Double-blind naltrexone and placebo comparison study in the treatment of pathological gambling

An Empirical Investigation of the Three-Pathway Model and its Contribution to the Gambling Disorder Psychopathology

BACKGROUND

Blaszczynski and Nower (2002) proposed a theoretical model that leads to problem gambling via three pathways: (1) operant conditioning; (2) emotional vulnerability; and (3) impulsivity and psychopathy. In the current investigation, we explored the relationship between these three putative causative dimensions and clinical core features of Gambling Disorder (GD): gambling craving, gambling-related cognitive distortions, gambling (wagering) behavior, and gambling severity.

RESULTS

Data on 343 people with disordered gambling were analyzed. Measures representing the three pathways were analyzed using principal component analysis (PCA). The PCA generated three profiles. The original dimension of impulsivity/psychopathy was divided into two parts; the impulsivity-related traits were combined with symptoms of depression and anxiety to form one single component representing a volatile emotional, cognitive and behavioral style, named the Affect-instability component. The other two components were Psychopathy and Operant Behavior. Linear regression models for each PCA component found that the Affect-instability component was associated with all core features of GD, i.e., craving, cognitive distortions, gambling behavior and severity (standardized Β range: 0.298-0.448, all p < 0.001). Operant Behavior was significantly associated with gambling behavior (standardized Β=-0.137, p = 0.038) and gambling severity (standardized Β=-0.157, p = 0.006). Psychopathy was associated only with gambling cognitive distortions (standardized Β=-0.300, p < 0.001), suggesting a wider dimension of cognitive challenges in GD.

DISCUSSION

An instability component encompassing emotional and cognitive dysregulation was the strongest predictor of all clinical features of GD. The correlation between operant conditioning and gambling severity suggests that behavioral conditioning plays a role in the persistence of maladaptive gambling.

Lifetime alcohol use disorder and gambling disorder: clinical profile and treatment response

OBJECTIVES

Gambling disorder affects 0.5-2.4% of the population and shows strong associations with lifetime alcohol use disorder. Very little is known regarding whether lifetime alcohol use disorder can impact the clinical presentation or outcome trajectory of gambling disorder.

METHODS

Data were pooled from previous clinical trials conducted on people with gambling disorder, none of whom had current alcohol use disorder. Demographic and clinical variables were compared between those who did versus did not have lifetime alcohol use disorder.

RESULTS

Of the 621 participants in the clinical trials, 103 (16.6%) had a lifetime history of alcohol use disorder. History of alcohol use disorder was significantly associated with male gender (relative risk [RR] = 1.42), greater body weight (Cohen's D = 0.27), family history of alcohol use disorder in first-degree relative(s) (RR = 1.46), occurrence of previous hospitalization due to psychiatric illness (RR = 2.68), and higher gambling-related legal problems (RR = 1.50). History of alcohol use disorder was not significantly associated with other variables that were examined, such as severity of gambling disorder or extent of functional disability. Lifetime alcohol use disorder was not significantly associated with the extent of clinical improvement in gambling disorder symptoms during the subsequent clinical trials.

CONCLUSIONS

These data highlight that lifetime alcohol use disorder is an important clinical variable to be considered when assessing gambling disorder because it is associated with several untoward features (especially gambling-related legal problems and prior psychiatric hospitalization). The study design enabled these associations to be disambiguated from current or recent alcohol use disorder.

Treatment discontinuation in pharmacological clinical trials for gambling disorder

BACKGROUND

Gambling disorder affects 0.5-2% of the population, and of those who receive treatment, dropout tends to be relatively high. Very little is known about participant-specific variables linked to treatment discontinuation/dropout in gambling disorder, especially in pharmacological clinical trial settings.

METHODS

Data were pooled from eight previous randomized, controlled pharmacological clinical trials conducted in people with gambling disorder. Demographic and clinical variables were compared between those who did versus did not subsequently dropout from those treatment trials.

RESULTS

The sample comprised data from 635 individuals, and the overall rate of treatment dropout was 40%. Subsequent treatment dropout was significantly associated with the following: positive family history of gambling disorder in one or more first degree relatives (relative risk [RR] of dropout in those with positive history vs not = 1.30), preference for mainly strategic vs non-strategic gambling activities (RR = 1.43), lower levels of education (Cohen's D = 0.22), and higher levels of functional disability (Cohen's D = 0.18). These variables did not differ significantly as a function of treatment condition (medication versus placebo). Dropouts and completers did not differ significantly in terms of the other demographic or clinical variables that were considered.

CONCLUSIONS

This study identified several candidate participant-specific predictors of pharmacological treatment dropout in gambling disorder. The findings highlight the need for future studies to address a wider range of contextual variables at large scale (including also study-specific variables e.g. trial/intervention duration), including in naturalistic treatment and clinical trial settings, with a view to developing algorithms that might usefully predict dropout risk.

Pharmacological management of gambling disorder: an update of the literature

INTRODUCTION

Gambling disorder (GD) is a mental health condition characterized by persistent and problematic betting behavior. GD generates distress and impairment, and treatment options include psychological and pharmacological interventions.

AREAS COVERED

This narrative review explores existing pharmacological treatments for GD. The following classes of medications were considered: opioid-receptor antagonists (e.g. naltrexone and nalmefene), serotonin reuptake inhibitors (e.g. fluvoxamine, paroxetine, sertraline, escitalopram, and citalopram), glutamatergic agents (e.g. N-acetylcysteine (NAC), acamprosate, and memantine), mood stabilizers (e.g. topiramate, carbamazepine, lithium), and other medications (e.g. modafinil, nefazodone, olanzapine, haloperidol, tolcapone, and bupropion).

EXPERT OPINION

Due to the limitations of the studies reviewed, solid conclusions regarding the optimal choice of pharmacotherapy for individuals with GD are challenging to draw at this time. Despite some medications, such as naltrexone and nalmefene, showing promising results, efficacy has varied across studies. The review highlights current gaps/limitations, including small sample sizes, limited diversity in participant demographics, the need for exploring different gambling subtypes and treatment responses, high placebo response rates, lack of longer-term longitudinal information, limited investigation of neurobiological correlates and co-occurring disorders, and the importance of implementation research. Further research is needed to address these gaps and explore additional medications, as well as interventions like neuromodulation.

Duration of untreated illness in gambling disorder

OBJECTIVE

Gambling disorder is common, affects 0.5-2% of the population, and is under-treated. Duration of untreated illness (DUI) has emerged as a clinically important concept in the context of other mental disorders, but DUI in gambling disorder, has received little research scrutiny.

METHODS

Data were aggregated from previous clinical trials in gambling disorder with people who had never previously received any treatment. DUI was quantified, and clinical characteristics were compared as a function of DUI status.

RESULTS

A total of 298 individuals were included, and the mean DUI (standard deviation) was 8.9 (8.4) years, and the median DUI was 6 years. Longer DUI was significantly associated with male gender, older age, earlier age when the person first started to gamble, and family history of alcohol use disorder. Longer DUI was not significantly associated with racial-ethnic status, gambling symptom severity, current depressive or anxiety severity, comorbidities, or disability/functioning. The two groups did not differ in their propensity to drop out of the clinical trials, nor in overall symptom improvement associated with participation in those trials.

CONCLUSIONS

These data suggest that gambling disorder has a relatively long DUI and highlight the need to raise awareness and foster early intervention for affected and at-risk individuals. Because earlier age at first gambling in any form was strongly linked to longer DUI, this highlights the need for more rigorous legislation and education to reduce exposure of younger people to gambling.

