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Expert Gambling Addiction Treatment Online

 A subgroup of people unable to control their gambling can develop Gambling Disorder, with potentially severe financial, emotional, relationship, occupational, and possible legal consequences.

Gambling Disorder and Other Behavioral Addictions: Recognition and Treatment

Addiction professionals and the public are recognizing that certain nonsubstance behaviors–such as gambling, Internet use, video-game playing, sex, eating, and shopping–bear resemblance to alcohol and drug dependence.

Growing evidence

It suggests that these behaviors warrant consideration as nonsubstance or “behavioral” addictions and has led to the newly introduced diagnostic category “Substance-Related and Addictive Disorders” in DSM-5. At present, only gambling disorder has been placed in this category, with insufficient data for other proposed behavioral addictions to justify their inclusion.

This review summarizes recent advances in our understanding of behavioral addictions, describes treatment considerations, and addresses future directions. Current evidence points to overlaps between behavioral and substance-related addictions in phenomenology, epidemiology, comorbidity, neurobiological mechanisms, genetic contributions, responses to treatments, and prevention efforts.

Differences

Differences also exist. Recognizing behavioral addictions and developing appropriate diagnostic criteria are important in order to increase awareness of these disorders and to further prevention and treatment strategies.

SSRIs

The most studied medication class in gambling disorder is SSRIs, but results have been mixed at best.

In one study, lithium was superior to placebo in reducing gambling symptoms during 10 weeks of treatment in patients with gambling disorder and bipolar spectrum disorders. However, olanzapine was found no more effective than placebo.

Opioid Receptor Antagonists

Multiple studies have demonstrated the efficacy of opioid receptor antagonists in the treatment of gambling disorder. Opioid antagonists dampen gambling-related excitement and cravings by decreasing dopamine neurotransmission in the nucleus accumbens and interconnected reward and motivational neurocircuitry.

In the initial study, naltrexone (mean dose: 188 mg/day) demonstrated superiority to placebo in reducing gambling-related behaviors, thoughts, and urges, and was particularly effective in gamblers with more severe gambling urges [124]. A second naltrexone study confirmed the findings of the initial study over a longer (18-week) period [125].

The efficacy of as-needed placebo or naltrexone (50 mg) and psychosocial support on reduction of gambling severity, gambling-related thoughts and urges, and gambling frequency and expenditures was assessed among 101 problem gamblers over 20 weeks [126]. Overall, the as-needed naltrexone provided no substantial benefit over psychosocial support.

Nalmefene

Nalmefene is a long-acting analog of naltrexone administered by injection. Its efficacy was demonstrated in 207 subjects treated for 16 weeks, with significant reductions in gambling urges, thoughts, and behavior observed in 59% with nalmefene, compared with 34% with placebo [127]. A second nalmefene trial failed to show statistically significant differences from placebo.

Subsequent research found low-dose nalmefene significantly more effective than higher doses. Over 16 weeks, nalmefene (25 mg and 50 mg per day) led to significantly greater reductions in pathologic gambling severity than placebo. With nalmefene (25 mg/day), 59.2% of patients were rated as “much improved” or “very much improved,” compared with 34.0% with placebo.

At a dosage of 25 mg/day was effective and showed few adverse events, but 50-mg and 100-mg doses had intolerable side effects.

Catechol-O-Methyl-Transferase Inhibitors

Catechol-O-methyl-transferase (COMT) is an enzyme that degrades dopamine to regulate cognitive functioning in the PFC. As discussed, PFC-mediated cognitive dysfunction is implicated in the pathophysiology of gambling disorder, and a small uncontrolled study evaluated the COMT inhibitor tolcapone in 24 patients with gambling disorder who also received fMRI before and after treatment.

Moreover, compared with controls, the subjects with gambling disorder showed underactivation during executive planning tasks pretreatment.

Dopaminergic Modulators

Dopamine binding is positively correlated with gambling severity and impulsivity, and dopamine release in disordered gamblers is related to excitement and worsened behavioral performance. The dopamine-1 (D1) receptor antagonist ecopipam was evaluated in patients with gambling disorder when taken as needed for nine weeks.

Moreover, compared with placebo, ecopipam led to statistically significant reductions in Yale-Brown Obsessive Compulsive Scale Modified for Pathological Gambling (PG-YBOCS) total score (25.6 baseline vs. 14.0 at study end) and subscales of thought-urge and behavior. Ecopipam may reduce pathologic gambling behavior .

