How to recognize and treat the pathological gambler
Here are guidelines on recognizing pathological gambling, an algorithm on how to treat the gambler with medication, and clues for overcoming obstacles to treatment. The approaches reviewed in this article represent significant advances across recent years.
When naltrexone is indicated Naltrexone appears to be a reasonable first-line agent for patients who report intense urges to gamble (Table 2). Many patients who report “obsessions” with gambling may suffer from uncontrollable urges that interfere with daily functioning. By eliminating or reducing the urges, the preoccupation often disappears. Patients taking naltrexone often report less-intense urges. The urges may not go away completely; instead, they are often reduced enough for the patient to resist them more easily. Patients also report enjoying the gambling experience less when taking naltrexone; the “high” associated with gambling is reduced.
Naltrexone has been tested in psychiatric conditions in which urges are a dominant symptom.14 The greatest amount of evidence supports the agent’s use in treating alcohol dependence (see related article on page 55) and opiate dependence, both of which are FDA-approved indications.
In the case of pathological gambling, a small body of literature suggests that naltrexone is effective. One case report describes a patient suffering from both pathological gambling and alcohol dependence who responded to naltrexone 50mg/d.15 The first study using naltrexone in pathological gambling showed a significant decline in the intensity of urges to gamble, gambling thoughts, and gambling behavior when using 157 mg/d on average.16 This was followed by a larger study in which an average naltrexone dosage of 188mg/d resulted in improvement in gambling urges, thoughts, and behavior.14
Clinically, a patient will usually respond to a particular dose of naltrexone within 2 weeks. After that, an adjustment in dose is usually necessary. Patients often report nausea and diarrhea. Dizziness, sedation, and headaches occur less commonly. The side effects are usually mild and go away within the first week. Nausea, however, may be moderate to severe in some patients, so patients should be started on 25mg/d for the first 3 or 4 days to reduce that possibility. Ondansetron 4 mg/d is often given adjunctively for the same period to prevent the nausea.
Given the risk of associated hepatic transaminase elevations, liver function tests should be monitored in all patients taking naltrexone.14,16 A boxed warning refers to the potential hepatotoxicity of naltrexone at 50 mg/d, the dosage recommended for treating alcohol or opioid dependence. The warning also states that naltrexone use is contraindicated in acute hepatitis or liver failure, and its use in individuals with active liver disease must be carefully considered.
Initial liver function tests should be evaluated prior to naltrexone administration and again 3 to 4 weeks after starting the drug. Repeat testing should be performed at 2- to 4-week intervals for the next 2 months, a potential high-risk period. Thereafter, tests should be done approximately once a month for the following 3 months. After 6 months, liver enzyme elevations appear to occur rarely and testing 3 to 4 times a year should suffice unless an undue risk arises, e.g., excessive alcohol consumption. If elevated, the enzymes return to normal levels after discontinuing the naltrexone.
Research in this area is still in an early stage and clinicians prescribing the drug for pathological gambling should take extra caution in administering naltrexone at high doses and monitor for potential adverse consequences. Nonsteroidal analgesics should not be used in conjunction with high-dose naltrexone,14 as their concurrent use seems to cause a higher risk of hepatic transaminase elevation.
Mood stabilizers Successful responses to lithium and carbamazepine were described in 2 early case reports. Three subjects who were treated with lithium 1,800mg/d reported cessation of gambling.17 An early case report also found that carbamazepine resulted in improvement in pathological gambling disorder.18 Preliminary studies of lithium and valproate further support the notion that mood stabilizers may be useful. The benefit from carbamazepine, lithium, and valproate may be attributed to their efficacy in treating bipolar disorder and to the existence of features shared by pathological gambling and bipolar disorder (e.g., impulsivity).
Atypical antipsychotics Although there is little evidence that atypical antipsychotics work against pathological gambling when used alone, clinically atypical neuroleptic augmentation of SSRIs may be beneficial.
Atypical antipsychotics have been explored as augmenting agents in the treatment of nonpsychotic disorders and behaviors, including OCD. A recent trial of olanzapine in the treatment of pathological video poker gamblers showed no difference in outcomes between the patients on medication and those on placebo.19
Cognitive behavioral therapy There is also mounting evidence that cognitive behavioral treatments are effective for pathological gambling.6,20-21 Combined pharmacological and behavioral therapy is considered the optimal treatment strategy for many psychiatric disorders, including substance dependence.
In our clinical experience, patients who only partially respond or fail to respond to pharmacotherapy alone are more likely to find relief with a combination of drug and cognitive behavioral therapies. Future studies should explore directly how pharmacological and behavioral therapy contribute to clinical improvement as part of combination treatment strategies for pathological gambling.
