TMS for Addiction: Alcohol, Cocaine and Beyond

The only addiction use of TMS that the FDA has cleared is smoking: BrainsWay's deep TMS system is cleared "as an aid in short-term smoking cessation for adults." TMS for alcohol, cocaine, methamphetamine or other substances is off-label and research-stage. Trials mostly show reduced craving, which is not the same as staying abstinent, and a 2020 European expert guideline found no Level A or B evidence for rTMS in addiction.

For someone with a substance use disorder, TMS is best thought of as a possible future add-on to established treatment, available today mainly through clinical trials. There is also a specific safety issue: alcohol withdrawal and stimulant use both lower the seizure threshold.

Smoking: the one cleared use

The clearance rests on a multicenter trial by Zangen and colleagues, published in 2021. It enrolled 262 chronic smokers who had failed at least one previous quit attempt. Each session began with cues designed to trigger craving, followed by deep TMS of the lateral prefrontal cortex and insula on both sides, daily for 3 weeks and then weekly for 3 weeks.

The outcome was four weeks of continuous abstinence through week 18, confirmed by urine cotinine. In the intention-to-treat analysis, 19.4% quit with active treatment versus 8.7% with sham; among those who completed treatment, the figures were 28.0% versus 11.7%. That is a meaningful relative gain, but most participants still did not quit, and the label is worded modestly: "aid" and "short-term".

A practical guide to the smoking protocol for patients is in TMS to quit smoking. Note that clearance has not brought coverage: Aetna lists smoking cessation among conditions for which TMS is experimental, and Optum lists it as unproven.

Substance by substance

Research on opioids, cannabis and behavioral addictions such as gambling is earlier-stage; this article focuses on the substances with the most trial data.

Alcohol: the most active research area

A 2025 meta-analysis of 12 randomized trials with 475 participants, each giving at least 10 sessions, found that rTMS reduced alcohol craving immediately after treatment, but heterogeneity between studies was very high (I² of 93%). A 2026 meta-analysis of 19 trials and 942 patients also found reduced craving and advised interpreting it "with caution".

Some trials have also measured drinking itself. In a 2022 proof-of-concept study, 51 recently abstinent patients with moderate to severe alcohol use disorder received deep TMS of the medial prefrontal and anterior cingulate cortex (H7 coil) or sham: 15 sessions over 3 weeks, then 5 more over 3 months. During follow-up, heavy drinking days were lower with active treatment (2.9% versus 10.6% of days), and craving was lower after treatment. The authors called for a full-scale multicenter trial to confirm the result, which is the right reading of a 51-person study.

How addiction protocols differ from depression TMS

Addiction TMS is not simply the depression protocol aimed at a new problem. The trials differ in three ways that matter if you are evaluating a program.

• Target. Depression TMS stimulates the left dorsolateral prefrontal cortex. The smoking protocol stimulates the lateral prefrontal cortex and insula on both sides, and the 2022 alcohol trial targeted midline structures, the medial prefrontal and anterior cingulate cortex. Only the cocaine literature points mainly to the left prefrontal region used in depression.
• Provocation. In the smoking trial, each session began with cues designed to trigger craving, on the theory that stimulation works best on an activated circuit. Depression sessions involve no such step.
• Schedule. The smoking and alcohol protocols front-load daily sessions and then taper to less frequent sessions over follow-up.

A program that offers "TMS for addiction" using a standard depression setup is extrapolating beyond the trials. Reasonable questions to ask include which target and coil will be used, which published trial the protocol follows, whether sessions include cue exposure, how use will be measured (ideally with lab testing, not only self-report), and how the TMS fits with counseling and medical care.

Craving is not the same as recovery

Most addiction TMS trials measure craving on a questionnaire. Craving matters to patients, but it is a step removed from what patients and families care about: days without drinking or using, health, work and relationships. Both the cocaine and methamphetamine findings rest on craving scores, not proven abstinence. Until trials consistently show fewer days of use months after treatment, TMS for addiction should be described as promising for craving and unproven for recovery.

Seizure risk, withdrawal and timing

This is where addiction differs most from other TMS uses. The 2021 IFCN safety guideline lists "alcohol withdrawal" and "use of stimulants such as cocaine or MDMA" among factors that lower seizure threshold, along with sleep deprivation and increased alcohol use. Withdrawal itself can cause seizures, independent of any TMS.

The risk is not theoretical. In the pivotal deep TMS depression trial, a generalized seizure occurred near the end of a 26-year-old's ninth session; the investigators attributed it to heavy drinking the night before, which she had not disclosed, and possible alcohol withdrawal. She recovered without lasting effects. Deep TMS also showed a higher seizure rate per patient than figure-8 coils in a large clinician survey, although the absolute risk was low for both.

In practice, a careful TMS team will want:

• an accurate history of alcohol and drug use, including the past few days, before every course and if anything changes;
• withdrawal to be complete and medically managed before stimulation starts;
• attention to sleep, since deprivation also lowers threshold;
• clear agreement that a session will be postponed after heavy use rather than given anyway.

The full safety data are in TMS safety and seizure risk, and coil differences in deep versus standard TMS.

