Tyler Vanderhoof, MD PGY-4 Psychiatry Resident Department of Psychiatry and Behavioral Sciences Emory University Atlanta, Georgia
John J. Reitz, MD PGY-4 Psychiatry Resident Department of Psychiatry and Behavioral Sciences Emory University Atlanta, Georgia
Yi-lang Tang, MD, PhD Associate Professor Department of Psychiatry and Behavioral Sciences Emory University Atlanta, Georgia Addiction Psychiatrist Substance Abuse Treatment Program Atlanta Veteran Health Care System Decatur, Georgia
Disclosures The authors report no financial relationships with any companies whose products are mentioned in this article, or with manufacturers of competing products.
Before starting baclofen, patients should be informed about its adverse effects. Common adverse effects include sedation and motor impairment. More serious but less common adverse effects include seizures, respiratory depression with sleep apnea, severe mood disorders (ie, mania, depression, or suicide risk), and mental confusion. Baclofen should be gradually discontinued, because there is some risk of clinical withdrawal symptoms (ie, agitation, confusion, seizures, or delirium).
Among the medications discussed in this section, the evidence for gabapentin and topiramate is moderate to strong, while the evidence for baclofen is overall weaker or mixed. The American Psychiatric Association’s Practice Guideline suggests offering gabapentin or topiramate to patients with moderate to severe AUD whose goal is to achieve abstinence or reduce alcohol use, or those who prefer gabapentin or topiramate or cannot tolerate or have not responded to naltrexone and acamprosate.19 Clinicians must ensure patients have no contraindications to the use of these medications. Due to the moderate quality evidence for a significant reduction in heavy drinking and increased abstinence,14,20 a practice guideline from the US Department of Veterans Affairs and US Department of Defense21 recommends topiramate as 1 of 2 first-line treatments (the other is naltrexone). This guideline suggests gabapentin as a second-line treatment for AUD.21
Gambling disorder
CASE 2
Mr. P, age 28, seeks treatment for GD and cocaine use disorder. He reports a 7-year history of sports betting that has increasingly impaired his functioning over the past year. He lost his job, savings, and familial relationships due to his impulsive and risky behavior. Mr. P also reports frequent cocaine use, about 2 to 3 days per week, mostly on the weekends. The psychiatrist tells Mr. P there is no FDA-approved pharmacologic treatment for GD or cocaine use disorder. The psychiatrist discusses the option of naltrexone as off-label treatment for GD with the goal of reducing Mr. P’s urges to gamble, and points to possible benefits for cocaine use disorder.
GD impacts approximately 0.5% of the adult US population and is often co-occurring with substance use disorders.22 It is thought to share neurobiological and clinical similarities with substance use disorders.23 There are currently no FDA-approved medications to treat the disorder. In studies of GD, treatment success with antidepressants and mood stabilizers has not been consistent,23,24 but some promising results have been published for the opioid receptor antagonist naltrexone24-29and N-acetylcysteine (NAC).30-32
Naltrexoneis thought to reduce gambling behavior and urges via downstream modulation of mesolimbic dopamine circuitry.24 It is FDA-approved for the treatment of AUD and opioid use disorder. Open-label RCTs have found a reduction in gambling urges and behavior with daily naltrexone.25-27 Dosing at 50 mg/d appears to be just as efficacious as higher doses such as 100 and 150 mg/d.27 When used as a daily as-needed medication for strong gambling urges or if an individual was planning to gamble, naltrexone 50 mg/d was not effective.28