Validation of a Spanish Adaptation of the Gambling Symptom Assessment Scale (G-SAS) in Persons with Recent History of Gambling

Gambling is becoming increasingly frequent and problematic, especially due to the explosion of online alternatives. Evaluating the severity of gambling symptomatology is therefore more important than ever. However, innovations in the gambling field have generally focused on its treatment rather than its evaluation. The Gambling Symptom Assessment Scale (G-SAS) is a well-established measure of gambling-related symptomatology (e.g., gambling urges, gambling-related thoughts and behaviours, and interpersonal functioning). The aim of this study is to validate a Spanish adaptation of the G-SAS so that individual differences in gambling symptomatology can be assessed by clinicians and researchers. The internal structure of the G-SAS was investigated using an exploratory factor analysis with a sample of 364 individuals from the general population in Spain (mean age = 28.84 years, SD = 11.73; 54% males). A four-factor structure was preferred considering fit indices (Chi-square = 22.62, p = .162, RMSEA = 0.030, CFI = 0.998, TLI = 0.995) and internal consistency estimates (0.67 ≤ α ≤ 0.89). The factors were labelled gambling-related symptoms, control of gambling urges/thoughts, interference, and arousal. Regarding construct validity, the four factors of the G-SAS were positively and significantly (all p < .001) correlated with measures of problematic gambling severity (0.40 ≤ r ≤ .73), problematic gambling diagnostic (0.40 ≤ r ≤ .67), gambling cognitions (0.48 ≤ r ≤ .57), impulsivity (0.26 ≤ r ≤ .42), anxiety (0.22 ≤ r ≤ .38), and depression (0.16 ≤ r ≤ .42), and negatively with quality of life (-0.24 ≤ r≤-.42). In sum, this study provides Spanish clinicians and researchers with a tool that serves to assess the status of individuals in relation to gambling symptomatology, which can be used to screen for at-risk profiles and evaluate treatment response.

Pharmacotherapy and gambling disorder: a narrative review

BACKGROUND

Gambling disorder (GD) is a psychiatric disorder classified in the DSM-5 as a non-substance-related and addictive disorder with extensive health and socioeconomic impacts. Its chronic and high-relapsing nature makes it essential to find treatment strategies that improve functioning and reduce impairment associated with it. The purpose of this narrative review is to evaluate and summarize the available evidence on the effectiveness and safety of pharmacotherapy in GD.

METHODS

An electronic literature search of Medline, Embase, and Cochrane Central was conducted to identify systematic reviews, meta-analyses, and reviews on pharmacological interventions in patients with gambling disorder. A similar search of these databases and of Prospero, Clinicaltrials.gov, and Epistemonikos was conducted to identify clinical trials that were published since 2019.

RESULTS

The initial search identified 1925 articles. After screening and duplicate removal, 18 articles were included in the review (11 studies were systematic reviews and meta-analyses, 6 were reviews, and 1 was an open-label trial). Eight pharmacological agents (naltrexone, nalmefene, paroxetine, fluvoxamine, citalopram, escitalopram, lithium, and topiramate) that were studied in randomized controlled trials and open-label trials showed small to moderate effect sizes in reducing GD symptoms in some studies during post-hoc analyses.

CONCLUSION

The overall sum of evidence in the literature on the use of pharmacotherapy in GD is conflicting and inconclusive. Some studies have shown that pharmacotherapy's role in GD is promising, especially when the choice of the agent is guided by comorbid psychiatric disorders. However, significant limitations exist in the study designs, which need to be addressed in future research on the topic. Conducting future and more rigorous trials that address the limitations in the existing literature is necessary to establish more accurate efficacy data on the use of pharmacotherapy in this population.

Pharmacological interventions for the treatment of disordered and problem gambling

BACKGROUND

Pharmacological interventions for disordered and problem gambling have been employed in clinical practice. Despite the availability of several reviews of the efficacy of pharmacological interventions for disordered or problem gambling, few have employed systematic search strategies or compared different categories of pharmacological interventions. Systematic reviews of high-quality evidence are therefore essential to provide guidance regarding the efficacy of different pharmacological interventions for disordered or problem gambling.

OBJECTIVES

The primary aims of the review were to: (1) examine the efficacy of major categories of pharmacological-only interventions (antidepressants, opioid antagonists, mood stabilisers, atypical antipsychotics) for disordered or problem gambling, relative to placebo control conditions; and (2) examine the efficacy of these major categories relative to each other.  SEARCH METHODS: We searched the Cochrane Common Mental Disorders Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL), Ovid MEDLINE, Embase, and PsycINFO (all years to 11 January 2022).

SELECTION CRITERIA

We included randomised trials evaluating a pharmacological intervention for the treatment of disordered or problem gambling. Eligible control conditions included placebo control groups or comparisons with another category of pharmacological intervention.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures, including systematic extraction of included study characteristics and results and risk of bias assessment. Our primary outcome was reduction in gambling symptom severity. Our secondary outcomes were reduction in gambling expenditure, gambling frequency, time spent gambling, depressive symptoms, anxiety symptoms, and functional impairment; and responder status. We evaluated treatment effects for continuous and dichotomous outcomes using standardised mean difference (SMD) and risk ratios (RR), respectively, employing random-effects meta-analyses. A minimum of two independent treatment effects were required for a meta-analysis to be conducted (with only meta-analytic findings reported in this abstract).

MAIN RESULTS

We included 17 studies in the review (n = 1193 randomised) that reported outcome data scheduled for end of treatment. Length of treatment ranged from 7 to 96 weeks.  Antidepressants: Six studies (n = 268) evaluated antidepressants, with very low to low certainty evidence suggesting that antidepressants were no more effective than placebo at post-treatment: gambling symptom severity (SMD -0.32, 95% CI -0.74 to 0.09, n = 225), gambling expenditure (SMD -0.27, 95% CI -0.60 to 0.06, n = 144), depressive symptoms (SMD -0.19, 95% CI -0.60 to 0.23, n = 90), functional impairment (SMD -0.15, 95% CI -0.53 to 0.22, n = 110), and responder status (RR 1.24, 95% CI 0.93 to 1.66, n = 268). Opioid antagonists: Four studies (n = 562) evaluated opioid antagonists, with very low to low certainty evidence showing a medium beneficial effect of treatment on gambling symptom severity relative to placebo at post-treatment (SMD -0.46, 95% CI -0.74 to -0.19, n = 259), but no difference between groups in responder status (RR 1.65, 95% CI 0.86 to 3.14, n = 562). Mood stabilisers: Two studies (n = 71) evaluated mood stabilisers (including anticonvulsants), with very low certainty evidence suggesting that mood stabilisers were no more effective than placebo at post-treatment: gambling symptom severity (SMD -0.92, 95% CI -2.24 to 0.39, n = 71), depressive symptoms (SMD -0.15, 95% CI -1.14 to 0.83, n = 71), and anxiety symptoms (SMD -0.17, 95% CI -0.64 to 0.30, n = 71). Atypical antipsychotics:Two studies (n = 63) evaluated the atypical antipsychotic olanzapine, with very low certainty evidence showing a medium beneficial effect of treatment on gambling symptom severity relative to placebo at post-treatment (SMD -0.59, 95% CI -1.10 to -0.08, n = 63). Comparative effectiveness: Two studies (n = 62) compared antidepressants with opioid antagonists, with very low certainty evidence indicating that antidepressants were no more effective than opioid antagonists on depressive symptoms (SMD 0.22, 95% CI -0.29 to 0.72, n = 62) or anxiety symptoms (SMD 0.21, 95% CI -0.29 to 0.72, n = 62) at post-treatment. Two studies (n = 58) compared antidepressants with mood stabilisers (including anticonvulsants), with very low certainty evidence indicating that antidepressants were no more effective than mood stabilisers on depressive symptoms (SMD 0.02, 95% CI -0.53 to 0.56, n = 58) or anxiety symptoms (SMD 0.16, 95% CI -0.39 to 0.70, n = 58) at post-treatment. Tolerability and adverse events: Several common adverse effects were reported by participants receiving antidepressants (e.g. headaches, nausea, diarrhoea/gastrointestinal issues) and opioid antagonists (e.g. nausea, dry mouth, constipation). There was little consistency in the types of adverse effects experienced by participants receiving mood stabilisers (e.g. tiredness, headaches, concentration difficulties) or atypical antipsychotics (e.g. pneumonia, sedation, increased hypomania). Discontinuation of treatment due to these adverse events was highest for opioid antagonists (10% to 32%), followed by antidepressants (4% to 31%), atypical antipsychotics (14%), and mood stabilisers (13%).

