Systematic review and meta-analysis: Combining transcranial magnetic stimulation or direct current stimulation with pharmacotherapy for treatment of substance use disorders

Effect of Transcranial Direct Current Stimulation on Craving, Cognitive Functions, and Serum Brain-Derived Neurotrophic Factor Level in Individuals on Maintenance Treatment for Opioid Use Disorder, A Randomized Sham-Controlled Trial

OBJECTIVES

To investigate the effects of transcranial direct current stimulation (tDCS) on brain-derived neurotrophic factor (BDNF) levels, craving, and executive functions in individuals on maintenance treatment for opioid use.

METHODS

We randomized 70 right-handed men aged 18-55 years into 2 groups: the intervention group and the sham group. The intervention was 10 sessions of 2 mA stimulation over 5 days. Each session in the sham group ended after 30 seconds. Craving was measured using the Desire for Drug Questionnaire (DDQ), Obsessive Compulsive Drug Use Scale (OCDUS), and visual analog scale (VAS). The measurements were taken before and after the intervention, as well as 2 months later. BDNF was measured before and after the intervention. Repeated-measures analysis of variance, the generalized estimating equation model, and independent t test were used for data analysis.

RESULTS

The mean differences (95% confidence intervals) in pre and post craving scores in the intervention group were (12.71 [9.10 to 16.32], P = 0.167) for VAS, (1.54 [1.12 to 1.96], P = 0.012) for OCDUS, and (1.71 [1.27 to 2.15], P = 0.125) for DDQ. These measures in the control group were -0.44 (-1.19 to 0.30), 0.01 (-0.21 to 0.23), and 0.126 (-0.11 to 0.36), respectively. BDNF serum levels significantly increased after the intervention (difference, 0.84 [0.69 to 0.99], P < 0.001); however, this change was not significant in the generalized estimating equation model. The effect of tDCS on craving was significant in OCDUS, but not significant in VAS and DDQ.

CONCLUSIONS

The tDCS reduces craving and improves executive functions in the short term. BDNF serum level was not associated with tDCS.

Managing Opioid Withdrawal Symptoms During the Fentanyl Crisis: A Review

Illicitly manufactured fentanyl (IMF) is a significant contributor to the increasing rates of overdose-related deaths. Its high potency and lipophilicity can complicate opioid withdrawal syndromes (OWS) and the subsequent management of opioid use disorder (OUD). This scoping review aimed to collate the current OWS management of study populations seeking treatment for OWS and/or OUD directly from an unregulated opioid supply, such as IMF. Therefore, the focus was on therapeutic interventions published between January 2010 and November 2023, overlapping with the period of increasing IMF exposure. A health science librarian conducted a systematic search on November 13, 2023. A total of 426 studies were screened, and 173 studies were reviewed at the full-text level. Forty-nine studies met the inclusion criteria. Buprenorphine and naltrexone were included in most studies with the goal of transitioning to a long-acting injectable version. Various augmenting agents were tested (buspirone, memantine, suvorexant, gabapentin, and pregabalin); however, the liberal use of adjunctive medication and shortened timelines to initiation had the most consistently positive results. Outside of FDA-approved medications for OUD, lofexidine, gabapentin, and suvorexant have limited evidence for augmenting opioid agonist initiation. Trials often have low retention rates, particularly when opioid agonist washout is required. Neurostimulation strategies were promising; however, they were developed and studied early. Precipitated withdrawal is a concern; however, the rates were low and adequately mitigated or managed with low- or high-dose buprenorphine induction. Maintenance treatment continues to be superior to detoxification without continued management. Shorter induction protocols allow patients to initiate evidence-based treatment more quickly, reducing the use of illicit or non-prescribed substances.