What medications are used to treat porn addiction?

Medication for Problematic Pornography Use

SSRIs, particularly paroxetine, represent the first-line pharmacological approach for problematic pornography use when conceptualized within an obsessive-compulsive framework, though evidence is limited and psychotherapy should be prioritized. 1, 2

Clinical Framework and Diagnostic Considerations

Problematic pornography use (PPU) can manifest through multiple pathophysiological mechanisms, requiring careful assessment before initiating pharmacotherapy:

• Obsessive-compulsive presentation: Look for intrusive thoughts about pornography, compulsive checking behaviors (e.g., monitoring arousal responses), reassurance-seeking patterns, and anxiety-driven use that mirrors sexual orientation OCD patterns 3
• Hypersexual/addictive presentation: Assess for loss of control, continued use despite consequences, craving, and functional impairment in relationships or work 4, 2
• Comorbid conditions: Screen specifically for depression, anxiety disorders, other substance use disorders, and OCD, as these frequently coexist and influence treatment selection 4, 2

Pharmacological Treatment Algorithm

First-Line: SSRIs

When pharmacotherapy is indicated, initiate with an SSRI using OCD-level dosing:

• Paroxetine 40-60 mg daily is the most studied agent for PPU specifically, with case series demonstrating initial efficacy in reducing pornography use frequency and associated anxiety 1, 2
• Fluoxetine 60-80 mg daily can be considered as an alternative, particularly if comorbid depression is prominent, though it requires higher doses than standard depression treatment 5
• Treatment duration should be 8-12 weeks minimum to assess efficacy, with most improvement occurring in the first 2-4 weeks 3

Critical Safety Considerations

Monitor closely for paradoxical effects and adverse outcomes:

• Emergence of new compulsive sexual behaviors has been reported after 3 months of paroxetine treatment, potentially representing disinhibition or symptom substitution 1
• Discontinuation syndrome is particularly severe with paroxetine, characterized by dizziness, sensory disturbances, paresthesias, and anxiety—taper slowly if discontinuing 5
• Sexual dysfunction (delayed ejaculation, anorgasmia) occurs commonly with SSRIs at high doses and may paradoxically worsen distress 3
• Consider pharmacogenetic testing for CYP2D6 status before initiating high-dose SSRI therapy, as poor metabolizers have 7-fold higher drug exposure with paroxetine and 11.5-fold higher exposure with fluoxetine 60 mg, increasing toxicity risk including QT prolongation 5

Second-Line: Naltrexone

For patients with prominent addictive/reward-seeking features:

• Naltrexone may be considered as an alternative or augmentation strategy, based on its efficacy in other behavioral addictions, though specific PPU evidence is limited 2
• This approach is most appropriate when PPU resembles substance use disorder patterns (craving, loss of control, continued use despite harm) rather than OCD patterns 2

Integration with Psychotherapy

Pharmacotherapy should never be used as monotherapy for PPU:

• Cognitive-behavioral therapy (CBT) is the primary treatment modality, with large effect sizes demonstrated in meta-analyses for reducing PPU severity, frequency/duration of use, and sexual compulsivity 6
• Acceptance and commitment therapy (ACT) also shows large effect sizes and should be considered as an alternative evidence-based approach 6
• Combined pharmacotherapy plus CBT follows the same principles as treatment for OCD, where augmentation of SSRIs with CBT produces larger effect sizes than medication alone 3
• Psychotherapy effects are stable at follow-up, whereas medication effects may diminish or produce paradoxical outcomes over time 1, 6

Treatment Duration and Monitoring

Establish clear monitoring parameters:

• Assess pornography use frequency, duration, associated anxiety/distress, and functional impairment at baseline and every 2-4 weeks initially 1
• If response is achieved, continue pharmacotherapy for minimum 12-24 months following OCD treatment guidelines, as relapse risk is high with premature discontinuation 3
• Re-evaluate at 3 months specifically for emergence of new problematic sexual behaviors or symptom substitution 1
• Monitor for treatment-emergent suicidality, particularly in younger patients on paroxetine 5

Common Pitfalls to Avoid

• Do not use standard antidepressant doses—OCD-level dosing (paroxetine 60 mg, fluoxetine 60-80 mg) is required for efficacy 5
• Do not prescribe SSRIs without concurrent psychotherapy—medication alone has limited durability and may produce paradoxical effects 1, 6
• Do not abruptly discontinue paroxetine—severe discontinuation syndrome is common and may be mistaken for relapse 5
• Do not ignore comorbidities—treat co-occurring depression, anxiety, or substance use disorders as these influence outcomes 4, 2
• Do not assume all PPU is the same—distinguish between OCD-spectrum presentations (intrusive thoughts, anxiety-driven) versus addictive presentations (reward-seeking, loss of control) as this guides treatment selection 3, 2

When Pharmacotherapy May Not Be Appropriate

Prioritize psychotherapy alone when:

• PPU is mild to moderate severity without significant functional impairment 6
• Patient preference strongly favors non-pharmacological approaches 3
• No comorbid psychiatric conditions requiring medication are present 3
• Access to trained CBT or ACT therapist is available 6