| Paper authors: | Victor M. Tang, Scott Aaronson, Mohamed Abdelghani, Chris Baeken, Tracy Barbour, André R. Brunoni, Samuel Bulteau, Linda L. Carpenter, Paul E. Croarkin, Zafiris J. Daskalakis, Paul B. Fitzgerald, F. Andrew Kozel, Bernard Le Foll, Urvakhsh Meherwan Mehta, Yoshihiro Noda, Frank Padberg, Christian Plewnia, Hang Su, Philip van Eijndhoven, Eric van Exel, Iris van Oostrom, Fidel Vila-Rodriguez, Daphne Voineskos, Saydra Wilson, Daniel M. Blumberger |
| Year of paper publication: | 2025 |
| Post authors: | Caleb Pozdnikoff, Sarah Kesler, Fidel Vila-Rodriguez |
| Link to full research article: | Tang et al. (2025) Assessment and Management of Concurrent Substance Use in Patients Receiving Repetitive Transcranial Magnetic Stimulation for Depressive, Obsessive-Compulsive, Psychotic, and Trauma-Related Disorders: A Delphi Consensus Study and Guideline |
Introduction
Repetitive transcranial magnetic stimulation (rTMS) is becoming a common treatment for treatment-resistant depression, along with other mental health diagnoses. However, determining how to assess and manage current substance use (recreational and nonmedical drug and alcohol use) in patients receiving rTMS is complex and currently lacks detailed, specific recommendations. This is important because the dose of rTMS is calibrated to a baseline sensitivity of the brain required for brain cells to fire, however substance use can change this baseline. This may make rTMS treatments less effective or safe, as there is a risk of overdosing or underdosing the stimulation intensity.
In this study, the authors gathered a panel of doctors and researchers who are experts in the field of rTMS. By asking all the experts a series of questionnaires, they reached a consensus on the best approach to manage substance use for people receiving rTMS. This was done to create a consistent safety framework for doctors and researchers to advise their patients.
Methods
These guidelines were created using the Delphi method, an established approach for guiding experts toward agreement through systematic surveys and feedback. An international panel of 23 rTMS experts was assembled. Through questionnaires, they offered their opinions on what recommendations should be made for patients using substances while receiving rTMS for psychiatric disorders. The experts completed three consecutive rounds of questionnaires, and only recommendations with a very high level of agreement were included in the guideline.
The study specifically focused on assessing and managing the use of alcohol, cannabis, stimulants (i.e. cocaine, MDMA), and opioids (i.e. heroin, oxycodone), aiming to provide detailed recommendations for clinical practice and future research.
Results
- People with an active substance use disorder should be assessed for the risk, type, acuity, and severity of substance use.
- An active substance use disorder does not automatically rule someone out for treatment; a review of their specific circumstances is warranted.
- Patients should be advised not to abruptly increase, decrease, or discontinue substance use immediately prior to receiving rTMS.
- This is because sudden changes in substance use can influence the individual’s seizure threshold.
- The most significant safety risk associated with active substance use is the presence of intoxication or withdrawal states, particularly with alcohol or recreational stimulant use.
- This is due to the potential for increased seizure risk.
- If a patient is identified as being intoxicated or in withdrawal from substance use, rTMS treatment should be postponed.
- Physicians need to monitor changes in substance use patterns to ensure the patient’s brain is not more or less easily excitable by the TMS device.
Conclusion
These guidelines advise against automatically excluding patients who use substances non-medically and recreationally. They instead recommend an individualized approach based on the frequency and amount of use. The greatest safety concern is intoxication or withdrawal states, especially involving alcohol or recreational stimulants which increase the risk of rTMS-induced seizures.
Although there is no definitive evidence that active substance use reduces rTMS efficacy for a psychiatric disorder, the lack of data warrants caution when treating patients who actively use substances. Future research is needed to systematically collect data on substance use in clinical and research settings to better inform understanding of its impact on both the safety and efficacy of rTMS.