AUTHORS' CONCLUSIONS

This review provides preliminary support for the use of opioid antagonists (naltrexone, nalmefene) and atypical antipsychotics (olanzapine) to produce short-term improvements in gambling symptom severity, although a lack of available evidence precludes a conclusion regarding the degree to which these pharmacological agents can improve other gambling or psychological functioning indices. In contrast, the findings are inconclusive with regard to the effects of mood stabilisers (including anticonvulsants) in the treatment of disordered or problem gambling, and there is limited evidence to support the efficacy of antidepressants. However, these conclusions are based on very low to low certainty evidence characterised by a small number of included studies, high risk of bias, modest pooled sample sizes, imprecise estimates, moderate between-study heterogeneity, and exclusion of participants with psychiatric comorbidities. Moreover, there were insufficient studies to conduct meta-analyses on many outcome measures; to compare efficacy across and within major categories of interventions; to explore dosage effects; or to examine effects beyond post-treatment. These limitations suggest that, despite recommendations related to the administration of opioid antagonists in the treatment of disordered or problem gambling, pharmacological interventions should be administered with caution and with careful consideration of patient needs. A larger and more methodologically rigorous evidence base with longer-term evaluation periods is required before definitive conclusions can be drawn about the effectiveness and durability of pharmacological treatments for disordered or problem gambling.

Is there a therapeutic potential in combining bupropion and naltrexone in schizophrenia?

INTRODUCTION

A sustained-release tablet composed of a combination of the dopamine and norepinephrine reuptake inhibitor bupropion (BUP) and the µ-opioid receptor antagonist naltrexone (NAT) is marketed under the brand name Contrave by Orexigen Therapeutics for appetite control. Minimal literature is available regarding the use of combination bupropion and naltrexone (BUPNAT) in individuals with schizophrenia.

AREAS COVERED

In this review, we propose a theoretical model where BUPNAT may have a therapeutic effect in the treatment of schizophrenia. We explore the pathways targeted by the constituent drugs BUP and NAT and summarize the literature on their efficacy and possible adverse effects. We then look at the potential use of BUPNAT in schizophrenia.

EXPERT OPINION

Research has hinted that BUP's dopaminergic properties affect the same striatal pathways involved in schizophrenia. NAT, via opioid receptor antagonism, indirectly increases striatal dopamine release by disinhibiting nicotinic acetylcholine receptors. As such, we hypothesize that BUPNAT can have a therapeutic effect in schizophrenia, particularly on negative symptoms. We also suggest that it may ameliorate comorbidities frequently seen in this group of patients, including obesity, smoking, and substance use. Further research and clinical data are needed to elucidate the potential clinical benefits of BUPNAT in the treatment of schizophrenia.

Gambling disorder in minority ethnic groups

BACKGROUND

Although the data on racial/ethnic associations with gambling disorder are limited, studies suggest that ethnicity may have associations with both symptom severity and psychosocial impairment linked to gambling disorder. Based on the current literature, we hypothesized that there would be a difference in gambling symptom severity, and co-occurring disorders, as a function of racial-ethnic group.

METHODS

475 adults (mean age = 47.6 (±11.6) years; 54.3 % females) with gambling disorder who had participated in clinical trials on pharmacotherapy or psychotherapy were included. Participants were assessed for gambling severity, comorbidities, health issues, quality of life and psychosocial functioning. Participants who self-identified as Black, Asian or Minority Ethnic (BAME) were compared to those who self-identified as white Caucasian (non-BAME). Significance was defined as p < 0.01.

RESULTS

The BAME group had significantly earlier age of first gambling. The two groups did not differ significantly in terms of age when gambling first became problematic, disability, current gambling disorder symptom severity, previous suicide attempt(s), quality of life, percent of salary in past year lost to gambling, or likelihood of having received treatment for gambling disorder in the past, nor in terms of having used Gamblers Anonymous.

CONCLUSIONS

These data show that having gambling disorder and being from a minority racial-ethnic group was associated with significantly earlier age at first gambling, in clinical trial settings. Future work should further examine differences in the clinical features of gambling disorder in different minority groups in larger sample sizes, ideally also longitudinally, across a range of settings. Identification of the reasons/mechanisms for differences in earlier age of first gambling may lead to new public health and treatment targets to minimize gambling harms.

Update on Gambling Disorder

Gambling disorder (GD) is estimated to be experienced by about 0.5% of the adult population in the United States. The etiology of GD is complex and includes genetic and environmental factors. Specific populations appear particularly vulnerable to GD. GD often goes unrecognized and untreated. GD often co-occurs with other conditions, particularly psychiatric disorders. Behavioral interventions are supported in the treatment of GD. No medications have a formal indication for the GD, although clinical trials suggest some may be helpful. Noninvasive neuromodulation is being explored as a possible treatment. Improved identification, prevention, and treatment of GD are warranted.

Gambling disorder in the UK: key research priorities and the urgent need for independent research funding

Gambling in the modern era is pervasive owing to the variety of gambling opportunities available, including those that use technology (eg, online applications on smartphones). Although many people gamble recreationally without undue negative effects, a sizeable subset of individuals develop disordered gambling, which is associated with marked functional impairment including other mental health problems, relationship problems, bankruptcy, suicidality, and criminality. The National UK Research Network for Behavioural Addictions (NUK-BA) was established to promote understanding of, research into, and treatments for behavioural addictions including gambling disorder, which is the only formally recognised behavioural addiction. In this Health Policy paper, we outline the status of research and treatment for disordered gambling in the UK (including funding issues) and key research that should be conducted to establish the magnitude of the problem, vulnerability and resilience factors, the underlying neurobiology, long-term consequences, and treatment opportunities. In particular, we emphasise the need to: (1) conduct independent longitudinal research into the prevalence of disordered gambling (including gambling disorder and at-risk gambling), and gambling harms, including in vulnerable and minoritised groups; (2) select and refine the most suitable pragmatic measurement tools; (3) identify predictors (eg, vulnerability and resilience markers) of disordered gambling in people who gamble recreationally, including in vulnerable and minoritised groups; (4) conduct randomised controlled trials on psychological interventions and pharmacotherapy for gambling disorder; (5) improve understanding of the neurobiological basis of gambling disorder, including impulsivity and compulsivity, genetics, and biomarkers; and (6) develop clinical guidelines based on the best contemporary research evidence to guide effective clinical interventions. We also highlight the need to consider what can be learnt from approaches towards mitigating gambling-related harm in other countries.

Intranasal as needed naloxone in the treatment of gambling disorder: A randomised controlled trial

BACKGROUND

Gambling disorder (GD) is a global phenomenon affecting millions of people. GD can result in severe social and financial difficulties and efficacious treatments are warranted. Psychosocial treatments form the basis of treatment. Opioid antagonists (OAs) have however shown promise in previous studies. In a recent imaging study intranasal naloxone was found to rapidly and fully occupy brain μ-opioid receptors. This trial investigates the effect and safety of as needed naloxone in the treatment of gambling disorder.

