Case report

Treating a patient with dopamine agonist-related gambling disorder while tapering off his medication

Author

F. Grazioli¹, A. Hughes², M. Okuda¹

Affiliations

¹ New York State Psychiatric Institute and the Department of Psychiatry, Columbia University, New York NY
² Columbia University College of Physicians and Surgeons, New York NY

Corresponding author

Mayumi Okuda, M.D.
Director Gambling Disorders Clinic
New York State Psychiatric Institute
Department of Psychiatry, Division of Substance Abuse
College of Physicians and Surgeons of Columbia University
710 W 168th Street, 12 Floor
New York, New York 10032
E-mail: mo2339@cumc.columbia.edu

 

Keywords

Gambling disorder; impulse control disorders; compulsive behavior; dopamine agonist; dopamine agonist withdrawal syndrome; Parkinson’s disease; Restless Legs Syndrome

Introduction

It is now well established that behavioral addictions, including GD (gambling disorder), excessive buying, sexual behaviors and overeating can occur as a complication of dopamine agonist use in Parkinson’s disease (PD) and Restless Legs Syndrome (RLS) [1-3]. These phenomena have been most commonly associated with higher doses of these agents with data suggesting that male sex, younger age, younger age at PD onset, a prior or a family history of addiction, prior gambling problems and impulsive personality traits may increase the risk [4].
Currently there are no available official guidelines to manage the behavioral addictions associated with dopamine agonist use. Most experts recommend dose reduction or discontinuation of the dopamine agonist which typically leads to the resolution of the behavioral addiction [1,5]. However, dopamine agonist reduction or discontinuation may be challenging or impossible in some patients due to worsening of the underlying condition (motor function in PD, restlessness in RLS) or Dopamine Agonist Withdrawal Syndrome (DAWS) [6]. The following case illustrates how ongoing, close communication between the therapist, neurologist and psychiatrist treating a patient with severe GD was key to obtain positive clinical outcomes while the patient was on the medication.

Case Description

Mr. C is a 46 years old, separated male with one teenage son who lives in a small city in the Mid-Atlantic region of the United States. He holds advanced academic degrees, is employed in corporate management, and pursued a variety of hobbies including camping, fishing, and multiple outdoors activities. At age 40 Mr. C. received a diagnosis of diabetes and a few years later he was diagnosed with restless leg syndrome (RLS). At age 43 he began a course of pramipexole, a dopamine agonist, for his RLS. Around this time, Mr. C’s work became more demanding and his tasks required frequent traveling. Mr. C found himself overwhelmed with responsibility for maintaining his household and his career. In this context, he began to make weekly trips to casinos to play blackjack to “deal with stress.” His visits quickly increased in frequency to daily visits, and he moved from the blackjack table to playing slot machines: “blackjack became too slow.”
By the time Mr. C presented for treatment he met criteria for a severe GD. His financial debts caused by gambling exceeded tens of thousands of dollars and he had filed for bankruptcy, his house was in pre-foreclosure, his wife had separated from him and began divorce proceedings, and friends and other family members began to shun him. He endorsed anxiety and mood symptoms including passive suicidal ideation but denied suicidal intent or plans. Mr. C had never used drugs and only drank socially. He had no family history of psychiatric disorders or addictions. He felt overwhelmed with urges to continue gambling in spite of the negative consequences, something he found completely “out of character” for him as he identified himself as a “professional, disciplined and family-oriented man.”
Upon presentation, the therapist conducting the initial evaluation consulted with a psychiatrist who identified the contribution of the dopamine agonist to Mr. C’s GD. Mr. C’s progression from social gambling (casual poker matches for social connection with his high school friends) to severe GD closely correlated with the onset of pramipexole use. Mr. C was provided with information around the association between the dopamine agonist and GD and he consented for a prompt communication of the findings to his neurologist. Mr. C’s neurologist reported that in spite of screening for behavioral addictions throughout treatment, gambling behavior never came up. Mr. C acknowledged that he felt somewhat disconnected from the severity of his gambling and felt uncomfortable disclosing it. Upon learning about the association between pramipexole and his gambling behavior, Mr. C abruptly stopped taking the medication, which led to significant worsening of RLS, anxiety, insomnia and distress described by the patient as “an unbearable nightmare.” While his neurologist resumed a very challenging and slow switch of pramipexole to gabapentin and a benzodiazepine, the psychiatrist focused on motivational interviewing (MI) to enhance his motivation to switch to a different regimen that could cease the strong urges to gamble.
In the meantime, the therapist initiated Cognitive Behavioral Therapy (CBT) focused on psychoeducation about GD, development of adaptive coping responses to stress, and cognitive reframing including understanding cognitive distortions about gambling. Mr. C was able to identify that he frequently chased losses (“the machine should pay up soon”). With the CBT tool of a functional analysis, the therapist guided Mr. C through an exercise to recall and record his gambling experiences from pre- to post-gambling event. Mr. C was thus able to conduct an inventory his triggers (stress at work) that lead to feelings of anger and guilt, urges to escape, thoughts about and ultimately decisions to gamble, and short- and long-term consequences (instantaneous escape vs. financial harm). Distress-tolerance sessions helped Mr. C to tolerate urges and navigate and quell triggering factors though this proved challenging while still taking pramipexole. Although he was able to stop gambling while taking pramipexole, he endured urges with significant discomfort and attempts to decrease the dose led to withdrawal symptoms. Close communication between the neurologist and psychiatrist ultimately allowed for complete discontinuation of pramipexole over several months which led to cessation of gambling urges. In the meantime, the therapist focused on helping Mr. C identify values he maintained in his family, professional, and social roles and connect these to new activities as a way to help him meet his goals.
At time of publication, Mr. C is no longer gambling. He continues to receive monthly maintenance sessions focused on his recovery and relapse prevention. On his new medication regimen he does not experience strong urges to gamble but does acknowledge to occasional “triggering” from casino roadside billboard ads. In these scenarios he uses the skills he mastered with CBT to recall the negative consequences and talk himself out of gambling. Although anxiety and depressive symptoms subsided, the psychiatrist continued to follow up with Mr. C in the context of the difficulties he experienced while discontinuing pramipexole and afterwards, when dealing with the sadness related to his separation. Mr. C began to explore new social contacts and is effectively managing stress at work.

