 throughout strategic partners intensifying action in eight strategic areas named in that release. 

In addition to the importance of increasing public awareness and strengthening prevention programs among the public as some of the strategic areas highlighted by the WHO, it is strongly worth considering the make neuromodulation therapies like rTMS available for populations with high-prevalence of depression and/ or alcohol and SUD, also, offering this modality of treatment to those in the early stages of exposure to alcohol and or drugs. This most likely would need a well-resourced and outreaching primary healthcare system with efficient networking with specialised addiction treatment facilities and neuromodulation units available in the proximity of the served population.