METHODS

This was a 12-week double blind, randomised control trial comparing intranasal naloxone to placebo. The primary endpoint was gambling urge measured by the Gambling symptom Assessment Scale (G-SAS). Secondary outcome measures were gambling severity measures (PGSI) as well as quality of life (WHO:EUROHIS-8), alcohol consumption (AUDIT), depression (MARDS) and internet use (IDS-9SF). In addition, safety of treatment was assessed. Both treatment groups received psychosocial support.

RESULTS

126 participants were randomised to treatment groups in a 1:1 ratio. 106 patients completed the study. Gambling urge (GSAS) and other gambling related measured improved in both groups, but no statistically significant difference could be found. Intranasal naloxone was well tolerated, no subjects discontinued the study due to adverse events. No serious adverse drug reactions were observed.

CONCLUSIONS

This study found no difference between the as-needed administration of intranasal naloxone and placebo in reducing gambling urge in persons with GD. Intranasal naloxone was safe and well tolerated.

Individual strategies in the rat gambling task are related to voluntary alcohol intake, but not sexual behavior, and can be modulated by naltrexone

INTRODUCTION

Gambling disorder (GD) is the first non-substance or behavioral addiction to be included in substance-related and addictive disorders in DSM-5. Since GD is a younger phenomenon relative to alcohol and substance use disorders, little is known about potential unique features in GD and to what extent characteristics are shared with alcohol and substance use disorders. The rat gambling task (rGT) is used to study decision-making in rats. This study aimed to identify individual differences in rGT strategies and explore the stability of these strategies over time. Moreover, motor impulsivity, sexual behavior, and voluntary alcohol intake were examined in rats with different rGT strategies. Finally, the response to naltrexone on performance in rats with different rGT strategies was investigated.

METHODS

Male Lister hooded rats (n = 40) underwent repeated testing in the rGT, repeated copulatory behavioral tests, and 7 weeks of voluntary alcohol intake through a modified intermittent two-bottle free-choice paradigm. Finally, rats were treated with naltrexone prior to testing in the rGT.

RESULTS

The results revealed individual choice strategies in the rGT that were stable over time, even after multiple interruptions and other behavioral testing. The rats with a risky choice strategy displayed higher motor impulsivity and voluntary alcohol intake than the other groups. No difference in sexual behavior was found between the different rGT groups. Finally, in all rats irrespectively of rGT strategy, treatment with naltrexone decreased the number of completed trials and premature responses, and increased omissions, which indicates an overall lowered motivation.

DISCUSSION

In conclusion, rats with risky rGT strategies had higher voluntary alcohol intake but not elevated sexual behavior, indicating shared underlying mechanisms between rGT strategies and alcohol intake but not natural rewards in terms of sexual behavior. Finally, naltrexone treatment resulted in an overall lowered motivation in the rGT.

Treatment of gambling disorder: review of evidence-based aspects for best practice

PURPOSE OF REVIEW

Despite a significant body of literature related to the treatment of gambling disorder, there are still an insufficient number of evaluation studies regarding their effectiveness or firm conclusions on specific treatment elements that contribute to it. The aim of this article was to provide a review of scientific results regarding the treatment of gambling disorder, to present the most commonly applied modalities of treatment and to explore the elements of the most successful therapeutic interventions.

RECENT FINDINGS

A substantial body of literature has shown that the most successful therapeutic protocols are psychological interventions, especially based on cognitive-behavioral therapy/methods and/or motivational interviewing. Other interventions with promising results include different self-help interventions and mindfulness. Interventions such as couples therapy and support groups, may have positive effects in terms of increasing therapeutic adherence and retention, while pharmacotherapy is especially useful in patients with comorbidities.

SUMMARY

Gambling disorder is a complex mental health problem caused by a wide spectrum of different biological, psychological, and social risk factors. Treatment options for gambling disorder need to be wide, flexible, accessible, and economically justified, providing early inclusion, retention, and sustainability of long-term effects of the treatment, that is, abstinence and higher quality of psychosocial functioning.

Managing Problematic Usage of the Internet and Related Disorders in an Era of Diagnostic Transition: An Updated Review

INTRODUCTION

Problematic Usage of the Internet (PUI) refers to a broad and likely heterogeneous group of Internet-related conditions associated with behavioural disturbances and functional impairment.

METHODS

Within PUI several conditions have been reported, including Gaming Disorder, Shopping Addiction, Cyberchondria, Gambling Disorder, Cyberpornography Addiction and Cyberbullying. While increasing reports in the field try to define the epidemiologic and clinical boundaries of these conditions, the rapid and continuous evolution of Internet related behaviours as well as their problematic/pathological expressions are often difficult to diagnose, assess, approach with treatment interventions and follow-up.

RESULTS

In addition, some of the PUI-related conditions show characteristics of addiction to the Internet as a preferential tool to engage in specific behaviours, while some others exclusively manifest on the Internet, making it necessary to find distinct assessment and treatment pathways.

CONCLUSION

The inclusion of Internet Gaming Disorder in Section III by the DSM-5 and the recognition of Gaming Disorder by the ICD-11 opened the way for a systematic clinical investigation of this and other PUI-related conditions, particularly in terms of preventive and therapeutic strategies. The present article is aimed at offering an updated clinical overview on the main expressions of PUI, focussing on the latest acquisitions in this evolving field.

Testing the Validity of the Pathways Model: A Latent Class Analysis of Potential Pathological Gambling Subtypes in a Non-Treatment Sample

Latent class analysis (LCA) was used to test the validity of the Pathways Model in 285 subjects with DSM-IV pathological gambling (PG). In addition to identifying three subtypes that roughly correspond with those described in the model (Behaviorally Conditioned, or BC, Emotionally Vulnerable, or EV, Antisocial-Impulsivist, or AI), LCA identified a fourth class, termed the Antisocial Drinker, or AD, characterized by high rates of antisociality, conduct disorder, and alcohol use disorder. BC gamblers comprised 45% of the sample, followed by EV (24%), AD (22%), and AI (9%) gamblers. Women were more likely to be EV gamblers (OR = 1.89) and less likely to be AD gamblers (OR = 0.46). Those who had attempted suicide were more likely to be EV (OR = 3.06) or AI (OR = 3.05) gamblers and less likely to be BC (OR = 0.37) or AD gamblers (OR = 0.50). Greater childhood maltreatment was associated with AD (standardized OR = 1.81) and AI (standardized OR = 1.43) gamblers. Individuals with later PG onset were less likely to be AI gamblers (standardized OR = 0.48). Individuals who preferred slots were more likely to be EV gamblers (OR = 1.83) and less likely to be AD gamblers (OR = 0.33). The BC subtype was associated with better health outcomes, better social functioning, less childhood maltreatment, and less severe PG. The AI subtype was associated with worse health outcomes, worse social functioning, and higher PG severity. The findings provide a better understanding PG heterogeneity that could be relevant to clinical management.

Habitual versus affective motivations in obsessive-compulsive disorder and alcohol use disorder

OBJECTIVE

To (1) confirm whether the Habit, Reward, and Fear Scale is able to generate a 3-factor solution in a population of obsessive-compulsive disorder and alcohol use disorder (AUD) patients; (2) compare these clinical groups in their habit, reward, and fear motivations; and (3) investigate whether homogenous subgroups can be identified to resolve heterogeneity within and across disorders based on the motivations driving ritualistic and drinking behaviors.

METHODS

One hundred and thirty-four obsessive-compulsive disorder (n = 76) or AUD (n = 58) patients were assessed with a battery of scales including the Habit, Reward, and Fear Scale, the Yale-Brown Obsessive-Compulsive Scale, the Alcohol Dependence Scale, the Behavioral Inhibition/Activation System Scale, and the Urgency, (lack of ) Premeditation, (lack of ) Perseverance, Sensation Seeking, and Positive Urgency Impulsive Behavior Scale.