Discussion

This case portraits many of the challenges encountered when working with patients with dopamine agonist-related behavioral addictions. For Mr. C, dopamine agonist reduction and discontinuation was challenging given that it worsened his RLS and he experienced DAWS. DAWS has been reported by approximately one third of patients taking dopamine agonists who attempt to discontinue or decrease them [6]. Previous studies have demonstrated that the clinical manifestations of DAWS are similar to those found in withdrawal from other psychostimulants including psychiatric (anxiety, dysphoria, depression, agitation, irritability, suicidal ideation) and autonomic (orthostatic hypotension, diaphoresis) symptoms [5,6]. Currently, there is no well-established treatment for DAWS. Importantly, it appears that DAWS does not respond to substitution of L-dopa for the dopamine agonist, or to the addition of other medications [5] and therefore, as this case illustrates, it requires close management by the neurologist.
Though there are no official guidelines to manage the behavioral addictions related to dopamine agonists when discontinuing or decreasing them is not possible, some of the recommendations include the addition of levodopa (L-dopa), cathechol-O-methyl transferase inhibitors, or monoamine oxidase inhibitors [5]. Evidence for the use of amantadine is mixed [7,8]. At this point there is no clear evidence on whether the addition of psychotropic medications without the concomitant reduction of the dopamine agonist is effective [5]. Although a case report described a successful treatment of dopamine-agonist induced GD with naltrexone in a patient who was unable to tolerate the discontinuation [9], one small randomized controlled trial (n=50) testing naltrexone for patients with dopamine-agonist behavioral addictions failed to show differences in the primary outcome measure [10]. Nonetheless, the study found a significant improvement of symptoms which warrants replication in larger trials. A trial examining CBT for this population showed improved global symptom severity [11], however the specific CBT techniques that appear most helpful are yet to be clarified. Not all CBT’s are the same. One CBT modality is focused on the examination and correction of erroneous thinking [12] while another one focuses on coping responses and the acquisition of skills to manage high-risk situations [13].
The presence of biological and psychosocial factors in Mr. C’s case, together with the difficulties discontinuing the medication, supported a dual intervention. In this case, being able to recognize the association between the patient’s gambling and the use of dopamine agents, helped establish the trust between the treatment team and the patient. While the neurologist worked on decreasing and eventually discontinuing the dopamine agonist, the psychiatrist and therapist enhanced his motivation to work on such endeavor. Given that the discontinuation of the dopamine agonist proved challenging, the simultaneous use of CBT helped the patient develop coping skills to deal with situational triggers and cognitive reframing to stop gambling while on the medication. Most importantly, his recovery was made possible because of his providers’ collaborative work.

Funding/Conflict of  Interest: Mr. Grazioli and Dr. Okuda receive funding from the NYS Office of Alcoholism and Substance Abuse Services (OASAS). Mr. Grazioli, Mr. Hughes and Dr. Okuda report no biomedical financial interests or potential conflicts of interest.

Doi

https://doi.org/10.30435/ABA.01.2019.07

References

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