Clinical Textbook of Addictive Disorders 3rd ed - R. Frances, S. Miller, A. Mack (Guilford, 2005) WW

13. Pathological Gambling and Other “Behavioral” Addictions 309between gambling and alcohol use disorders (Cunningham-Williams, Cottler,Compton, & Spitznagel, 1998; Welte, Barnes, Wieczorek, Tidwell, & Parker,2001). A Canadian epidemiological survey estimated that the relative risk foran alcohol use disorder is increased 3.8-fold when disordered gambling is present(Grant, Kushner, & Kim, 2002), and odds ratios ranging from 3.3 to23.1 have been reported between PG and alcohol abuse/dependence in U.S.population-based studies (Cunningham-Williams et al., 1998; Welte et al.,2001).TreatmentGiven the high rates of placebo response often observed in treatment trials ofPG, the treatment section focuses on findings from double-blind, placebocontrolledtrials (see Table 13.2).AntidepressantsSRIs are the most well-studied pharmacotherapy for PG. In a double-blindstudy with one subject, 125 mg/day of clomipramine resulted in significantimprovement. The patient sustained improvement for 28 weeks on a dose of175 mg/day (Grant, Kim, & Potenza, 2003). Fluvoxamine has demonstratedmixed results in two placebo-controlled, double-blind studies, with one 16-week crossover study supporting its efficacy at an average dose of 207 mg/day(Hollander et al., 2000), and a second 6-month parallel-arm study with highrates of dropout finding no significant difference in response to active or placebodrug (Blanco, Petkova, Ibanez, & Saiz-Ruiz, 2002).Paroxetine at doses between 20 and 60 mg/day (average end-of-study dose= 52 mg/day) has been shown in a short-term, parallel-arm, placebo-controlled,double-blind study to be well-tolerated and efficacious in the treatment of PG(Kim, Grant, Adson, Shin, & Zaninelli, 2002). However, a 16-week multicenterstudy of paroxetine did not find a statistically significant differencebetween active drug and placebo, perhaps in part due to the high placeboresponse rate (48% to placebo, 59% to active drug) (Grant, Kim, Potenza, etal., 2003). A similarly high placebo response rate was seen in a recent studyusing sertraline (Saiz-Ruiz et al., 2005).Opioid AntagonistsGiven their ability to modulate dopaminergic transmission in the mesolimbicpathway, mu opioid receptor antagonists have been investigated in the treatmentof PG. Initially, open-label treatment suggested the efficacy of naltrexone,an FDA-approved treatment for alcohol dependence, in reducing theintensity of urges to gamble, gambling thoughts, and gambling behavior when