RESULTS

A 3-factor solution reflecting habit, reward, and fear subscores explained 56.6% of the total variance of the Habit, Reward, and Fear Scale. Although the habit and fear subscores were significantly higher in obsessive-compulsive disorder (OCD) and the reward subscores were significantly greater in AUD patients, a cluster analysis identified that the 3 clusters were each characterized by differing proportions of OCD and AUD patients.

CONCLUSIONS

While affective (reward- and fear-driven) and nonaffective (habitual) motivations for repetitive behaviors seem dissociable from each other, it is possible to identify subgroups in a transdiagnostic manner based on motivations that do not match perfectly motivations that usually described in OCD and AUD patients.

The Psychometric Properties of the Online Gambling Symptom Assessment Scale (OGSAS)

Over the last decade, many psychometric instruments have been developed that assess various online problematic behaviors. Despite the many scales assessing gambling disorder (and its equivalents), no instrument assessing the consequences of problematic online gambling currently exists. In order to assess the symptoms and consequences of online gambling disorder, the Gambling Symptom Assessment Scale (G-SAS) was modified and its psychometric properties were assessed using exploratory factor analysis. The data were collected from 326 undergraduate and graduate students from a large public Midwestern university in the USA. Results suggest that the newly developed Online Gambling Symptom Assessment Scale (OGSAS) is reliable and valid as regards assessing the symptoms of online gambling disorder.

Galangin treatment during dendritic cell differentiation confers tolerogenic properties in response to lipopolysaccharide stimulation

Tolerogenic dendritic cells (tolDCs) can induce the differentiation of immunosuppressive regulatory T cells and are therefore candidates for the prevention or treatment of various inflammatory diseases. Galangin, a major component of propolis and Alpinia officinarum, has well-established anti-inflammatory effects, but its ability to induce a tolerogenic state in DCs has not been demonstrated. In this study, we investigated the effects of galangin on DC differentiation and immune responses. In particular, we compared phenotypic and functional differences between DCs (Gal-DCs) generated by galangin treatment during DC differentiation and bone marrow-derived DCs. Gal-DCs were generated by adding culture medium containing various doses of galangin (1.8-18.5 µM) on 3 and 6 day. Upon lipopolysaccharide (100 ng/mL) stimulation for 24 h, Gal-DCs generated with 7.4 µM galangin treatment showed lower levels of CD86 and lower major histocompatibility complex class II antigen-presentation than those of bone marrow-derived DCs. Furthermore, Gal-DCs showed markedly increased programmed death ligand 1 expression and IL-10 production via the activation of mitogen-activated protein kinases. Interestingly, Gal-DCs co-cultured with allogeneic CD4 T cells exhibited the reduced cell proliferation and differentiation into Th1-, Th2-, and Th17-type cell; instead, Gal-DCs contributed to the induction of CD4+CD25+Foxp3+ Tregs. Taken together, our data suggest that exposure to galangin during DC differentiation confers tolerogenic properties, efficiently inducing Th cell differentiation to immunosuppressive Tregs. These findings provide new insights into the molecular mechanism underlying the anti-inflammatory effects of galangin on DCs.

A comparison of fraud to fund gambling with fraud for other reasons

In order to compare the characteristics, including diagnosed mental disorder, of people who commit fraud offences to fund gambling with those who committed fraud for other reasons, we examined a complete series of reports prepared for legal proceedings by two of the authors from between January 2002 and June 2019. A total of 160 fraud offenders were located, of whom 48 (30%) reported offending to fund gambling. Females made up 47.5% of the total sample and 43.8% of the gamblers. Of the problem gambling group, 44% had diagnoses of anxiety or depression, 44% had substance use disorder, 17% had bipolar and other psychosis, and 38% reported childhood trauma. There were no significant differences in the frequencies of diagnosis of mental illness or previous criminal convictions compared to the non-gambling group. Two thirds reported only gambling on poker machines. Only 19% of gamblers reported seeking treatment prior to being charged.

Nalmefene in the Treatment of Internet Pornography Addiction - A Case Report and Review of Literature

: The mu-opioid antagonist nalmefene (18 mg per day) was administered in the treatment of a heterosexual male with internet pornography addiction. The patient had no other co-addictions or psychiatric comorbidities, allowing a direct measurement for the effectiveness of nalmefene on internet pornography addiction. Over a period of 72 weeks and an assessment frequency between 1 and 18 weeks, self-monitoring assessments of craving and pornography consumption were collected on different craving and obsessive-compulsive scales. Results indicate that nalmefene impressively decreased addictive symptoms. Importantly, the patient-induced discontinuation of nalmefene led to an immediate increase of craving scores and addictive behavior, which dropped again after restarting the medication. The patient has been in complete remission of symptoms for over a year under our supervision, and for further 2 years after that according to his account. Therefore, nalmefene seems to be a useful adjunction for patients with internet pornography addiction.

Current pharmacotherapy for gambling disorder: a systematic review

Introduction: Gambling disorder is classified as an addictive disorder and is associated with significant distress and impairment in personal, social, occupational or other important areas of functioning. Although no pharmacotherapy has a formal indication for gambling disorder, data suggest potential benefits of specific medications.Area covered: This systematic review evaluated findings from 19 randomized controlled trials testing pharmacotherapies for the treatment of gambling disorder.Expert opinion: Few randomized controlled trials have studied pharmacotherapies for gambling disorder. Though results are limited, opioid antagonists like naltrexone showed promise in the pharmacological treatment of gambling disorder. Pharmacotherapy combined with psychotherapy treatments for gambling disorder may provide better rates of patient retention in comparison to pharmacology-only treatments, though further research is needed in this area. Future studies should address gaps relating to considerations of racial, ethnic, gender and other individual differences in clinical studies. Because gambling disorder often co-occurs with other psychiatric disorders, additional research is needed to test treatments for dually diagnosed patients.

Intranasal naloxone rapidly occupies brain mu-opioid receptors in human subjects

Nasal spray formulations of naloxone, a mu-opioid receptor (MOR) antagonist, are currently used for the treatment of opioid overdose. They may have additional therapeutic utility also in the absence of opioid agonist drugs, but the onset and duration of action at brain MORs have been inadequately characterized to allow such projections. This study provides initial characterization of brain MOR availability at high temporal resolution following intranasal (IN) naloxone administration to healthy volunteers in the absence of a competing opioid agonist. Fourteen participants were scanned twice using positron emission tomography (PET) and [¹¹C]carfentanil, a selective MOR agonist radioligand. Concentrations of naloxone in plasma and MOR availability (relative to placebo) were monitored from 0 to 60 min and at 300-360 min post naloxone. Naloxone plasma concentrations peaked at ~20 min post naloxone, associated with slightly delayed development of brain MOR occupancy (half of peak occupancy reached at ~10 min). Estimated peak occupancies were 67 and 85% following 2 and 4 mg IN doses, respectively. The estimated half-life of occupancy disappearance was ~100 min. The rapid onset of brain MOR occupancy by IN naloxone, evidenced by the rapid onset of its action in opioid overdose victims, was directly documented in humans for the first time. The employed high temporal-resolution PET method establishes a model that can be used to predict brain MOR occupancy from plasma naloxone concentrations. IN naloxone may have therapeutic utility in various addictions where brain opioid receptors are implicated, such as gambling disorder and alcohol use disorder.

