Restless Legs Drugs and Compulsive Gambling: A Hidden Danger

Most Americans assume that bad habits come down to willpower. If someone gambles away their savings, binges on food or shops compulsively, the typical response is simple: they should have exercised more self-control! The idea that a prescribed medication could hijack behavior, pushing someone toward risky or destructive impulses, seems almost impossible to accept. And yet the research is clear that some of the restless legs drugs can modify brain chemistry enough to trigger unwelcome activities.

Neuroscientists and drug safety experts have long warned that certain medications affecting the brain chemical dopamine may alter behavior in surprising ways. Drugs prescribed for restless legs syndrome (RLS) and Parkinson disease have been linked to powerful impulse control problems, including compulsive gambling, hypersexuality and binge eating.

Please don’t take our word for this idea. Readers describe how unsettling this adverse reaction can be!

A Reader Reports Restless Legs Drugs and Compulsive Gambling

Q. I take pramipexole to treat restless leg syndrome. When I play casinos, I seem not to be able to stop playing. I have almost maxed out my credit cards.

My doctor said a drug I was taking could cause an addiction, but I really couldn’t believe it would happen to me. I have also gained weight, which has caused stress with my wife.

I would never have believed I could have a gambling issue. The restless leg syndrome is under control, but I play casino games on my phone until I run out of money. I never had this problem before.

A. Most people find it hard to believe that a medication could lead to excessive gambling. However, neuroscientists have long recognized that drugs affecting the brain chemical dopamine may predispose some individuals to compulsive behavior. In this category, ropinirole (Requip) and pramipexole (Mirapex) are both prescribed for restless leg syndrome as well as Parkinson disease.

One study introduced the topic this way (Pharmaceutical Medicine, Jan. 7, 2023):

“Problematic gambling has been suggested to be a possible consequence of dopaminergic medications used mainly in neurological conditions, i.e. pramipexole and ropinirole, and possibly by one antipsychotic compound, aripiprazole.”

The authors conclude:

“Since the neurobiology of GD [gambling disorder] is only partly understood, the mechanism of how dopaminergic and serotonergic drugs can increase addictive behavior is still subject to speculation. Given the clear association in large study populations and many indicators from molecular research, a causal relationship is likely but has not been proven yet.”

Restless Legs Drugs and Prescribing Information:

When doctors consult the official prescribing information for a medication such as pramipexole, they read:

“Cases of pathological gambling, hypersexuality, and compulsive eating (including binge eating), and compulsive shopping have been reported in patients treated with dopamine agonist therapy, including pramipexole therapy.”

Doctors, nurse practitioners, physician associates and pharmacists should warn patients that restless legs drugs could have some strange behavioral side effects. Because most people probably cannot imagine themselves engaging in destructive behaviors, such a warning may go unheeded. That’s why it can be helpful to read what other patients have gone through.

Earlier Reports of Restless Legs Drugs and Compulsive Gambling

This is not the first time readers have alerted us to this disturbing complication. One reader wrote:

Q. I almost fell off my chair when I accidentally came across information that ropinirole could trigger impulsive gambling. I have been taking this drug for eight years for restless legs. When it was first prescribed, I thought it was an absolute godsend because it relieved my restless legs and allowed me to sleep at night.

Now I finally understand why I became a gambling addict shortly after starting this medication. I hated what I was doing, but could not stop.

A. Ropinirole (Requip) and pramipexole (Mirapex) are prescribed for restless legs syndrome (RLS) and Parkinson’s disease.

A study published in JAMA Internal Medicine (December, 2014) confirmed that such drugs can trigger pathological gambling, compulsive shopping and hypersexuality.

Most health professionals believe these side effects are extremely rare, but some drug safety experts suspect the incidence of impulse control problems could be as high as 10 percent. They have called for stronger warnings to protect unwary patients.

The authors of the article cited above introduce their article this way:

“The development of unusual but severe impulse control disorders has been reported for dopamine receptor agonist drugs used to treat Parkinson disease, restless leg syndrome, and hyperprolactinemia.¹ The events typically involve behaviors such as pathological gambling, hypersexuality, compulsive shopping, and, less frequently, binge eating and punding (the compulsive fascination with and performance of repetitive mechanical tasks). They can have catastrophic effects on jobs, marriages, and family finances. Reports have indicated high prevalence rates, on the order of 6% to 24%. In numerous case reports, the abnormal behavior ceased on discontinuation of the dopamine receptor agonist drug, and in some case reports, it reappeared when therapy was resumed.”

Their conclusions about restless legs drugs are strong:

“At present, none of the dopamine receptor agonist drugs approved by the FDA have boxed warnings about the potential for the development of severe impulse control disorders as part of their prescribing information. Our data, and data from prior studies, show the need for these prominent warnings. Physicians who prescribe dopamine agonists should also vigilantly monitor their patients, and ensure that patients, families, and caregivers are counseled about the risk of these serious adverse events.”

As far as we can tell, the Food and Drug Administration has still not required boxed warnings for these drugs. We think that is an important oversight. And agree that prescribers should monitor patients and make sure family members are informed about these problems such as gambling, hypersexuality and compulsive shopping.

How Restless Legs Drugs Can Trigger Compulsive Gambling

The proposed mechanism behind gambling addiction, hypersexuality, compulsive shopping and other unwanted behaviors involves the brain chemical called dopamine.

