Guidelines for TMS/tES Clinical Services and Research through the COVID-19 Pandemic

BACKGROUND: The COVID-19 pandemic has broadly disrupted biomedical treatment and research including non-invasive brain stimulation (NIBS). Moreover, the rapid onset of societal disruption and evolving regulatory restrictions may not have allowed for systematic planning of how clinical and research work may continue throughout the pandemic or be restarted as restrictions are abated. The urgency to provide and develop NIBS as an intervention for diverse neurological and mental health indications, and as a catalyst of fundamental brain research, is not dampened by the parallel efforts to address the most life-threatening aspects of COVID-19; rather in many cases the need for NIBS is heightened including the potential to mitigate mental health consequences related to COVID-19. OBJECTIVE: To facilitate the re-establishment of access to NIBS clinical services and research operations during the current COVID-19 pandemic and possible future outbreaks, we develop and discuss a framework for balancing the importance of NIBS operations with safety considerations, while addressing the needs of all stakeholders. We focus on Transcranial Magnetic Stimulation (TMS) and low intensity transcranial Electrical Stimulation (tES) - including transcranial Direct Current Stimulation (tDCS) and transcranial Alternating Current Stimulation (tACS). METHODS: The present consensus paper provides guidelines and good practices for managing and reopening NIBS clinics and laboratories through the immediate and ongoing stages of COVID-19. The document reflects the analysis of experts with domain relevant expertise spanning NIBS technology, clinical services, and basic and clinical research - with an international perspective. We outline regulatory aspects, human resources, NIBS optimization, as well as accommodations for specific demographics. RESULTS: A model based on three phases (early COVID-19 impact, current practices, and future preparation) with an 11-step checklist (spanning removing or streamlining in-person protocols, incorporating telemedicine, and addressing COVID-19-associated adverse events) is proposed. Recommendations on implementing social distancing and sterilization of NIBS related equipment, specific considerations of COVID-19 positive populations including mental health comorbidities, as well as considerations regarding regulatory and human resource in the era of COVID-19 are outlined. We discuss COVID-19 considerations specifically for clinical (sub-)populations including pediatric, stroke, addiction, and the elderly. Numerous case-examples across the world are described. CONCLUSION: There is an evident, and in cases urgent, need to maintain NIBS operations through the COVID-19 pandemic, including anticipating future pandemic waves and addressing effects of COVID-19 on brain and mind. The proposed robust and structured strategy aims to address the current and anticipated future challenges while maintaining scientific rigor and managing risk

Chronic heroin use disorder and the brain:current evidence and future implications

The incidence of chronic heroin use disorder, including overdose deaths, has reached epidemic proportions. Here we summarise and evaluate our knowledge of the relationship between chronic heroin use disorder and the brain through a narrative review. A broad range of areas was considered including causal mechanisms, cognitive and neurological consequences of chronic heroin use and novel neuroscience-based clinical interventions. Chronic heroin use is associated with limited or very limited evidence of impairments in memory, cognitive impulsivity, non-planning impulsivity, compulsivity and decision-making. Additionally, there is some evidence for certain neurological disorders being caused by chronic heroin use, including toxic leukoencephalopathy and neurodegeneration. However, there is insufficient evidence on whether these impairments and disorders recover after abstinence. Whilst there is a high prevalence of comorbid psychiatric disorders, there is no clear evidence that chronic heroin use per se causes depression, bipolar disorder, PTSD and/or psychosis. Despite the growing burden on society from heroin use, knowledge of the long-term effects of chronic heroin use disorder on the brain remains limited. Nevertheless, there is evidence for progress in neuroscience-based interventions being made in two areas: assessment (cognitive assessment and neuroimaging) and interventions (cognitive training/remediation and neuromodulation). Longitudinal studies are needed to unravel addiction and neurotoxic mechanisms and clarify the role of pre-existing psychiatric symptoms and cognitive impairments.PostprintPeer reviewe

