الفهرس 
Opioids and cravingOnly 14 pages are availabe for public view
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Abstract
SUD remains one of the leading causes of death worldwide, despite efforts to control it. Currently, available treatment options offer results that are barely satisfactory, hence the search for novel, more effective treatment tools is mandatory.
TMS is a non-invasive brain stimulation treatment modality that has gained approval in treatment resistant major depressive disorder and Obsessive Compulsive Disorder, and recently received an FDA clearance for smoking cessation. Its potential in addiction treatment has been explored and research is underway to refine an optimum protocol for treatment that could yield more satisfactory cessation rates.
This study hypothesized that a course of 10 Hz rTMS of the left DLPFC will reduce craving for opioids. It was a single-blinded randomized controlled trial carried out in real life conditions to assess the role of using rTMS for reduction of opioid craving. It aimed to determine whether rTMS at this site would have a decremental effect on cravings after 18 treatment sessions in OUD patients receiving real TMS versus these receiving sham TMS.
Fifty-two subjects were recruited through Ain Shams Okasha Institute of Psychiatry outpatient clinic and inpatient unit. Current OUD patients in early abstinence of male gender between the ages of 18 and 65 who were willing to comply with the study procedures were included. To control for confounders, subjects with history of mental illness such as: Bipolar disorder, Psychotic illness, Major Depression with psychotic features, OCD or eating disorders were excluded. Subjects with contraindication to rTMS (history of neurological disorder or seizure, increased intracranial pressure, brain surgery, or head trauma with loss of consciousness for >15 minutes, implanted electronic device or metal in the head), history of autoimmune, endocrine, viral, or vascular disorder affecting the brain; history or MRI evidence of neurological disorder that would lead to local or diffuse brain lesions or significant physical impairment, or unstable cardiac disease, uncontrolled hypertension, severe renal or liver insufficiency also were excluded.
After an informed consent was obtained, the 52 subjects were matched then randomized to both study arms, baseline craving was measured using HCQ for heroin and BSCS for opiates other than heroin and followed up at the end of the study sessions after the 18th session. The rTMS procedure involved using the Magventure R 30 stimulator with a figure-eight coil. A protocol was chosen on the assumption that stimulation at such site would produce neuromodulation effects on the dopamine system with a number of sessions that may be acceptable for a scalable implantation treatment. The active rTMS protocol involved stimulation at a frequency of 10 Hz in 100 trains/day, 20 pulses/train, and inter-train interval of 15s done at 90% of the motor threshold (after identification of the resting Motor Threshold Potential [rMTP]) at the left dorsolateral prefrontal cortex, determined by moving the TMS coil 6 cm anterior to M1 along a parasagittal line. Subjects received 18 sessions over 6 weeks (3 sessions/week). Sham rTMS involved using a sham coil with the same stimulation parameters or tilting the coil away from the head during delivery of the pulse. Participation was to be terminated upon request or in case of intolerable adverse events including intolerable headache and seizures.
At the end of the follow-up period, 47 subjects completed the trial. Subjects were followed up for cravings using the initial scales (HCQ and BSCS).
Main findings indicated that 18 sessions of rTMS on the left DLPFC were clinically and statistically superior to sham treatment as regards reduction of craving in opiates other than heroin (morphine and Tramadol) as well as for heroin indicating higher treatment response in the active rTMS group. This finding, along with findings from other studies indicates that rTMS has a role as an aid in treatment of OUD, yet a more refined protocol has yet to be discovered to set a standard for treatment using this modality.