When depression and substance use occur together

Many people with addiction also have depression, and the question is often not "TMS for addiction" but "TMS for depression in someone who drinks or uses". That is an on-label question, but insurers add hurdles. Aetna excludes coverage for patients with substance abuse in the last 90 days, and a Carelon request form asks clinicians to attest to no active substance use in the past year. Payer specifics are in Aetna TMS coverage.

Depression that persists after a period of sobriety deserves its own assessment, because some of it lifts with abstinence and some does not. Ruling out medical contributors comes first, as covered in the medical workup before TMS.

If you are thinking about suicide or are in crisis, call or text 988 (the 988 Suicide & Crisis Lifeline) or go to the nearest emergency room.

The bottom line

TMS has one cleared addiction use, smoking, with a modest absolute benefit: roughly one extra quitter for every nine smokers treated in the intention-to-treat analysis, by the trial's own figures. For alcohol and stimulants, the craving data are encouraging and the drinking-day data are preliminary. The seizure considerations around withdrawal and stimulant use mean that any TMS in this population needs careful timing and an honest substance history.

For now, addiction care rests on established treatments: medically supervised withdrawal where needed, behavioral therapy, mutual support and medication where appropriate. The practice's broader approach is described in addiction recovery and mental health support; other research directions appear in GLP-1 medications and substance use. For the wider TMS evidence, see the TMS physician's guide, and for TMS as a treatment option, the TMS service page.

Frequently asked questions

Is TMS FDA-cleared for alcohol use disorder?

No. The only cleared addiction indication is BrainsWay deep TMS as an aid in short-term smoking cessation for adults. TMS for alcohol is off-label and research-stage.

Can I have TMS while I am still drinking?

That is a decision for the treating physician, but heavy drinking and alcohol withdrawal both lower the seizure threshold. Most teams will want withdrawal completed and an honest, current drinking history before starting.

Does TMS stop cravings permanently?

There is no evidence of that. Trials show reduced craving soon after treatment, and longer-term effects on drinking or drug use are still being studied.

Does insurance cover TMS for smoking?

Usually not, despite the FDA clearance. Aetna lists smoking cessation as experimental for TMS and Optum lists it as unproven.

Can someone in recovery get TMS for depression?

Yes, depression TMS can be considered on its own merits, but some insurers require a period without substance use first, such as Aetna's 90-day rule.

Sources

1. 510(k) K200957 and K203616: BrainsWay Deep TMS System, smoking cessation. U.S. FDA, 2021. accessdata.fda.gov
2. Repetitive transcranial magnetic stimulation for smoking cessation: a pivotal multicenter double-blind randomized controlled trial. World Psychiatry, 2021. pubmed.ncbi.nlm.nih.gov
3. Evidence-based guidelines on the therapeutic use of repetitive transcranial magnetic stimulation (rTMS): An update (2014-2018). Clinical Neurophysiology, 2020. europepmc.org
4. Repetitive Transcranial Magnetic Stimulation for Alcohol Craving in Alcohol Use Disorders: A Meta-analysis. Journal of Addiction Medicine, 2025. europepmc.org
5. The Effects of Transcranial Magnetic Stimulation on Alcohol Craving, Efficacy, Emotion, and Cognitive Function in Patients With Alcohol Use Disorders: A Systematic Review and Meta-Analysis of Randomized Controlled Trial. Brain and Behavior, 2026. europepmc.org
6. Repetitive Transcranial Magnetic Stimulation in Alcohol Dependence: A Randomized, Double-Blind, Sham-Controlled Proof-of-Concept Trial Targeting the Medial Prefrontal and Anterior Cingulate Cortices. Biological Psychiatry, 2022. pubmed.ncbi.nlm.nih.gov
7. Effects of transcranial magnetic stimulation on cocaine addiction: A systematic review of randomized controlled trials. Psychiatry Research, 2023. europepmc.org
8. Efficacy of Repetitive Transcranial Magnetic Stimulation in Patients With Methamphetamine Use Disorder: A Systematic Review and Meta-Analysis of Double-Blind Randomized Controlled Trials. Frontiers in Psychiatry, 2022. europepmc.org
9. Safety and recommendations for TMS use in healthy subjects and patient populations, with updates on training, ethical and regulatory issues: Expert Guidelines. Clinical Neurophysiology, 2021. europepmc.org
10. Efficacy and safety of deep transcranial magnetic stimulation for major depression: a prospective multicenter randomized controlled trial. World Psychiatry, 2015. europepmc.org
11. Seizure risk with repetitive TMS: Survey results from over a half-million treatment sessions. Brain Stimulation, 2021. europepmc.org
12. Transcranial Magnetic Stimulation and Cranial Electrical Stimulation (Clinical Policy Bulletin 0469). Aetna, 2026. aetna.com
13. Behavioral Clinical Policy: Transcranial Magnetic Stimulation. Optum Behavioral Health Solutions, 2026. providerexpress.com
14. Carelon Behavioral Health Repetitive Transcranial Magnetic Stimulation Request Form (commercial contracts). Carelon Behavioral Health, undated. carelonbehavioralhealth.com
15. K231926 510(k) Summary: NeuroStar Advanced Therapy System. U.S. FDA, 2024. accessdata.fda.gov

Educational information, not medical advice. Whether TMS or any treatment fits you is a decision to make with a psychiatrist who knows your history.