Review Article by Derya Özeş, M.S., M.A., LMFT, Chief Program Officer

Transcranial Magnetic Stimulation (rTMS), a non-invasive brain stimulation treatment, is emerging as a promising option worth tracking for people with stimulant use disorders. rTMS is a non-invasive FDA approved method that uses magnetic fields to stimulate the nerve cells. Broadly speaking, it is applied on a person’s head, typically on the left side of the forehead targeting the dorsolateral prefrontal cortex. By doing so, the electromagnetic signals stimulate cells in the brain to treat mental health and substance use conditions such as major depression and addiction (Mann., 2023). This method is most often used and recommended by health care professionals when medication fails for clients endorsing mental health diagnosis. The stimulation is known to regulate mood and promote neuroplasticity.

Per national data, relapse rates for individuals who successfully completed substance use treatment fluctuate between 60-90% within the first six months of graduating from their treatment programs. Given such significant rates, considering TMS as a protective option to reduce the likelihood of susceptibility for severe depressive symptoms, cravings for smoking, anxiety symptoms and addictive tendencies presents a strong and reasonable intervention for clients in recovery. TMS is shown to effectively suppress these tendencies by its ability to modulate neural circuits that function in the brains craving and impulse control mechanisms.

The need is real, as there are currently no FDA-approved medications for cocaine or methamphetamine use disorder, and the ASAM/AAAP guidelines don’t strongly recommend any medication for these conditions (ASAM/AAAP Stimulant Use Disorder Guidelines), although other off-label medications are mentioned. A large multi-site clinical trial called STIMULUS is now underway to test whether 30 sessions of rTMS, delivered over 8 weeks alongside cognitive behavioral therapy and contingency management, can reduce craving and use in people with cocaine or methamphetamine use disorder (Atoui et al., 2025). Results from this and similar trials over the next few years should give the field a much clearer picture.

Early signals from a related study called START-D are encouraging enough to keep this on our radar. In this trial of an “accelerated” rTMS protocol, multiple sessions packed into a shorter timeframe, patients with methamphetamine or cocaine use disorder stayed engaged, completing an average of nearly 49 out of 50 sessions (Jha, 2026). Preliminary observations suggest reductions in depression, lower cravings for stimulants and alcohol, and a stronger self-reported ability to resist using. These are early findings from a small group, and the pivotal evidence is still being gathered, but for SUD providers, rTMS is shaping up as a development worth following closely as the larger trials read out.

Despite the promising findings suggesting efficacy, there are some concerns regarding how well tolerated rTMS is, given the potential side effects.

Per VUMC Department of Psychiatry and Behavioral Sciences in Meharry Medical College, Tennessee, scientists conducted studies across 45 distinct participants who were diagnosed and clinically identified representing severe impairment related to Substance Use diagnosis, Clinical Depression lasting more than two months, and severe anxiety disorders such as Obsessive Compulsive Disorder.

As precaution, individuals receiving TMS were required to be older than 18 years of age and were medically approved to participate in the study. Individuals actively using substances such as alcohol and therefore had a higher risk of seizures were not permitted to participate.

Adverse effects after initial reception of TMS were identified as headache, neck pain, fatigue, dizziness, short term cognitive impairment, insomnia, nausea, and potentially worsening depression or mania in the short term. In order to determine true risk of side effects, confidence intervals were calculated. Confidence intervals calculate percent of the populations likelihood of being impacted by the stimuli of interest.

Of the 2,865 participants with a substance use diagnosis monitored, 1 participant out of every 1,000 presented with strongest adverse side effect.

Common side effects of participants were reflected in headache or scalp discomfort (8-9%), fatigue (1-2%), dizziness (0.8%) and nausea (0.9%); neck pain and cognitive impairment were found most in sham conditions than those in active treatment. This suggests these symptoms were nonspecific to the TMS.