Glutamate-Modulating Agents

Another promising area of pharmacotherapy in gambling disorder is glutamate-modulating agents. N-acetylcysteine (NAC), one such agent, was studied in subjects with gambling disorder over eight weeks.

In the open-label phase, 59% experienced significant symptom reductions and were classified as responders. At the end of the double-blind phase, 83% of those assigned to NAC remained responders (vs. 28.6% assigned to placebo).

Smoking

Cigarette smoking is highly prevalent in gambling disorders. Imaginal desensitization plus NAC was evaluated in patients with gambling disorder and nicotine dependence.

After six weeks, subjects randomized to NAC or placebo both showed significant benefit from imaginal desensitization, but at three-month follow-up, NAC led to significant additional benefit in gambling severity reduction compared with placebo .

Other glutamate agents, such as topiramate, have not shown benefit.

Pharmacological Treatments for Disordered Gambling:
A Meta-analysis

Disordered gambling is a public health concern. It is associated with detrimental consequences for affected individuals and social costs. Currently, to reduce symptoms of uncontrolled gambling, opioid antagonists are one of the first-line treatments.

 A multilevel literature search yielded 34 studies including open-label and placebo-controlled trials totaling 1340 participants to provide a comprehensive evaluation of the short- and long-term efficacies of pharmacological and combined treatments.

Treatments

Pharmacological treatments associates with large and medium pre-post reductions in global severity, frequency, and financial loss (Hedges’s g: 1.35, 1.22, 0.80, respectively). The controlled effect sizes for the outcome variables were significantly smaller (Hedges’s g: 0.41, 0.11, 0.22), but robust for the reduction of global severity at the short term. In general, medication classes yielded comparable effect sizes independent of predictors of treatment outcome.

Of the placebo-controlled studies, results showed that opioid antagonists and mood stabilizers, particularly the glutamatergic agent topiramate combined with cognitive intervention and lithium for gamblers with bipolar disorders demonstrated promising results. However, more rigorously designed, large-scale randomized controlled trials with extended placebo lead-in periods are necessary.

Psychosocial

Moreover, future studies need to monitor concurrent psychosocial treatments, the type of comorbidity, use equivalent measurement tools, include outcome variables according to the Banff, Alberta Consensus, and provide follow-up data in order to broaden the knowledge about the efficacy of pharmacological treatments for this disabling condition.

DSM-5 Diagnostic Criteria for Gambling Disorder

A. Persistent and recurrent problematic gambling behavior leading to clinically significant impairment or
distress, as indicated by the individual exhibiting four (or more) of the following in a 12­month period:

a. Needs to gamble with increasing amounts of money in order to achieve the desired excitement.
b. Is restless or irritable when attempting to cut down or stop gambling.
c. Has made repeated unsuccessful efforts to control, cut back, or stop gambling.
d. Is often preoccupied with gambling (e.g., having persistent thoughts of reliving past gambling
experiences, handicapping or planning the next venture, thinking of ways to get money with
which to gamble).
e. Often gambles when feeling distressed (e.g., helpless, guilty, anxious, depressed).
f. After losing money gambling, often returns another day to get even (“chasing” one’s losses).
g. Lies to conceal the extent of involvement with gambling.

h. Has jeopardized or lost a significant relationship, job, or educational or career opportunity
because of gambling.
i. Relies on others to provide money to relieve desperate financial situations caused by gambling.

Specify if:
Episodic: Meeting diagnostic criteria at more than one time point, with symptoms subsiding
between periods of gambling disorder for at least several months.
Persistent: Experiencing continuous symptoms, to meet diagnostic criteria for multiple years.

  • Specify if:

    In early remission: After full criteria for gambling disorder were previously met, none of the criteria
    for gambling disorder have been met for at least 3 months but for less than 12 months.
    In sustained remission: After full criteria for gambling disorder were previously met, none of the
    criteria for gambling disorder have been met during a period of 12 months or longer.
    Specify current severity:
    Mild: 4–5 criteria met.
    Moderate: 6–7 criteria met.
    Severe: 8–9 criteria met.

From the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (section 312.31).

Gambling problems impact 0.2%-4.0% of the population, and research related to treating gambling has burgeoned in the last decades. This paper reviews trials for psychosocial treatments of gambling problems. Using Preferred Reporting Items for Systematic reviews and MetaAnalyses standards, we identified 21 randomized trials.