Naltrexone differentially modulates the neural correlates of motor impulse control in abstinent alcohol-dependent and polysubstance-dependent individuals

Identifying key neural substrates in addiction disorders for targeted drug development remains a major challenge for clinical neuroscience. One emerging target is the opioid system, where substance-dependent populations demonstrate prefrontal opioid dysregulation that predicts impulsivity and relapse. This may suggest that disturbances to the prefrontal opioid system could confer a risk for relapse in addiction due to weakened 'top-down' control over impulsive behaviour. Naltrexone is currently licensed for alcohol dependence and is also used clinically for impulse control disorders. Using a go/no-go (GNG) task, we examined the effects of acute naltrexone on the neural correlates of successful motor impulse control in abstinent alcoholics (AUD), abstinent polysubstance-dependent (poly-SUD) individuals and controls during a randomised double blind placebo controlled fMRI study. In the absence of any differences on GNG task performance, the AUD group showed a significantly greater BOLD response compared to the control group in lateral and medial prefrontal regions during both placebo and naltrexone treatments; effects that were positively correlated with alcohol abstinence. There was also a dissociation in the positive modulating effects of naltrexone in the orbitofrontal cortex (OFC) and anterior insula cortex (AIC) of the AUD and poly-SUD groups respectively. Self-reported trait impulsivity in the poly-SUD group also predicted the effect of naltrexone in the AIC. These results suggest that acute naltrexone differentially amplifies neural responses within two distinct regions of a salience network during successful motor impulse control in abstinent AUD and poly-SUD groups, which are predicted by trait impulsivity in the poly-SUD group.

Gambling disorder

Gambling disorder is characterized by a persistent, recurrent pattern of gambling that is associated with substantial distress or impairment. The prevalence of gambling disorder has been estimated at 0.5% of the adult population in the United States, with comparable or slightly higher estimates in other countries. The aetiology of gambling disorder is complex, with implicated genetic and environmental factors. Neurobiological studies have implicated cortico-striato-limbic structures and circuits in the pathophysiology of this disorder. Individuals with gambling disorder often go unrecognized and untreated, including within clinical settings. Gambling disorder frequently co-occurs with other conditions, particularly other psychiatric disorders. Behavioural interventions, particularly cognitive-behavioural therapy but also motivational interviewing and Gamblers Anonymous, are supported in the treatment of gambling disorder. No pharmacological therapy has a formal indication for the treatment of gambling disorder, although placebo-controlled trials suggest that some medications, such as opioid-receptor antagonists, may be helpful. Given the associations with poor quality of life and suicide, improved identification, prevention, policy and treatment efforts are needed to help people with gambling disorder.

Pharmacological Treatments for Disordered Gambling: A Meta-analysis

Disordered gambling is a public health concern associated with detrimental consequences for affected individuals and social costs. Currently, opioid antagonists are considered the first-line treatments to reduce symptoms of uncontrolled gambling. Only recently, glutamatergic agents and combined pharmacological and psychological treatments have been examined appearing promising options for the management of gambling disorder. 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. Pharmacological treatments were associated 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 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 a 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. 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.

Problem gambling and associated mental health concerns in elite athletes: a narrative review

Opportunities to participate in gambling have dramatically changed during the past 20 years. Casinos have proliferated as have electronic gambling machines, lotteries, sports betting, and most recently online gambling. Gambling among the general population has moved from being perceived negatively to a socially acceptable pastime. As over 80% of individuals have reported gambling for money during their lifetime, governments recognise that regulating gambling-a multibillion dollar industry-is a significant source of revenue. While the vast majority of individuals engaged in some form of gambling have no or few gambling-related problems, an identifiable proportion of both adolescents and adults experience significant gambling-related problems. Elite athletes have not been immune to the lure of gambling nor its concomitant problems. Prevalence studies suggest higher rates of gambling problems among athletes than the general population. In this narrative review, we examine several risk factors associated with gambling problems among elite athletes and new forms of gambling that may be problematic for this population. Given the potential serious mental health and performance consequences associated with a gambling disorder for athletes, we aim to increase coaches', athletic directors' and health professionals' knowledge concerning the importance of screening and treatment referrals.

A transdiagnostic dimensional approach towards a neuropsychological assessment for addiction: an international Delphi consensus study

BACKGROUND

The US National Institutes of Mental Health Research Domain Criteria (RDoC) seek to stimulate research into biologically validated neuropsychological dimensions across mental illness symptoms and diagnoses. The RDoC framework comprises 39 functional constructs designed to be revised and refined, with the overall goal of improving diagnostic validity and treatments. This study aimed to reach a consensus among experts in the addiction field on the 'primary' RDoC constructs most relevant to substance and behavioural addictions.

METHODS

Forty-four addiction experts were recruited from Australia, Asia, Europe and the Americas. The Delphi technique was used to determine a consensus as to the degree of importance of each construct in understanding the essential dimensions underpinning addictive behaviours. Expert opinions were canvassed online over three rounds (97% completion rate), with each consecutive round offering feedback for experts to review their opinions.

RESULTS

Seven constructs were endorsed by ≥ 80% of experts as 'primary' to the understanding of addictive behaviour: five from the Positive Valence System (reward valuation, expectancy, action selection, reward learning, habit); one from the Cognitive Control System (response selection/inhibition); and one expert-initiated construct (compulsivity). These constructs were rated to be related differentially to stages of the addiction cycle, with some linked more closely to addiction onset and others more to chronicity. Experts agreed that these neuropsychological dimensions apply across a range of addictions.

CONCLUSIONS

The study offers a novel and neuropsychologically informed theoretical framework, as well as a cogent step forward to test transdiagnostic concepts in addiction research, with direct implications for assessment, diagnosis, staging of disorder, and treatment.

Efficacy of Pharmacological Interventions in Targeting Decision-Making Impairments across Substance and Behavioral Addictions

Decision-making impairments reflect tendencies towards risky or unwise choices as manifested by presence of psychiatric symptoms or cognitive impairment (e.g. representation of value, inhibitory control-response selection, learning). Such impairments are suggested by the hallmark symptoms of substance and behavioral addictions, which include escalation over time (of substance intake or a given behavior), lack of control, neglect of other domains of life, and cognitive distortions (such as ‘chasing losses’ in gambling disorder). Amongst the putative behavioral addictions, most epidemiological data exist for gambling disorder, which is now included in DSM-5 as a substance-related and addictive disorder. However, other disorders share parallels and may also constitute behavioral addictions, such as compulsive stealing (kleptomania), compulsive shopping, and compulsive sexual behavior. The current paper presents a narrative review of evidence for cognitive decision-making impairments in addictions, as well as pharmacological treatments of these disorders that may have relevance for improving decision-making. We find that objective decision-making deficits have been widely reported in patients with substance use disorders and gambling disorder, compared to controls. Decision-making in the other behavioral addictions is under-studied. Evidence-based pharmacological treatments for some of these addictive disorders, for example, opioid antagonists and glutamatergic agents, modulate neural systems playing key roles in decision-making. But clinical trials have seldom examined effects of such treatments on objective decision-making measures. Future research directions are discussed, including the need to include standardized outcome measures of decision-making (tasks and imaging) alongside traditional clinical measures, to better understand and enhance underlying treatment mechanisms.

Brain and Cognition for Addiction Medicine: From Prevention to Recovery Neural Substrates for Treatment of Psychostimulant-Induced Cognitive Deficits

Addiction to psychostimulants like cocaine, methamphetamine, and nicotine poses a continuing medical and social challenge both in the United States and all over the world. Despite a desire to quit drug use, return to drug use after a period of abstinence is a common problem among individuals dependent on psychostimulants. Recovery for psychostimulant drug-dependent individuals is particularly challenging because psychostimulant drugs induce significant changes in brain regions associated with cognitive functions leading to cognitive deficits. These cognitive deficits include impairments in learning/memory, poor decision making, and impaired control of behavioral output. Importantly, these drug-induced cognitive deficits often impact adherence to addiction treatment programs and predispose abstinent addicts to drug use relapse. Additionally, these cognitive deficits impact effective social and professional rehabilitation of abstinent addicts. The goal of this paper is to review neural substrates based on animal studies that could be pharmacologically targeted to reverse psychostimulant-induced cognitive deficits such as impulsivity and impairment in learning and memory. Further, the review will discuss neural substrates that could be used to facilitate extinction learning and thus reduce emotional and behavioral responses to drug-associated cues. Moreover, the review will discuss some non-pharmacological approaches that could be used either alone or in combination with pharmacological compounds to treat the above-mentioned cognitive deficits. Psychostimulant addiction treatment, which includes treatment for cognitive deficits, will help promote abstinence and allow for better rehabilitation and integration of abstinent individuals into society.