Patterns of pre-treatment drug abuse, drug treatment history and characteristics of addicts in methadone maintenance treatment in Iran

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A global survey on changes in the supply, price, and use of illicit drugs and alcohol, and related complications during the 2020 covid-19 pandemic

Background and Aims: COVID-19 has infected more than 77 million people worldwide and impacted the lives of many more, with a particularly devastating impact on vulnerable populations, including people with substance use disorders (SUDs). Quarantines, travel bans, regulatory changes, social distancing, and “lockdown” measures have affected drug and alcohol supply chains and subsequently their availability, price, and use patterns, with possible downstream effects on presentations of SUDs and demand for treatment. Given the lack of multicentric epidemiologic studies, we conducted a rapid global survey within the International Society of Addiction Medicine (ISAM) network in order to understand the status of substance-use patterns during the current pandemic. Design: Cross-sectional survey. Setting: Worldwide. Participants: Starting on April 4, 2020 during a 5-week period, the survey received 185 responses from 77 countries. Measurements: To assess addiction medicine professionals' perceived changes in drug and alcohol supply, price, use pattern, and related complications during the COVID-19 pandemic. Findings: Participants reported (among who answered “decreased” or “increased”) a decrease in drug supply (69.0%) and at the same time an increase in price (95.3%) globally. With respect to changes in use patterns, an increase in alcohol (71.7%), cannabis (63.0%), prescription opioids (70.9%), and sedative/hypnotics (84.6%) use was reported, while the use of amphetamines (59.7%), cocaine (67.5%), and opiates (58.2%) was reported to decrease overall. Conclusions: The global report on changes in the availability, use patterns, and complications of alcohol and drugs during the COVID-19 pandemic should be considered in making new policies and in developing mitigating measures and guidelines during the current pandemic (and probable future ones) in order to minimize risks to people with SUD

Locally Estimated Hemodynamic Response Function and Activation Detection Sensitivity in Heroin-Cue Reactivity Study

INTRODUCTION: A fixed hemodynamic response function (HRF) is commonly used for functional magnetic resonance imaging (fMRI) analysis. However, HRF may vary from region to region and subject to subject. We investigated the effect of locally estimated HRF (in functionally homogenous parcels) on activation detection sensitivity in a heroin cue reactivity study. METHODS: We proposed a novel exploratory method for brain parcellation based on a probabilistic model to segregate the brain into spatially connected and functionally homogeneous components. Then, we estimated HRF and detected activated regions in response to an experimental task in each parcel using a joint detection estimation (JDE) method. We compared the proposed JDE method with the general linear model (GLM) that uses a fixed HRF and is implemented in FEAT (as a part of FMRIB Software Library, version 4.1). RESULTS: 1) Regions detected by JDE are larger than those detected by fixed HRF, 2) In group analysis, JDE found areas of activation not detected by fixed HRF. It detected drug craving a priori regions-of-interest in the limbic lobe (anterior cingulate cortex [ACC], posterior cingulate cortex [PCC] and cingulate gyrus), basal ganglia, especially striatum (putamen and head of caudate), and cerebellum in addition to the areas detected by the fixed HRF method, 3) JDE obtained higher Z-values of local maxima compared to those obtained by fixed HRF. CONCLUSION: In our study of heroin cue reactivity, our proposed method (that estimates HRF locally) outperformed the conventional GLM that uses a fixed HRF

The Psychometric Properties of the Obsessive Compulsive Drug Use Scale (OCDUS) Among Iranian Methamphetamine Abusers

