Transdiagnostic Pharmacology of Addictions: Current Evidence and Future Perspectives

Background: Addictive disorders are highly heterogeneous and frequently comorbid, limiting the clinical utility of categorical diagnoses. Transdiagnostic pharmacology seeks to address these limitations by targeting symptom dimensions and shared neurobiological processes across addictions. Methods: We conducted a theory-driven narrative review of studies indexed in MEDLINE, PubMed, LILACS, and Web of Science (October–November 2025), integrating clinical, mechanistic, and dimensional evidence. Findings were organized using the Dysregulation Phenomena of the Three Main Modes of the Predostatic Mind and the Advanced Cognitive Emotional Regulation Therapy (DREXI3/ACERT) framework, which conceptualizes addiction as dysregulation across three interacting systems—Alarm, Seeking, and Balance—and six transdiagnostic symptom dimensions, with a proposed expansion into twenty clinically observable domains (TDPM-20). Results: Pharmacological interventions consistently target neurobiological systems related to stress, reward, impulsivity, and compulsivity. Across studies, the most clinically relevant outcomes remain abstinence, reduction in substance use, and treatment retention. While these outcomes are essential, expanding outcome frameworks to incorporate dimensional and mechanistically informed measures may enhance the identification of clinically meaningful subgroups. Across studies, multiple pharmacological classes show transdiagnostic potential, but their clinical application remains variably aligned with dimensional clinical profiles. Conclusions: A dimensionally oriented approach grounded in neurobiological principles may improve alignment between clinical processes and therapeutic strategies. The DREXI3/ACERT model provides a structured framework for individualized treatment planning and research integration. This approach should be understood as complementary to, rather than a replacement for, established evidence-based treatments for specific substance use disorders, particularly in contexts where therapeutic options remain limited or insufficient. Advancing transdiagnostic pharmacology will require broader dimensional stratification, expanded outcome frameworks capable of capturing patient heterogeneity, and integrative trial designs to strengthen precision psychiatry in addictive disorders.