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There are currently no FDA-approved medications specifically indicated for gambling disorder. At the same time, the scientific literature is accumulating evidence that medications from other areas of addiction medicine and psychiatry may, in some patients, be associated with reduced urges to gamble and a lower frequency of gambling episodes.
This refers to off-label use, when a medication is prescribed for a reason not listed in its label. Such practice is possible in medicine, but it requires especially careful assessment of benefits and risks, particularly since the evidence base for gambling disorder remains fragmented.
Why the topic regained attention after DSM-5
A new wave of interest in pharmacological strategies is linked to how the disorder itself was described in DSM-5. It was reclassified from the category of impulse-control disorders to “Substance-Related and Addictive Disorders,” based on a set of characteristics that bring it closer to substance addictions.
The similarities are discussed at several levels at once, from symptoms and typical relapses to biological mechanisms and genetic factors. Therefore, the logic of searching for medications is often built by analogy with the treatment of addictions and certain mental disorders, where there are already established targets, regimens, and tools for assessing effects.
DSM-5 diagnostic criteria
To make a DSM-5 diagnosis, at least four criteria from the list are required. This makes it possible to distinguish occasional gambling involvement from a clinically significant condition, when the behavior becomes persistent and destructive.
DSM-5 criteria when four or more signs are present:
- Needing to gamble with increasing amounts of money to achieve the desired level of excitement
- Restlessness or irritability when attempting to cut down or stop gambling
- Repeated unsuccessful efforts to control or stop gambling
- Preoccupation with gambling
- Gambling as a way to cope with distress
- Chasing losses (returning to get even after losing money)
- Lying to conceal the extent of involvement
- Jeopardizing or losing a relationship, job, or other important opportunities because of gambling
- Relying on loved ones for money because of financial crises caused by gambling
Taken together, these signs usually describe loss of control, escalating involvement, and noticeable harm in everyday life, when gambling stops being entertainment and begins to set the rules.
Why the problem of gambling disorder has become more pressing
The disorder itself has been known for decades; however, in recent years the problem has become more pressing due to the development of the iGaming segment. Online casinos have made gambling extremely accessible, which has led to an increase in the number of people in a high-risk group. Specialists also point to a change in the nature of games. They have become simpler and more dynamic, which contributes to faster development of addiction.
Simplicity and dynamism are two features characteristic of both games with new game mechanics and live streams. Most players consider such features to be advantages. We saw this after visit www.xxxtremeroulette.com, dedicated to the live roulette game XXXtreme Roulette. The authors highlight the game’s fast pace as an advantage.
At this pace, the brain receives more dopamine signals in a short time, which may accelerate the development of addictive behavior. Combined with the fact that access to gambling has become easier, a very dangerous combination has formed.
A rare but severe condition and frequent comorbid problems
Estimates suggest that the lifetime prevalence of the disorder is about 1%. At the population level this looks like a small share, but clinically the problem is noticeable due to the high health burden and social consequences, which often have long-lasting repercussions.
People with the disorder more often experience poorer overall health and comorbidities, including substance use disorders, mood disorders, and anxiety disorders. In studies, changes in craving and behavior were assessed, among other things, using the modified Yale–Brown Obsessive Compulsive Scale adapted for pathological gambling, later usually referred to as PG YBOCS.
What is known about the effectiveness of medications
The most convincing signals in reviews and individual trials come from the opioid receptor antagonists naltrexone and nalmefene. Compared with placebo, a number of studies noted reductions in urges to gamble and measures of gambling activity, including time and money, as well as improvements on PG YBOCS.
Even in this group, there is not that much data, and sample sizes are often small, so the results look more like a guide than an established standard. In addition, the question remains as to which patient subtypes show a stronger effect, since gambling disorder is rarely uniform in terms of impulsivity profile and comorbid disorders.
With antidepressants, the picture is less consistent. Early results for fluvoxamine and paroxetine in individual studies looked better than placebo, but subsequent work did not confirm these findings. Interpretation is influenced by differences in designs and small groups, as well as by the fact that depression and anxiety can change the subjective assessment of craving.
Some medications in trials did not outperform placebo, and for others there are only preliminary signals. Sertraline and bupropion did not show an advantage, while citalopram and escitalopram looked promising in open-label studies. An open-label design increases the risk of systematic bias, when the expectations of the clinician and the patient can subtly push outcomes toward improvement.
Mood stabilizers also provide grounds for cautious interest. In a single-blind study, lithium and divalproex equally reduced the severity of the problem in people without bipolar disorder. At the same time, the lack of a control group does not allow a reliable separation of the drug’s effect from the placebo effect and natural fluctuations in symptoms.
There are also negative results. For topiramate and olanzapine, no convincing advantage over placebo was obtained for gambling problems, and the applicability of the conclusions depends on the composition of the samples and the duration of follow-up.
Modafinil is discussed separately, where the effect turned out to be mixed. In a short episode of play on slot machines, it reduced the desire to gamble and the riskiness of decisions in people with high impulsivity, but produced the opposite effect in players with low impulsivity. In open-label studies, memantine, acamprosate, and N-acetylcysteine were associated with reductions in craving and behavior on PG YBOCS, but the reliability of such data is limited by the design itself.
Why it is still too early to talk about a standard of care
Even when results look promising, the overall body of data still does not allow for confident recommendations that are equally applicable in broad practice. The research resembles a mosaic, where some pieces are vivid, but the full picture has not yet come together.
Among the key limitations, the following factors are most often mentioned:
- small sample sizes
- short trial durations
- heterogeneous patient groups and differences in comorbidities
- differences in outcome assessment methods
- differences in study design, including placebo control and open-label studies
Under such conditions, the need for larger, longer, and methodologically comparable studies remains central in order to clarify which classes of medications truly help, at what dosages, and for which specific patient groups.