Patients with Parkinson disease (PD) have a deficiency of this neurotransmitter. Beginning in the 1960s researchers discovered that they could reduce symptoms of PD by boosting dopamine activity with medications such as:

• levodopa
• bromocriptine (Parlodel, Cyclist)
• cabergoline (Dostinex)
• ropinirole (Requip)
• pergolide (Permax)
• pramipexole (Mirapex)

These medications are often called dopamine agonists because they stimulate dopamine receptors in the brain.

Unfortunately, altering dopamine signaling can also affect reward pathways involved in pleasure, motivation and risk-taking. Researchers began noticing a troubling pattern: some patients developed impulse control disorders, including compulsive gambling (Neuropsychiatric Disease and Treatment, Feb., 2007).

Real Stories of Restless Legs Drugs and Compulsive Gambling

Many readers have described experiences that mirror what researchers have reported.

Leanne in California shared this:

“I have had severe restless leg syndrome (RLS) for the past 15 years. The first 10 years I took Requip and had to keep upping the dose every year by a milligram. I was up to 4 mg when I was switched to Mirapex a year ago.

“I have developed a severe gambling addiction, and I am lost on what to do.”

Arlene in Hammond, Indiana described multiple side effects:

“I am just learning about side effects from Mirapex. My hands and feet have swelled. I also have to urinate frequently without warning. I have been losing hair and falling asleep while cooking or on the computer. I also have sexual and gambling urges. I feel as if I have all the side effects and have been on this drug for more than 10 years.”

“Falling asleep without warning in the middle of the day is a known complication of both ropinirole and pramipexole.”

The FDA cautions:

“Patients treated with [pramipexole or ropinirole] have reported falling asleep while engaged in activities of daily living, including the operation of motor vehicles which sometimes resulted in accidents.”

Some people experience these sleep attacks without warning, even after taking the medicine for a year or longer.

Another reader, E.M., wrote about a gambling problem:

“I had RLS for a very long time. Most of the prescribed meds didn’t work. When I started ropinirole (Requip) several years ago I found that it caused me to have strong urges to gamble. This has become a very bad problem for me, not only financially but mentally. I cannot control the urge.”

Jen described how devastating the consequences can be:

“After being prescribed Mirapex and Requip for my RLS I gambled away all of my savings and became so depressed and ashamed that I decided to end my life. Fortunately, a friend found me in time and I was sent to the hospital.”

Legal Cases Involving Restless Legs Drugs and Compulsive Gambling

Courts have also wrestled with the consequences of these drug-induced behaviors.

ABC News reported (Feb 2, 2011):

“In 2008, a district court in Minneapolis awarded Gary Charbonneau $8.2 million in gambling losses and punitive damages in a suit against the makers of Mirapex, Pfizer and Boehringer Ingelheim.”

In May 2015 it was announced that Pfizer would settle a class-action lawsuit involving 172 Australian patients. They claimed medications for Parkinson’s disease or restless legs syndrome caused them to gamble away their life savings or develop compulsive sexual behaviors.

The settlement was estimated to be in the millions of dollars.

Medicines, the Brain and Impulse Control

We realize that some readers may find these stories hard to believe. But there is growing recognition that medications affecting the brain can sometimes trigger dramatic behavioral changes.

Just as antidepressants have been linked to suicidal thoughts and actions, violence, mayhem and deaths, (PLOS Medicine, Sept. 15, 2015) so too dopamine agonists appear to trigger unwanted behaviors in some patients.

We have written about this situation in this article:

Are Antidepressants Linked to Violence, Mayhem and Death?
Antidepressants can be extremely helpful for some people. Others may experience suicidal thoughts or angry outbursts. Can these drugs lead to violence?

Warning Signs of Drug-Induced Compulsive Behavior

People taking dopamine-activating medicines for restless legs syndrome or Parkinson disease should watch for sudden changes in behavior.

Warning signs may include:

• a new or escalating urge to gamble

• compulsive online gaming or casino betting

• uncontrolled shopping or spending

• binge or compulsive eating

• unusually strong sexual urges

• secretive financial behavior

• mounting credit-card debt or hidden losses

These behaviors can develop gradually and may be difficult for the person taking the medication to recognize. Family members are often the first to notice that something has changed.

Anyone experiencing these symptoms should talk with their physician promptly about adjusting treatment.

What Do You Think?

• Stories about restless legs drugs and compulsive gambling raise difficult questions. Should patients be responsible for gambling debts if they were never warned about these side effects?
• Does our legal system recognize that a medication might push someone to behave in ways completely out of character?
• What about other medication-induced behaviors such as aggression or suicidal impulses?
• Should drug companies share responsibility when medicines alter behavior in unexpected and sometimes dangerous ways?
• What responsibility to prescribers and dispenses have when it comes to warning about changes in behaviors?

Some people believe individuals should always be responsible for their actions, regardless of what medication they take. Others argue that when a drug alters brain chemistry and triggers compulsive behavior, the manufacturer and prescriber should share some responsibility.

These are complicated ethical and legal issues. We would very much like to hear what you think—and whether you or someone you know has experienced unexpected behavioral side effects from a medication.

Please share your perspective in the comment section below.