High hopes? Precision psychedelic addiction medicine

Despite decades of neuroscience research and significant investment in addiction neuroimaging, clinical outcomes for individuals with substance use and behavioural addictions remain poor. Only 1.8% of people with substance use disorders receive effective treatment, highlighting a major disconnect between mechanistic understanding and clinical utility. This paper calls for a reorientation of addiction neuroscience, from a predominantly diagnostic focus toward a theragnostic framework, in which biomarkers are used to stratify patients, guide treatment decisions, and predict outcomes. We argue that the integration of translational neuroimaging biomarkers, particularly fMRI, EEG, and PET, within psychedelic addiction research offers a unique and timely opportunity to catalyse this shift. Psychedelic compounds such as psilocybin represent a new class of therapeutics capable of engaging neuroplasticity, reward and emotional processing, and cognitive control networks central to addiction pathophysiology. We review how acute and pre-post neuroimaging paradigms can index pharmacodynamic effects and longer-term treatment response and propose a roadmap for embedding biomarkers in early and late phase clinical trials. Drawing on ongoing studies at the Centre for Psychedelic Research at Imperial College London, we outline how multimodal biomarkers are being co-developed alongside clinical trials in gambling and opioid use disorders to identify biotype-specific responses and build a deeply phenotyped treatment population. We argue that these biomarkers, if validated, could serve as regulatory-grade tools for drug theragnostic co-development, mirroring successful models in oncology and neurology. Importantly, we emphasise that realising this vision will require robust multi-stakeholder collaboration, including academia, industry, regulatory agencies, funders, healthcare systems, and patient groups alongside dedicated investment to build a scalable theragnostic infrastructure for addiction research and medicine. In conclusion, psychedelic therapy offers more than symptomatic relief, it presents a vehicle for transforming how we diagnose, treat, and understand addiction. By embracing theragnostic principles and prioritising biomarker integration, addiction medicine has the potential to move towards personalised and precision-guided care.