Transcranial Magnetic Stimulation for Alcohol Cravings

A new study finds transcranial magnetic stimulation may reduce alcohol cravings.

Reviewed by Jessica Schrader

Key points

• Alcohol use disorder is a serious, destructive, and difficult-to-treat addiction.
• While medication and therapy are effective, additional tools are needed to help reduce or stop alcohol misuse.
• Alcohol cravings are a key target in treatment, reducing risk of relapse and amount of alcohol consumed.

Transcranial magnetic stimulation, or "TMS," is an FDA-approved psychiatric treatment for major depressive disorder and obsessive-compulsive disorder (OCD), with intriguing clinical trials suggesting future application in a variety of difficult-to-treat conditions, including PTSD (post-traumatic stress disorder), anxiety disorders, eating disorder, addictions, ADHD (attention deficit/hyperactivity disorder), sleep issues, and a range of other applications—all currently "off-label" for clinical use, and under research investigation. In recent posts, we've looked at rapid protocols for treating depression, known as "accelerated TMS," as well as recent research directly comparing TMS with multiple medication trials and finding greater benefit from TMS than a series of medications¹. Because TMS is generally safe and well-tolerated, aside from issues with access and insurance coverage, it is often worth considering earlier in in treatment due to the favorable risk-benefit profile.

Strong Loops

Because TMS can activate brain circuits which improve executive control to slow down some of the habit and reward areas of the brain, there is a natural question as to whether it could help with addictions and compulsions. Alcohol cravings are particularly problematic for people with alcohol use disorder, and reducing cravings is correlated with lower rates of abuse and relapse from sobriety.

Medications like naltrexone can reduce cravings by blocking the brain's endogenous opioid system, and therapy can help people influence cravings to prevent undesired behaviors. TMS might be able to help control cravings, for example by activating executive brain centers to increase self-control, what people often subjectively experience as "willpower" or "discipline," buffering feelings of shame and guilt that come along with unwanted use.

With OCD, for example, TMS in one protocol is used to activate the dorsomedial prefrontal cortex, which is on the surface, or cortex, of the brain. Activating this region, in turn, provides an "cortical window" to deeper brain regions, interfering with over-active brain loops which drive OCD—what is called increased "functional connectivity" in the CSTC or cortico-striato-thalamo-cortico loop². The striatum is involved with habit, reward and conditioned response, and the thalamus, very roughly speaking, is like a switchboard to route brain signals. TMS is combined with therapeutic interventions to activate OCD fears during the treatment session itself, intending to leverage neuroplasticity to "recruit" individualized brain circuits and restore proper connectivity. TMS can help shift brain networks, therefore, from dysconnectivity to what I like to call euconnectivity, from the Greek prefix "eu-," meaning "good" or "well."

TMS for Alcohol Cravings

Given these considerations, researchers Treiber and colleagues (2024) conducted a review and analysis of all the studies on TMS and alcohol use, published in the Journal of Addiction Medicine³. As is often the case with research, not all studies are created equal. Looking at trials with at least 10 sessions of rTMS (repetitive TMS) with post-treatment measures of alcohol cravings and a sham, or fake, TMS group for comparison, they screened over 200 references to arrive at 12 studies comprising 475 patients treated.

In these studies, different TMS protocols were used, with sessions ranging from 10-20, and stimulation to areas including 1) the right dorsolateral prefrontal cortex (DLPFC, also often treated in ADHD studies); 2) the left dorsolateral prefrontal cortex (stimulated in major depression); the medial prefrontal cortex (overlapping with the OCD protocol, above); and 4) the insular cortex⁴, a key area involved with body awareness, often implicated in OCD, panic, eating disorders, and other conditions, associated with feelings of disgust among other things. Most studies used standard high-frequency rTMS, and 3 used intermittent theta burst stimulation, a much more convenient form of rTMS because sessions are only several minutes long.

They found overall TMS was effective in reducing alcohol cravings. Cravings were immediately reduced after at least 10 TMS sessions, and the effect persisted over the course of follow up, from one to three months. The effect size was moderate, which is considered a good response in terms of intervention impact, and notable given the small number of treatment sessions and good durability within a few months of treatment. This suggests that more robust TMS protocols, possibly accompanied by intermittent preservation treatments, could be a useful option as part of a broader treatment program.

Future Directions

More research is needed to determine the best target(s)—in this review, the analysis suggested mPFC may be more effective. In reality, people struggling with alcohol use disorder (AUD) often have co-occurring ("co-morbid") conditions including anxiety disorders, depression, ADHD, post-traumatic stress, and others. TMS protocols personalized to treat overlapping clinical presentations may ultimately be more useful—such as treating both mPFC and DLPFC for some patients. While standard rTMS sessions are approximately 30 minutes long, iTBS can be a few minutes, making treating more than one region per session feasible and convenient.

Research and clinical experience are also required to understand many aspects of how TMS may fit into AUD care, both in terms of working out preferred protocols, as well as in studying results for more than three months post-treatment. Likewise, more work is needed to understand how to use TMS to stimulate multiple areas, and how to best combine TMS with medication, therapy, and lifestyle changes to achieve optimal personalized results.