Opioid Antagonists for Pharmacological Treatment of Gambling Disorder: Are they Relevant?

Background:

To date, no drugs have been approved for gambling disorder. Numerous publications have described the value of opioid antagonists. Indeed, the mesocorticolimbic dopaminergic pathway has been suggested as the underlying cause of reward-seeking behaviour, and it is modulated by the opioid system.

Objective:

This study aims to evaluate the relevance of opioid antagonists for treating GD.

Method:

A systematic literature review was conducted. A search of the PubMed electronic database, PsycINFO and the Cochrane Systematic Review Database without any limits was performed.

Results:

There is little information concerning the effects of opioid antagonists on GD. The total search with “nalmefene and gambling” without any limits revealed only 11 articles. The search with “naltrexone and gambling” without any limits gener-ated 47 articles. Nevertheless, the best available data support the use of opioid antagonists, particularly in individuals with a history of alcohol use disorder or strong gambling urges.

Conclusion:

Future trials are still needed. Indeed, opioid antagonists effectiveness has been investigated in only a limited number of patients, clinical trials do not reflect the heterogeneity of GD and there is little knowledge of the predictive factors of response to treatments. Moreover, differential affinity to nalmefene for kappa receptors may be associated with a particular effect in a yet to be defined addiction phenotype. Head to head comparisons between naltrexone and nalmefene would be helpful in combining other medication or psychotherapy. The identification of subgroups of patients that are more likely to benefit from opioid antagonists should be a goal

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

The files of the 1,192 patients who were referred to the National Problem Gambling Clinic between January 2015 and June 2016 were 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.

Internet-Based Delivery of Cognitive Behaviour Therapy Compared to Monitoring, Feedback and Support for Problem Gambling: A Randomised Controlled Trial

The aim of this study was to investigate the efficacy of an Internet-based cognitive behavioural therapy program (I-CBT) for the treatment of problem gambling, when compared to a waitlist control and an active comparison condition consisting of monitoring, feedback, and support (I-MFS). Participants (N = 174) were randomly allocated to the three conditions. Variables of interest were gambling outcome and related mental health measures. Participants in the active conditions (I-CBT and I-MFS) completed six online modules. Both I-CBT and I-MFS conditions resulted in significant treatment gains on gambling severity. However, I-CBT was also associated with reductions in a range of other gambling-related and mental health outcomes. Compared with I-MFS, I-CBT produced greater effects across seven outcomes measures, relating to gambling urges, cognitions, stress, and life satisfaction. I-CBT participants also rated the program as significantly more satisfactory. Treatment gains observed for both active conditions were found to be stable through to 12 month follow up. The results indicate that the benefits of I-CBT were more than simply the non-specific effects of engaging in online treatment or receiving motivation, feedback, and support. Online treatments for gambling may be a valuable tool in increasing help-seeking and treatment engagement in this population, and be integrated as part of stepped care approaches to treatment.

How to measure monetary losses in gambling disorder? An evidence-based refinement

Diverse monetary measures have been utilized across different studies in gambling disorder (GD). However, there are limited evidence-based proposals regarding the best way to assess financial losses. We investigated how different variables of monetary losses correlate with validated assessments of gambling severity and overall functioning in a large sample of subjects with GD (n = 436). We found that relative monetary variables (i.e. when financial losses were evaluated in relation to personal income) showed the most robust correlations with gambling severity and overall psychosocial functioning. Percentage of monthly income lost from gambling was the variable with the best performance.

Who Are the Anonymous? Involvement and Predictors of Gamblers Anonymous Attendance Among Disordered Gamblers Presenting for Treatment

Gamblers Anonymous is the most widely available form of support for disordered gambling. Although chapters exist worldwide, knowledge of how attendees interact with the program is limited. The present study aimed to investigate involvement in Gamblers Anonymous among attendees, motives for attendance, and overall satisfaction with the program. Furthermore, potential gambling-related predictors of attendance versus deciding not to attend Gamblers Anonymous were investigated. A treatment-seeking sample of disordered gamblers (N = 512) from São Paulo, Brazil completed a series of self-report measures including an author-compiled Gamblers Anonymous survey. From the sample, 141 gamblers reported attending Gamblers Anonymous over the previous 30 days. An examination of involvement, satisfaction, and motives for attending Gamblers Anonymous was conducted, followed by regression analyses to assess predictors of attendance and satisfaction with the program. The majority of attendees (80%) reported some satisfaction with the program. The most common motive for attending Gamblers Anonymous was related to relapse prevention. Regression analyses revealed that greater gambling severity and number of days gambled were associated with not attending Gamblers Anonymous while giving testimonials was strongly related (OR = 6.18) to satisfaction with the program. The findings of this study contribute to the literature on Gamblers Anonymous. In particular, that members derive great satisfaction from the program and see it as a way to strengthen their abstinence goals. However, despite high satisfaction, the results also suggest that most members were passively involved in the program. More research that assesses the effectiveness of Gamblers Anonymous as either a stand-alone or adjunct treatment is needed.

Piloting the addition of contingency management to best practice counselling as an adjunct treatment for rural and remote disordered gamblers: study protocol

INTRODUCTION

Problematic gambling is a significant Canadian public health concern that causes harm to the gambler, their families, and society. However, a significant minority of gambling treatment seekers drop out prior to the issue being resolved; those with higher impulsivity scores have the highest drop-out rates. Consequently, retention is a major concern for treatment providers. The aim of this study is to investigate the efficacy of internet-delivered cognitive behavioural therapy (CBT) and internet-delivered CBT and contingency management (CM+) as treatments for gambling disorder in rural Albertan populations. Contingency management (CM) is a successful treatment approach for substance dependence that uses small incentives to reinforce abstinence. This approach may be suitable for the treatment of gambling disorder. Furthermore, internet-delivered CM may hold particular promise in rural contexts, as these communities typically struggle to access traditional clinic-based counselling opportunities.

METHODS AND ANALYSIS

54 adults with gambling disorder will be randomised into one of two conditions: CM and CBT (CM+) or CBT alone (CBT). Gambling will be assessed at intake, every treatment session, post-treatment, and follow-up. The primary outcome measures are treatment attendance, gambling abstinence, gambling, gambling symptomatology, and gambling urge. In addition, qualitative interviews assessing study experiences will be conducted with the supervising counsellor, graduate student counsellors, study affiliates, and a subset of treatment seekers. This is the first study to use CM as a treatment for gambling disorder in rural and remote populations.

ETHICS AND DISSEMINATION

This study was approved by the University of Lethbridge's Human Subject Research Committee (#2016-080). The investigators plan to publish the results from this study in academic peer-reviewed journals. Summary information will be provided to the funder.

TRIAL REGISTRATION NUMBER

NCT02953899; Pre-results.