Moreover, eleven studies evaluated interventions delivered via multi-session, in-person therapy: cognitive therapies, cognitive-behavioral (CB)
therapies, and motivational interventions (MI) alone or with CB therapies. An additional ten studies used approaches that involved one or fewer in-person sessions; these included workbooks with CB exercises alone or in combination with MI and brief feedback or advice interventions.

Although most studies found some benefits of CB therapy (alone or combined with MI) and brief feedback or advice relative to the control condition in the short term, only a handful of studies demonstrated any long-term benefits. Nearly half the studies used waitlist controls, precluding an understanding of long-term efficacy, and standardized outcomes measures are also lacking.

Populations also differ

Populations also differ markedly across studies, from non-treatment seeking persons who screened positive for gambling problems to those with severe gambling disorder, and these discrepant populations may require different interventions.

Although problem gamblers with less pronounced symptoms may benefit from very minimal interventions, therapist contact generally improved outcomes relative to entirely self-directed interventions, and at least some therapist contact may be necessary for patients with more severe gambling pathology to benefit from CB interventions. As treatment services for gambling continue to grow, this review provides timely information on best practices for gambling treatment

Gamblers Anonymous

Founded in the 1950s, Gamblers Anonymous (GA) is a mutual help fellowship based on the 12-step program of AA. With meetings in most North American communities, GA is established worldwide as a resource for people struggling with gambling problems. GA groups are peer-led and abstinence-focused and represent the most widely available option for recovery from gambling disorder.

Some GA meetings welcome family and friends to attend “open meetings,” recognizing the impact of disordered gambling often extends far beyond the patient and that support from non-gambling family and friends can be integral to recovery.

 http://www.gamblersanonymous.org/ga/content/about-us

GA

GA has a unique culture of recovery, distinct from AA and NA in specific areas. For example, GA recognizes that for many new members, addressing the crippling financial consequences is vitally important for their recovery. Senior members who confronted and resolved their own financial consequences guide and support the new members through these challenges.

GA members tend to have more severe gambling symptoms, are more motivated for treatment, and have greater involvement with professional gambling treatment.

GA can be used alone or combined with other interventions. Individuals who engage in GA and professional treatment have better gambling outcomes than those who receive professional care alone. GA is also a valuable resource if remitted gambling problems recur in the future.

Consequencies

The potentially severe consequences of gambling disorder elevate the need to identify factors that support gambling abstinence. In a study of GA members, the greatest predictors of gambling abstinence were participation and involvement in GA, support from family and friends, and connections with other GA members. High gambling urges and erroneous gambling cognitions strongly predicted relapse.

Of note, GA meeting attendance may be helpful, but involvement with GA meetings and members carried the greatest protection from relapse. GA and CBT are the two most widely used approaches for gambling disorder. A review of published evidence concluded that combining GA and CBT may enhance therapy engagement and reduce relapse risk.

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Naltrexone for Pathological Gambling

The use of naltrexone in pathological and problem gambling: A UK case series

Background and aims: To investigate the potential indications and adverse effects of using the opioid antagonist
naltrexone to treat problem gamblers.

Case presentation:

1,192 patients referred their filesto the National Problem Gambling Clinic between January 2015 and June 2016. all the files got audited. Seventeen patients were considered appropriate for treatment with naltrexone, having attended and failed to respond to psychological therapies at the clinic. Fourteen patients were placed on a regimen of 50 mg/day naltrexone.

Discussion:

Of the 14 patients who were treated with naltrexone, there were 10 for whom sufficient follow-up existed to analyze the treatment efficacy and side effects of naltrexone. Patients showed significant decreases in their craving to gamble and the majority (60%) were able to abstain completely from gambling in the treatment period, with a further 20% reducing their gambling to almost nothing.

The reported side effects from the naltrexone included: loss of appetite, gastrointestinal pain, headaches, sedation, dizziness, and vivid dreams. Two patients with concurrent alcohol-use disorder relapsed during the treatment. One patient relapsed after the treatment period.

Conclusions:

The study showed significant outcomes in reducing gambling cravings for the sample set. Given the design of the study as a case series, there was no control group, and a number of patients were on other psychotropic medications. We recommend care when prescribing to those suffering from concurrent alcohol-use disorder.

Psychological Treatments for Gambling Disorder

Many disordered gamblers can trace the course of their disease to an early win, followed by increasing gambling frequency and expenditure. Even early wins of $100 to $500 can increase excitement about gambling, distort self-perceptions of skill or expected returns, and strengthen irrational beliefs about gambling (e.g., illusion of control).