Background and Aim:Drug craving as a multidimensional subjective experience recently is accepted as a hallmark for addiction. The Obsessive Compulsive Drug Use Scale (OCDUS), measures the overall craving level within a period from a multidimensional perspective. This study aimed to investigate the psychometric properties of the OCDUSamong Iranian methamphetamine abusers. Materials and Methods:OCDUS was translated from English into Farsi by language experts. The questionnaire was then used for evaluation of craving among 50 male methamphetamine abusers. Then, OCDUS questionnaire' scores was subjected to exploratory principal components factor analysis. To assess construct validity of OCDUS, the model was evaluated using confirmatory factor analysis. Internal consistency was examined by calculating Cronbach’s alpha. Results:Exploratory factor analysis identified 2-dimensional components that included, "Desire consumption and mental employment with materials", "The Impact of drug desire and Thoughts on Consumer Work and Life". Finally, the Persian version of OCDUS was verified with 10 items and two factors with high eigenvalues 76.5% of the total variance. Given the relative fit of the confirmatory factor model, the construct validity of the OCDUS was verified. Conclusion:The Farsi-translated version of OCDUS questionnaires had good psychometric properties. The questionnaire could be considered as a valid and reliable instrument for the assessment of drug craving level in Iranian methamphetamine abusers

The Psychometric Properties of the Desires for Drug Questionnaire (DDQ) among Iranians Methamphetamine Abusers

Introduction: Drug-craving as a multidimensional subjective experience recently has beenaccepted as an addiction hallmark. Desire for Drug Questionnaire or DDQ is a well-knownquestionnaire for measurement of drug craving severity. This study aimed to investigate thepsychometric properties of the DDQ among Iranian methamphetamine abusers.Method: DDQ was translated from English into Farsi by language experts. The questionnaire wasthen used for evaluation of craving among 50 male methamphetamine abusers. Then, DDQquestionnaire' scores was subjected to an exploratory principal components factor analysis. Toassess construct validity of DDQ, the model was evaluated using confirmatory factor analysis.Internal consistency was examined by calculating cronbach’s alpha.Results: Finally, the Persian version of DDQ was verified with 13 items and three factors. Threefactors with high eigenvalues were identified by (PCA) that accounted for 70.63% of the totalvariance. Given the relative fit of the confirmatory factor model, the construct validity of the DDQwas verified. Cronbach’s alpha coefficient of the total score of the questionnaire was 0.86.Conclusion: The Farsi-translated version of DDQ questionnaires had good psychometric properties.The questionnaire could be considered as a valid and reliable instrument for the assessment of drugcraving level in Iranian methamphetamine abusers

Baseline executive functions and receiving cognitive rehabilitation can predict treatment response in people with opioid use disorder

TR and AF have received supports from the Cognitive Science and Technologies Council (CSTC) of Iran and Tehran University of Medical Sciences (TUMS) for the ongoing Clinical Trial with NECOREDA.Background Impaired cognitive functions, particularly executive function, predicts poor treatment success in people with substance use disorders. The current study investigated the effect of receiving adjunct cognitive rehabilitation and baseline executive function (EF) measures on treatment response among people with opioid use disorder (OUD). Method The analysis sample consisted of 113 participants with OUD who were discharged from a compulsory court-mandated methadone maintenance treatment (MMT) and followed for 3 months. We used the Backward digit span/Auditory verbal learning, Stroop, and Trail making tests to assess the three measures of EF, including working memory, inhibition, and shifting, respectively. Treatment response was operationalized as (1) treatment retention and (2) the number of positive urine tests for morphine during 3-month follow-up periods. The study used Cox's proportional hazards model and linear mixed model to identify predictive factors. Results Lower Stroop interference scores predicted increased length of stay in treatment (χ2 = 33.15, P < 0.001). The linear mixed model showed that scores on auditory verbal learning test and group intervention predicted the number of positive urine tests during a 3-month follow-up. Conclusion Working memory and inhibitory control, as well as receiving cognitive rehabilitation, could be potentially considered as predictors of treatment response for newly MMT admitted patients with OUD. Assessment of EF before treatment initiation may inform treatment providers about patient's cognitive deficits that may interfere with therapeutic interventions.PostprintPeer reviewe