What is most profound and promising is that no elevated risk was observed or reported relating to relapse, overdose, suicidality, or worsening psychiatric symptoms of clients based on their identified baseline conditions. Of all participants who experienced rTMS (Repetitive Transcranial Magnetic Stimulation), relapse after treatment was reported at 1.8% of all cases. While relapse was not 100% guaranteed, 1.8% compared 60-90% national averages post 6 months of outpatient SUD treatment highlights notable contrast. What is worth highlighting that this article overlooks is that individuals who graduate successfully from SUD residential level of care do not present as monumental relapse rates but instead are reflected in a relapse percentage of 40-60% national average (Nagy, 2022).

Perhaps one of the reasons rTMS is not more widely benefiting patients is due to the fragmentation of the healthcare system as well as patients lack awareness on all treatment options as well as its accessibility.

For example, in order for a patient to quality for rTMS, they must have received a formal diagnosis of Treatment-Resistant Major Depressive Disorder with documented failure of 2-4 antidepressant medications from different classes in addition to documented experience with psychotherapy (McClintock, 2018).

As a Licensed Marriage and Family Therapist who believes in the value add of such multidisciplinary approaches to improving client outcomes, requiring a client to prove medication resistance as a precursor to eligibility for rTMS surfaces some reflections related to factors that reinforce socio-economic inequity, spiritual and cultural barriers to client access for treatment.

While being an advocate for psychotherapy as a precursor to rTMS recommendation, treatment resistance to medication as a precursor implies that all patients are able to access medication and or are open and comfortable with normalizing psychotropic medications as an expectation for all.

While many individuals who receive medication can see improvement in wellbeing, a mental health and medical model that requires it as a precursor to rTMS appears a topic of further exploration when evaluating cohesion and consistency of person-centered approaches in mental health and medical models.

References: 

1. Nagy N, Ella E, Shorab E, Moneam M, Tohamy A. Assessment of addiction management program and predictors of relapse among inpatients of the Psychiatric Institute at Ain Shams University Hospital. NIH; National Library of Medicine;  2022;29(1):80. doi: 10.1186/s43045-022-00246-5 
2. McLeod S. Confidence Intervals: Examples, Formula & Interpretation.(2026).  
3. Vista Research,(2026, March).(20).Horizon Services Management Review. 
4.  Mann, S. Malhi N. (2023, March). Repetitive Transcranial Magnetic Stimulation. National Institutes of Health. 
5.  McClintock. Consensus Recommendations for the Clinical Application of Repetitive Transcranial Magnetic Stimulation (rTMS) in the Treatment of Depression. Journal of Clinical Psychiatry. 2018 Jan-Feb;79(1):16cs10905. doi: 10.4088/JCP.16cs10905 
6.  Machii K, Cohen D, Ramos-Estebanez C, Pascual-Leone A. Safety of rTMS to non-motor cortical areas in healthy participants and patients. Clin Neurophysiol. 2006;117(2):455-471. doi:10.1016/j.clinph.2005.10.014 
7.  Mehta DD, Praecht A, Ward HB, et al. A systematic review and meta-analysis of neuromodulation therapies for substance use disorders. Neuropsychopharmacology. 2024;49(4):649-680. doi:10.1038/s41386-023-01776-0 
8.  Mishra BR, Nizamie SH, Das B, Praharaj SK. Efficacy of repetitive transcranial magnetic stimulation in alcohol dependence: A sham-controlled study. Addiction. 2010;105(1):49-55. doi:10.1111/j.1360-0443.2009.02777.x 
9.  Chen T, Su H, Li R, et al. The exploration of optimized protocol for repetitive transcranial magnetic stimulation in the treatment of methamphetamine use disorder: A randomized sham-controlled study. EBioMedicine. 2020;60:103027. doi:10.1016/j.ebiom.2020.103027 
10.  Jha, M. K. (2026). Transcranial magnetic stimulation for stimulant use disorders [Presentation]. ASAM Annual Conference, San Diego, CA.