1. Decreasing Cocaine Use with Repetitive Transcranial Magnetic Stimulation
Cody Stekly and Kate Ziesenheim
School of PA Studies | Pacific University | 222 SE 8th Ave | Hillsboro | | Oregon
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BACKGROUND
Characteristics of Reviewed Studies, GRADE Profile
Dependence on cocaine causes significant functional impairment and morbidity in users and is extremely prevalent in the U.S. There were an estimated 18.2 million cocaine users worldwide in 2016,1 Unlike other abused substances, there is currently no effective standard of treatment to decrease cocaine cravings and prevent relapse. rTMS uses a non-invasive device to deliver magnetic stimulation to the prefrontal cortex to increase dopamine signaling in the brain and in turn decrease cravings for cocaine.2 This systematic review assesses whether current research shows that repetitive transcranial magnetic stimulation (rTMS) is an effective treatment for decreasing cocaine use.
Quality Assessment of Reviewed Articles
Study
Design
Downgrade Criteria
Upgrade Criteria
Quality
Limitations
Indirectness
Inconsistency
Imprecision
Publication bias
Bolloni et al4
RCT
Not Serious
Seriousa
Unlikely
None
Moderate
Terraneo et al5
Seriousb
Low
a High attrition rate and/or small sample size
b Open label study with no allocation concealment
RESULTS
DISCUSSION
CONCLUSION
The results of the randomized controlled trials in this review show preliminary evidence that rTMS is an effective treatment for decreasing cocaine use in people with cocaine use dependence. The Terraneo et al3 study showed a significant increase in abstinence during and 3 months after rTMS treatment and a significant decrease in cravings and depression as a secondary outcome. The Bolini et al2 study did not show a significant decrease in cocaine use during and 6 months after treatment for the rTMS group but did find a reduction in cocaine use on exploratory analysis.
Although the results of both studies are promising, there are limitations. Both studies had small sample sizes and high attrition rates. The Bolini et al2 trial was an open label study with no allocation concealment and did not have significant results until exploratory analysis was done. Trials that duplicate the results of these trials with larger samples sizes and lower attrition rates are required to make a clear argument that rTMS decreases cocaine use.
Despite the limitations of the research, there is no current effective treatment for reducing cocaine use and the adverse effects of rTMS are so mild that rTMS should be a consideration for treating cocaine use dependence, especially if previous treatment has failed or if current treatments such as inpatient rehabilitation are cost prohibitive.
There have only been two studies performed on rTMS’s effects on cocaine use specifically, which were both included in this review. The first study, Terraneo et al. 3 was an open label, randomized controlled trial that compared the effectiveness of pharmacologic treatment and rTMS treatment on decreasing cocaine use. The results showed that rTMS lowers cocaine use more than pharmacological treatment during and after treatment. The second study, Bolini et al2, was a double blinded, randomized controlled trial that compared the effectiveness of rTMS to a sham treatment on decreasing cocaine use. Exploratory analysis showed that rTMS lowers cocaine use more than the sham treatment during and after treatment.
Current research shows evidence that rTMS is a promising new treatment to successfully decrease cocaine use and help cocaine users to maintain abstinence even after treatment is complete. The current research, however, has only mild to moderate quality, based on the GRADE criteria. Future trials are needed which have larger sample sizes and longer follow up periods to show whether rTMS has a positive and longstanding effect on decreasing cocaine use.
METHODS
An exhaustive search of the medical literature databases was performed using Medline-Ovid, CINAHL, and Web of Science with the search words “cocaine” and “transcranial magnetic stimulation”. The studies reviewed2,3 were chosen based on inclusion and exclusion criteria and were assessed for quality using the GRADE criteria. A search of the National Institute of Health database for ongoing trials was also performed.
REFERENCES
United Nations Office on Drugs and Crime. World Drug Report Accessed July 13, 2017.
Bolloni C, Panella R, Pedetti M, Grazia Frascella A, Gambelunghe C, Piccoli T, Maniaci G, Brancato A, Cannizzario C, Diana M. Bilateral Transcranial Magnetic Stimulation of the Prefrontal Cortex Reduces Cocaine Intake: A Pilot Study. Frontiers in Psychiatry (2016) 7:133 .
Terraneo A, Leggio L, Saladini M, Ermani M, Bonci A, Gallimberti L. Transcranial magnetic stimulation of dorsolateral prefrontal cortex reduces cocaine use: a pilot study. Eur Neuropsychopharmacol (2016) 26(1):37–44 .
Clinicaltrials.gov: A service of the U.S. National Institutes of Health. Treatment With Transcranial Magnetic Stimulation for Cocaine Addiction: Clinical Response and Functional Connectivity. Accessed July 13, 2017
CONTACT INFORMATION
Kate Ziesenheim Physician Assistant Student T: E:
Cody Stekly
Physician Assistant Student T: E:
Acknowledgements
To our family and friends, thank you for all for all of the support.