Harnessing neuroimaging-guided transcranial magnetic stimulation for precision therapy in substance use disorders

Substance use disorders (SUDs) are a critical public health challenge characterized by high relapse rates, with existing treatments often proving inadequate. The focus of this review is to provide an update on the current state of transcranial magnetic stimulation (TMS) as a therapeutic intervention for SUDs and discuss neuroimaging-guided TMS practices. This review explores the neurobiology underlying SUDs, emphasizing the roles of the prefrontal cortex, striatal circuits, and dopaminergic pathways, and examines the theory that TMS modulates neurocircuitry to impact addiction-related behaviors. We discuss TMS procedural aspects and provide a comparative analysis of TMS protocols, focusing on repetitive, deep, single-pulse, paired-pulse, and a more recent approach, theta burst stimulation. We review recent randomized clinical trials (RCTs) to demonstrate reductions in cravings and use across SUDs as well as highlight the need for standardized protocols. We emphasize the power of combining neuroimaging techniques to show functional connectivity changes in the brain and identify potential biomarkers predictive of SUD treatment response, an unexplored area of discussion. With these topics, this review highlights the potential of TMS as a versatile and effective therapeutic modality for SUDs, especially when combined with neuroimaging. Key findings emphasize the necessity for future research to address methodological challenges, such as standardizing protocols and optimizing stimulation parameters. The integration of neuroimaging provides insights into functional connectivity changes, enabling enhanced precision and individualized treatment strategies. By validating TMS approaches and incorporating multimodal techniques, this field can advance toward a more robust clinical utility in addressing the complex neurocircuitry of addiction-related behaviors underlying SUDs.