An Analysis of Treatment-Seeking Behavior in Individuals with Gambling Disorder

Gambling disorder affects approximately 1.1-3.5% of the population, with the rates being higher in young adults. Despite this high prevalence, little is known regarding which pathological gamblers decide to seek treatment. This study sought to examine the differences in three groups of pathological gamblers: those who did not seek treatment (n = 94), those who sought therapy (n = 106) and those who sought medication therapy (n = 680). All subjects were assessed on a variety of measures including demographics, family history, gambling history, comorbid psychiatric disorders and an assortment of clinical variables such as the Quality of Life Inventory, Hamilton Depression and Anxiety Rating Scales, Yale Brown Obsessive Compulsive Scale for Pathologic Gambling (PG-YBOCS), Barratt Impulsiveness Scale, Eysenck Impulsiveness Questionnaire and select cognitive tasks. Those seeking treatment were more likely to be Caucasian, have lost more money in the past year due to gambling, and were more likely to have legal and social problems as a result of their gambling. Those seeking therapy or medical treatment also scored significantly higher on the PG-YBOCS. This study suggests that pathologic gamblers seeking treatment were more likely to exhibit obsessive-compulsive tendencies likely leading to the increased legal and social problems that exist in this group.

Prefrontal Cortical Opioids and Dysregulated Motivation: A Network Hypothesis

Loss of inhibitory control over appetitively motivated behavior occurs in multiple psychiatric disorders, including drug abuse, behavioral addictions, and eating disorders with binge features. In this opinion article, novel actions of μ-opioid peptides in the prefrontal cortex (PFC) that could contribute to inhibitory control deficits will be discussed. Evidence has accrued to suggest that excessive intra-PFC μ-opioid receptor (μ-OR) signaling alters the PFC response to excitatory drive, resulting in supernormal and incoherent recruitment of multiple PFC output pathways. Affected pathways include functionally opposed PFC→hypothalamus 'appetitive driver' and PFC→striatum 'appetitive limiter' projections. This network perturbation engenders disorganized, impulsive appetitive responses. Evidence supporting this hypothesis from human imaging and animal studies will be discussed, and combinatorial drug treatments targeting μ-ORs and specific PFC subcortical targets will be explored.

A prospective follow-up study of younger and older subjects with pathological gambling

Pathological gambling (PG) is a common and costly public health problem associated with impaired quality of life and high suicide rates. Despite its frequency in the general population, PG course is poorly understood in older adults who are especially vulnerable to its devastating consequences. We enrolled 175 subjects in a longitudinal study of gambling behavior: our case group of 53 older adults with PG (≥ 60 years), and two comparison groups including 72 younger adults with PG (< 40 years) and 50 older adults without PG (≥ 60 years). Subjects with PG met lifetime criteria for DSM-IV PG and had a South Oaks Gambling Screen (SOGS) and National Opinion Research Center DSM Screen for Gambling Problems (NODS) scores ≥ 5. Subjects were evaluated at intake and reassessed every 6 months and drop outs were replaced. Follow-up lasted a mean (SD) of 2.6 (1.4) years. At intake older PGs were more likely to be female, Caucasian, divorced, and to have a lower level of education. Older and younger PGs were similar in gambling severity, but older PGs were more likely to have sought PG treatment. Older PGs had lower rates of lifetime drug use disorders, attention deficit/hyperactivity disorder, and obsessive-compulsive disorder. They preferred slots, were more likely to receive PG treatment, and were less likely to discontinue participation in the study. Week by week gambling activity levels showed a significant general downward movement for older and younger PGs, although there were no differences between the groups. Elders without PG had no change in their level of gambling activity. We conclude that younger and older PGs moved toward a reduced level of gambling activity during follow-up. Our data challenge the notion that PG is chronic and progressive.

A Comparison of Sexual Side Effects of Antidepressants With and Without Naltrexone

OBJECTIVE

The aim of the study was to compare the rate of sexual side effects of the selective serotonin reuptake inhibitor paroxetine versus the tricyclic antidepressant desipramine and to examine the effect of co-prescription of naltrexone on sexual side effects among participants in a randomized clinical trial.

METHODS

This was a secondary analysis (N = 88) of veterans who participated in a 12-week trial. All veterans were randomized into one of four treatment groups: (a) desipramine/naltrexone, (b) desipramine/placebo, (c) paroxetine/naltrexone, and (d) paroxetine/placebo. The main outcome measure was the frequency of sexual side effects consisting of "decreased sex drive" and/or "impotence" reported by veterans at each weekly visit.

RESULTS

Approximately 61% of the veterans reported sexual side effects at least once during the trial, and 26.4% reported sexual side effects throughout the study. There were no significant differences in the frequency of sexual side effects among the four treatment groups. The results were similar when the comparison was made between the two antidepressant groups. There were no significant differences in the reporting of sexual side effects between those receiving desipramine and paroxetine. Also, the comparison between naltrexone and placebo did not alter the results.

CONCLUSIONS

This is the first study to compare frequency of sexual side effect reporting between paroxetine and desipramine. We found no statistically significant differences in sexual side effect reporting between the two antidepressants. Also, the addition of naltrexone did not show any beneficial effect on the sexual side effect profile.

Review of interventions to reduce ultraviolet tanning: Need for treatments targeting excessive tanning, an emerging addictive behavior

Millions of Americans engage in tanning each year, defined as intentional ultraviolet radiation (UVR) exposure in the form of sunbathing or the use of indoor tanning beds. An emerging body of research suggests that UVR has addictive properties and some tanners engage in excessive tanning. This article provides an overview of the evidence of tanning addiction and a systematic review of existing tanning interventions with the goal of evaluating their potential to impact addicted tanners. Our search identified 24 intervention studies that were summarized and discussed according to 3 primary themes. First, there is a dearth of tanning interventions that target excessive tanning or are designed as treatments for tanning addiction. Second, tanning interventions are primarily educational interventions designed to increase knowledge of the risks of tanning. Third, there are notable aspects of existing tanning interventions that are relevant to addiction science, including the use of brief motivational and cognitive-behavioral-based interventions. Future directions are considered including recommendations for utilizing the existing evidence base to formulate interventions targeting excessive tanners. (PsycINFO Database Record

Feeding-modulatory effects of mu-opioids in the medial prefrontal cortex: a review of recent findings and comparison to opioid actions in the nucleus accumbens

RATIONALE

Whereas reward-modulatory opioid actions have been intensively studied in subcortical sites such as the nucleus accumbens (Acb), the role of cortical opioid transmission has received comparatively little attention.

OBJECTIVES

The objective of this study is to describe recent findings on the motivational actions of opioids in the prefrontal cortex (PFC), emphasizing studies of food motivation and ingestion. PFC-based opioid effects will be compared/contrasted to those elicited from the Acb, to glean possible common functional principles. Finally, the motivational effects of opioids will be placed within a network context involving the PFC, Acb, and hypothalamus.

RESULTS

Mu-opioid receptor (μ-OR) stimulation in both the Acb and PFC induces eating and enhances food-seeking instrumental behaviors; μ-OR signaling also enhances taste reactivity within a highly circumscribed zone of medial Acb shell. In both the Acb and PFC, opioid-sensitive zones are aligned topographically with the sectors that project to feeding-modulatory zones of the hypothalamus and intact glutamate transmission in the lateral/perifornical (LH-PeF) hypothalamic areas is required for both Acb- and PFC-driven feeding. Conversely, opioid-mediated feeding responses elicited from the PFC are negatively modulated by AMPA signaling in the Acb shell.

CONCLUSIONS

Opioid signaling in the PFC engages functionally opposed PFC➔hypothalamus and PFC➔Acb circuits, which, respectively, drive and limit non-homeostatic feeding, producing a disorganized and "fragmented" pattern of impulsive food-seeking behaviors and hyperactivity. In addition, opioids act directly in the Acb to facilitate food motivation and taste hedonics. Further study of this cortico-striato-hypothalamic circuit, and incorporation of additional opioid-responsive telencephalic structures, could yield insights with translational relevance for eating disorders and obesity.