Several cognitive distortions are emblematic of gambling disorder, including:

  • The gambler’s fallacy (i.e., belief that a string of losses must predict an imminent win)
  • The availability heuristic (i.e., a selective recall of wins over losses)
  • Failure to recognize net losses with intermittent small wins (e.g., spending $400, a $50 win is deemed a success, despite the $350 net loss)
  • The idea of intensely needing to win makes winning likely
  • Beliefs about luck

Therapies targeting erroneous cognitions, gambling urges, and motivations are effective. A meta-analysis of behavioral therapy outcomes in gambling disorder found an effect size of 2.01 at the end of treatment and 1.59 at follow-up (mean: 17 months). Efficacy seems to diminish over time, but the effect sizes were robust.

Cognitive-Behavioral Therapy for Gambling Disorder

In the treatment of gambling disorder, cognitive therapy is based on the idea that gambling-related cognitive distortions contribute to disordered behavior. With this approach, the therapist helps patients identify and correct gambling-related cognitive distortions, with the goal of improving gambling abstinence by greater use of logical behavioral choices.

Moreover, one cognitive approach provides up to 20 weekly sessions until the patient stops gambling. Short-term outcomes show superior improvement relative to control groups. A frequent component is relapse prevention, which identifies high-risk situations for relapse and maladaptive beliefs related to control over gambling.

Bhavioral therapies

Behavioral therapies target gambling urges primarily with exposure-based therapies.

CBT focuses

on changing gambling-related cognitions and behaviors; it is effective and improves treatment engagement and outcomes. Brief, four- to six-session CBT interventions show some promise in problem and disordered gambling, but they require further evaluation in broader samples of treatment-seeking gamblers.

An eight-session CBT intervention for gambling disorder may follow the specific therapeutic focus outlined here:

  • Recognizing gambling triggers that precipitate gambling episodes: days/times, people, cues (cash), events (celebrations, arguments), and emotions (negative affect)
  • Examine gambling episodes using functional analysis
  • Increase alternate pleasurable activities
  • Manage anticipated and unanticipated triggers
  • Relaxation techniques to manage responses to gambling urges
  • Interpersonal conflicts, practice gambling refusal skills
  • Cognitive biases and distortions with gambling disorder
  • Relapse prevention, coping with major life events

Functional analysis

teaches patients with gambling disorder to identify triggers, related feelings, and resultant behaviors. Examine the positive and negative consequences of their triggers; and identify cognitive biases. Such as luck-related beliefs in their gambling behaviors.

The process of developing improved strategies to identify and manage triggers related to craving may increase PFC control over motivational drives involving subcortical brain regions. Increased awareness and understanding of irrational cognitions, such as those related to luck, near-miss events, and chasing behaviors, may increase the balance in activity of brain circuits that code conflicting motivational states .

Skills training

in CBT can include interpersonal skills and conflict resolution methods through role-playing and skills training. They intend to help the person recognize that gambling may provide short-lived rewards and enjoyment. But problematic long-term consequences of debt, interpersonal conflicts, and/or legal system involvement.

This type of intervention further addresses finance management and debt settlement—important concerns in gambling disorder.

Brief Motivational Interventions

Brief motivational intervention shows promise in reducing gambling when delivered alone or with other therapies. It is useful for engaging patients with poor problem recognition in further treatment or for spurring self-directed change. Therapy sessions focus on personalized feedback, brief advice, review of options (e.g., treatment options, change goals), and building self-efficacy, delivered in an empathic manner.

In one study, telephone brief motivational intervention combined with a self-help workbook was effective in improving gambling outcomes in problem gamblers.

Gambling Disorder and Comorbid Problem Drinking

Changes in alcohol use patterns during gambling treatment.  A study examines 163 people with gambling disorder for 36 weeks pre-, during, and post-treatment.

Overall, the use of alcohal is dec. But 31% showed risky drinking during and after treatment. Male sex, younger age, lower gambling severity, treatment condition, and gambling during treatment.

This greater drinking profile suggested ambivalence about gambling changes during treatment. And those less motivated to change their gambling may be less motivated to reduce their alcohol use.  One study found that problem gamblers with co-occurring lifetime alcohol dependence. It demonstrate addictive behavior across multiple domains and resistance to externally motivated treatment approaches.

And

Treatment for patients with gambling disorder and comorbid risky alcohol use may differ from non-risky drinkers. Disordered gamblers with low-risk alcohol use tend to have positive outcomes with group CBT, while high-risk drinkers tend to respond better to motivational interviewing.