Old treatments for new problems: Medications for pathological gambling show promising future

CrossCurrents

by Astrid Van Den Broek

Sin City is what they call it. And if it’s not being glamourized in movies such as Ocean’s 11, Casino or one of television’s newest cop shows, Las Vegas, gambling is seen just as an indulgence or, at its worst, a sin. For a long time, it was considered a habit a person could maintain control over, equal to other vices, such as shopping. Gambling as an addiction was certainly not seen in the same harsh light that falls on alcohol dependency and other substance use problems.

But that view has been changing. Gambling as an addiction is being validated as a serious compulsion to contend with. Along with that recognition, treatments for compulsive or pathological gambling are also evolving for the estimated two per cent of Canadians who have a gambling problem. Pharmaceutical treatments, in particular, are showing a promising role in treatment, thanks to the results of a growing body of research investigating the neurobiological underpinnings of gambling behaviour.

Dr. Marc Potenza, a psychiatrist at Yale University in New Haven, Connecticut, who is conducting studies on magnetic resonance imaging of the brain to study the brain activity behind problem gambling, describes the evolution of gambling treatment since Gamblers Anonymous was founded in 1957. “Over time, a number of other behavioural approaches to treat gambling addictions have been used with varying degrees of success,” he notes. “Some of the more recent forms of behavioural treatments have been borrowed from the substance abuse treatment field, including methods like cognitive-behavioural therapy and motivational enhancement. Ongoing studies are still examining the efficacy of these approaches.”

But more recently, trials investigating the use of medications as treatment options have grown in popularity. “While such therapy for pathological gambling dates back to about 1980, until the year 2000, there were no placebo-controlled trials of significant size, studies that involved more than one subject,” says Potenza.

Given the emerging emphasis on the neurobiological bases of various psychiatric disorders and addictions, and a growing understanding of how the brain works, it’s not surprising that pharmacotherapy would be considered an option in treating problem gambling.

The evolution of pharmacological treatment has found itself turning to old medications for new help. “Some people started toying with the idea that maybe gambling looks a bit like bipolar disorder,” says Dr. Jon Grant, chief of impulse disorders at Butler Hospital in Providence, Rhode Island. “So perhaps patients who are gamblers are big risk takers,” he adds. Therefore, mood stabilizers, which work through a brain transmitter that halts certain behaviours, were considered for treatment.

Other lines of thought were that pathological gambling may be linked with depression; therefore, antidepressants were integral to treating problem gambling. “Decreased measures of serotonin have long been associated with a variety of adult risk-taking behaviours. In the most simplistic understanding, selective serotonin reuptake inhibitors increase the level of serotonin in the frontal brain and help with this impulsivity,” says Grant, who is also an assistant professor in psychiatry at Brown University Medical School in Providence.

But while no magic pill is being developed for problem gambling, one medication that has been getting a lot of attention is naltrexone, which has traditionally been used to treat alcohol dependency. “It appears that naltrexone works to suppress the high associated with gambling as well as the cravings,” explains Grant. “The two appear to be in different areas of the brain but connected via neuronal circuitry. The high is dampened by blockade of opiate receptors. The cravings are affected probably by naltrexone’s indirect effect on dopamine and GABA (two neurotransmitters), although this may not be the entire picture.” Naltrexone is being studied by Tony Toneatto, Bruna Brands and Dr. Peter Selby at the Centre for Addiction and Mental Health in Toronto. Toneatto is a research scientist in the Clinical Research Department who focuses on concurrent alcohol and gambling addictions. He says that naltrexone creates a feeling of satiety, giving individuals the feeling that they have had enough of the behaviour long before they would have normally. “While naltrexone is indicated for alcohol problems, based on hypotheses about brain reward systems involving internal opiates that might be similar across addictions, we reasoned that naltrexone might be beneficial for gambling problems as well,” explains Toneatto. “The hypothesis is that this drug could possibly help both kinds of addictions.”

Grant and Dr. Suck Won Kim, a researcher and associate professor of psychiatry at the University of Minnesota’s Medical School in Minneapolis, Minnesota, have also conducted naltrexone studies. In 2001, they studied the short-term effects and efficacy of the medication and discovered that naltrexone may indeed control pathological gambling urges.

Yet, as promising as naltrexone looks as a viable treatment for pathological gambling, much work still lies ahead, say researchers. For example, some theorize that naltrexone will only work with a certain type of gambling problem. “The real question is not so much whether the medication will help gamblers, but in the end, which kinds of gamblers it will be good for,” says Toneatto. He envisions a future where naltrexone will almost be given a kind of prescriptive treatment: if you have gambling, with a certain level and severity and with this profile, then naltrexone may help you overcome your gambling addiction. “But usually, medications like naltrexone tend to work best when they are combined with counselling,” adds Toneatto.

Grant agrees that in the future, examining and screening sub-types of gamblers will be important in increasing treatment efficacy. “We’re going to realize that a diagnosis is only the first step in this type of treatment, and that not everybody who meets a diagnostic threshold for pathological gambling is the same and that one treatment fits all,” he says. “There are other sub-types, such as perhaps gamblers with undiagnosed attention-deficit disorder, who would call for a different type of intervention.”

Researchers are still at an early stage in terms of understanding the most effective treatments for people in general with gambling problems, says Potenza. “It will be important to refine our knowledge in terms of matching specific individuals with specific treatment, understanding what treatments are best over the long term for people and how to best combine behavioural and pharmacological approaches,” he says. “Those are some of the major areas of focus in the future.”

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