Theta burst Transcranial Magnetic Stimulation for Methamphetamine use disorder (TARTAN)

Stimulation Localisation: Scalp locations at which the TMS coil will be placed will be determined using standard EEG 10-20 system landmarks. These two locations are: Intermittent TBS (iTBS) to the left Dorso Lateral Pre Frontal Cortex (DLPFC): Treatment will be localised at the F3 EEG site which corresponds to left DLPFC. Continuous TBS (cTBS) to the left Orbito Frontal Cortex (OFC): Treatment will be localised at the FP1 EEG site which corresponds to the left OFC. Provision of intervention TBS will be administered with a TGA registered TMS device (Neuro-MSD and Angulated Fig8 Coil). Prior to the commencement of TBS treatment, single pulse TMS will be used to measure the resting motor thresholds (RMT) for the abductor pollicis brevis (APB) in all subjects using standard published methods. The RMT is used to determine the intensity of the TBS treatment for each individual participant Stimulation Parameters: TBS intervention Protocol A. First. iTBS will be delivered at the Left DLPFC(F3) as 3-pulse 50-Hz bursts applied at 5 Hz (i.e. 50 Hz burst of 3 pulses delivered every 200ms) with a 2-second train of TBS repeated every 10 seconds (i.e. 2 seconds of TBS followed by an 8 second rest). Total number of pulses is 600. Each TBS treatment session will take approximately 3 minutes. During the initial treatment sessions, the amplifier output will be escalated (over 30 sec) from 70% to 110% RMT to enhance tolerability. For clients who experience discomfort and are not able to comfortably tolerate increases in intensity, the level will be maintained at the maximally tolerable level. Participants will be withdrawn if they are unable to tolerate treatment at a minimum 70% of the RMT at the end of the 3rd day of treatment. Protocol B. Second: Following this, cTBS will be delivered at the left OFC: A single train of cTBS will be applied over the left frontal pole (Fp1) (3 pulse 50 Hz bursts applied at 5Hz, 15 pulses/sec, 600 pulses/train; 100% RMT. During the cTBS procedure the amplifier output will be escalated during the first train (over 30 sec) from 70% to 100% RMT to enhance tolerability. For clients who experience discomfort and are not able to comfortably tolerate this intensity, the level will progressively be decreased until a comfortable intensity is reached. Participants will be withdrawn if they are unable to tolerate treatment at 70% of the RMT at the end of the 3rd day of treatment. Then there is a 10 minute interval and Protocol A and B are repeated. Then protocol A and protocol B will be repeated for another two cycles in a treatment day with 10 minute intervals after protocol B (that is three cycles of Protocol A and B in a treatment day) if tolerated. TBS will be provided on three days of each week for a total of four weeks for each participant (that is a total of 12 sessions of TMS over four weeks). Medical specialists (Addiction Psychiatrists and Addiction Medicine Specialists) will screen patients and establish treatment parameters for each patient and do the first treatment. Clinical research officers under the supervision of medical specialists will deliver subsequent interventions. All will have a certificate of accreditation by Neurocare for delivery of TMS (course: rTMS for Depression, OCD & New Developments). Location of the intervention: Clinical Research rooms, Level 3, Newcastle Community Health Centre, 670 Hunter Street, Newcastle, NSW 2300. Counselling: All participants will be offered standard care for MA use disorders, involving psychosocial counselling (of approximately 50 minutes) for the duration of the study and referral to appropriate services post study as clinically indicated. Importantly, study related counselling sessions will provide support to participants through psychoeducation into the neurocircuitry of MA use disorder, relapse prevention for MA dependence and TMS treatment adherence. Counselling sessions will be offered face to face or by telehealth or telephone as requested. Clients will be offered one counselling session per week during the 4 weeks of treatment. Counselling will be performed by a trained HNELHD Drug and Alcohol Clinical Services counsellor independent of the study. Counselling will be standardised using an established protocol for Cognitive Behavioural Therapy for MA use disorder, and one counsellor independent of the TMS research team will deliver the sessions as per the standardised counselling protocol. Data. Every client will have an individual case record where adherence to each of the 12 TMS sessions is recorded (including partial treatment or missed sessions recorded), and adherence to the four counselling sessions will be recorded.