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Principles of Treatment

Pathological Gambling Disorder

Traditionally, gambling has been treated through counseling, group therapy and/or gamblers anonymous. More recently, cognitive behavior therapy has been introduced.

For patients who need cognitive behavior therapy we work closely with Matt Kushner, Ph.D. and Christopher Donahue, Ph.D.

We have specialized in dampening craving symptoms by use of various drugs.

Opioid Antagonists

Naltrexone: Method of using naltrexone in the treatment of craving symptoms

Opioid antagonists are highly effective in the treatment of human cravings but we have to use up to 150mg/day. In rare cases we use 200 mg/day. Physicians need to keep in mind that FDA has limited use of naltrexone to 50 mg/day and there is a black box warning about the risk of AST and ALT elevations (see below). Asians might need no more than 100 mg/day.

The most important information is that patients cannot take over-the-counter pain medicines such as aspirin, acetaminophen (Tylenol), ibuprofen (Motrin) etc while taking naltrexone at the same time. These drugs interact with naltrexone and can cause liver enzyme elevations (aspartate transaminase, alanine transaminase). Liver enzyme elevations occur only rarely if over-the-counter pain medicines are not used concurrently. We have reported our findings on this subject as follows:

Kim SW, Grant JE, Adson DE, Remmel RP. A Preliminary report on possible naltrexone and nonsteroidal analgesics interaction. Journal of Clinical Psychopharmacology (letter) 21:632-633, 2001.

Kim SW, Grant JE, Yoon GH, Kyle WA, Remmel RP: Safety of high dose naltrexone treatment: hepatic transaminase profiles among outpatients. Clinical Neuropharmacology 29:77-79, 2006.

We check liver enzymes at the first visit, at week 4 and week 8. We use clinical judgment after that. After the first 6 months we check liver enzymes (AST, ALT) about 2-3 times a year. If liver enzymes increase we stop naltrexone. Naltrexone can be discontinued overnight in contrast to most other drugs that need to be tapered over time. Elevated liver enzymes (if it happens) do not seem to cause any subjective symptoms and discontinuing naltrexone corrects the problem in 2-4 weeks.

Also, naltrexone should not be used for all impulsive disorders. We use it only for those who have strong cravings. Patients who have craving symptoms often have family history of craving symptoms. There are people who engage in an impulsive behavior to escape from depression, loneliness or some other reasons. We do not recommend naltrexone for these patients. We recommend naltrexone only for those who have strong cravings associated with a reward. Naltrexone has not been shown to be effective in the treatment of cigarette smoking or appetite suppression.

Method of drug administration:

25mg/day (half tablet) after a breakfast for two days, then 50mg/day after a breakfast for four days, then 50mg twice a day for 7 days, then 100mg after a breakfast and 50mg after dinner. If cravings stop at 100mg/day we do not increase the dose to 150mg/day. Most patients report substantial reduction or resolution of their craving symptoms within the first three weeks of treatment.

Nausea can happen during the first several days but almost always resolves within the first week. Nausea should be managed with prochlorperazine (Compazine) 10 mg a day or ondansetron 4-12mg as needed. Other side effects such as loose stool, drowsiness, muscle pain or headaches can also occur. If muscle pain occurs we usually discontinue naltrexone.

Naltrexone must be discontinued three days before any operation or a dental procedure. Patients need to inform physicians that they are on naltrexone. If an emergency pain medicine is required a physician familiar with naltrexone should be consulted upon.

We treat patients for two to three years. We then try to stop naltrexone. If symptoms come back we resume naltrexone for another 3-6 months. Otherwise we permanently discontinue naltrexone treatment.

Nalmefene: nalmefene is another opioid antagonist but is not available currently. It is under clinical investigation (disclosure: Kim SW serves as a consultant to BioTie Therapies and Somaxon Pharmaceuticals. University of Minnesota and Kim have a license agreement with BioTie Therapies on nalmefene).

Selective Serontonin Reuptake Inhibitors (SSRIs)

Fluoxetine (Prozac), paroxetine (Paxil), sertraline (Zoloft), fluvoxamine (Luvox), citalopram (Celexa), and escitalopram (Lexapro) are well known to physicians and public. We often use one of these drugs if there is a sign of depression. SSRIs can augment the efficacy of naltrexone so we often use both drugs together.

Anticonvulsants

Of all the anticonvulsants available we use only topiramate because it tends to suppress craving symptoms. We almost always start topiramate at 25 mg at night for one week and up-titrate the dose gradually over the next several weeks. We increase the dose by 25 mg per week. We explain side effects in detail because confusion, memory deficit, inability to bring up certain words, tremor, dizziness, numbness and other side effects occur commonly. A gradual up-titration of dose either prevents or reduces the intensity of side effects significantly. Most patients report reduction of craving symptoms at 100 mg to 150 mg per day. Asians may respond at a lower dose.

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