[Slide1]
PathologicalGamblingPathological Gambling
and Alcohol Use Disorders
Timothy Fong MD
First-Year AMSP Scholar
December 2005
I.
Introduction (This lecture is important for medicalstudentsmedical students
because) [Slide 2]
A. LifetimeriskLifetime risk of
pathological gambling (PG) is ~ 2%(1)
B. LifetimeriskLifetime risk of
alcohol use disorders (AUD) is ~ 13% (2)
C. LessresearchLess research on
PG vs. AUD
1. PubMed References: PG ~ 1,600, AUD ~ 55,000
2. MostphysiciansMost physicians
know little about pathological gambling (3)
3. MedicalschoolMedical school
curricula do not cover pathological gambling
D. Co-occurring PG and AUD are associated with worse outcomes (4)
1. TwiceasTwice as likely
to dropout of treatment (5-7)
2. ↓quality of life
E. ThislectureThis lecture
will cover:
[Slide 3]
1. PathologicalgamblingPathological gambling
(PG)
a. GamblinginGambling in the
United States
b. DSM-IV criteria
c. Epidemiology
d. Consequences
e. Screening
f. RiskfactorsRisk factors
g. Treatment
2. Alcohol usedisordersuse disorders (AUD)
a. AlcoholuseAlcohol use in
the United States
b. DSM-IVcriteriaIV criteria
c. Epidemiology
d. Consequences
e. Screening
f. RiskFactorsRisk Factors
g. Treatment
3. AUD and PG
[Slide 4]
a. Outcomes
b. Epidemiology
c. Similarities
d. Differences
e. TreatmentconsiderationsTreatment
considerations
A. GamblinginGambling in the
United States (8)
[Slide 5]
1. 85% of Americans have gambled over the last 12 months
2. 48 states in the United States have legalized gambling
3. $72billion/year
net revenue; more than amusement parks, movies and sporting eventscombinedevents combined
4. IncreasedculturalIncreased cultural
acceptance (9)
a. IncreasedpopularityIncreased popularity
of televised gambling
b. SchoolandSchool and
churches use gambling for fund-raising
c. 80% of parents aware and not opposed to children gambling (10)
B. DSM-IV Criteria (11, 12)
1. SocialgamblingSocial gambling(13)
[Slide6]
a. SimilarmeaningSimilar meaning
to Òsocial drinkingÓ
b. GamblingdoesGambling does
not meaningfully impact life
c. ~85% of gamblers
2. ProblemgamblingProblem gambling (1)
[Slide
7]
a. SimilartoSimilar to
Òsubstance abuseÓ
b. GamblingbehaviorsGambling behaviors:
problematic and beginning to interfere
c. ~5-6% of the general US population
3. PathologicalgamblingPathological gambling:
[Slides8
and 9]
a. DSM-IVcriteriaIV criteria
(5/10 criteria over last 12 months)(14)
i. PreoccupationwithPreoccupation with
gambling
ii. GambleswithGambles with
increasing money to achieve desired excitement
iii. RepeatedunsuccessfulRepeated unsuccessful
efforts to control, cut back, or stop gambling
iv. Restless/irritablewhenirritable when
attempts cutting down or stopping
v. GamblestoGambles to
escape problems or to relieve dysphoria
vi. ReturnstoReturns to get
even ("chasing" one's losses)
vii. LiestoLies to conceal
the extent of involvement
viii. IllegalactsIllegal acts
(e.g. forgery, fraud, theft, or embezzlement) to) to finance
gambling
ix. LostrelationshipLost relationship,
job, education, or career because of gambling
x. OthersprovideOthers provide
money for desperate financial situation
b. GamblingisGambling is not
better accounted for by a manic episode
C. EpidemiologyofEpidemiology of
PG (8, 15, 16)
[Slide10]
1. LifetimeprevalenceLifetime prevalence
a. ~1%of general population (15, 17, 18)
b. Higher within 50 miles of a casino
2. VulnerablepopulationsVulnerable populations
(19)
[Slide11]
a. Adolescents(20)
i. HardertoHarder to recoup
financial losses
ii. EarlyexposureEarly exposure
to gambling increases risk
b. Co-occurringsubstanceoccurring substance
use disorder; impairs judgment (21)
c. CasinoworkersCasino workers:
high access (22)
d. CurrentlyincarceratedCurrently incarcerated
(17)
i. HighfrequencyHigh frequency
of gambling in prisons/jails
ii. BoredomandBoredom and lack
of activities
D. ConsequencesofConsequences of
PG (23, 24)
[Slide12]
. 1. Financial
a. Debt: average is ~ $45,000 (25)
b. BankruptcyratesBankruptcy rates:
4 times higher, 20% (26)
c. EconomicburdenEconomic burden:
$35 billion per year (27)
2. Relationships
a. DivorceratesDivorce rates
54% (28)
b. DomesticviolenceDomestic violence: 10x more likely (29)
c. ChildabuseChild abuse and
neglect: case reports of abandonment in several states (30)
3. LossofLoss of time and
productivity: ~ 25 hours spent per week (31)
4. Medical
a. IncreasedfrequencyIncreased frequency
of stress-related illnesses like peptic ulcer, hypertension (28)
b. 25% attempt suicide (32)
5. Crime: 21% of PG commitPG commit
non-violent, financial crimes (33)
6. SubstanceuseSubstance use
disorders: 4x increased risk (34)
E. ScreeningtoolsScreening tools
[Slide13]
1. SouthOaksSouth Oaks
Gambling Screen (SOGS) (35, 36)
a. Self-reportquestionnairereport questionnaire
re: gambling behaviors and consequences
b. ScoreofScore of ³5 = probable PG
2. Lie/BetQuestionnaireBet Questionnaire
(37, 38)
a. TwoquestionsTwo questions:
i. EverliedEver lied about
your gambling?
ii. EverincreasedEver increased bet
to get same sense ofactionof action?
b. Two ÒyesÓ responses
= high= high sensitivity(sensitivity (.99), high, high
specificity (.91) andhighand high positive predictive value (.92)
3. NoobjectiveNo objective
tests
F. RiskfactorsRisk factors (19)
[Slide14]
1. Biological(39-41)
a. FamilystudiesFamily studies:
2-3x increased risk in family members (42, 43)
b. TwinstudiesTwin studies:
60% genetic risk (44)
c. Neuroimaging: implicate same
regions as substance use disorders (e.g. orbitofrontal cortexandcortex and
reward systems (45)
d. AlterationsinAlterations in
serotonin, dopamine and norepinephrine (41, 46)
2. Psychological [Slide 15]
a. PersonalitytraitsPersonality traits (47, 48)
i. ↑Impulsivity
ii. ↑Sensation-seeking
iii. ↑Risk-taking
b. ImpairedcopingImpaired coping
strategies (49)
i. AvoidresponsibilitiesAvoid responsibilities
ii. ManageshameManage shame and
emotional pain
iii. EscapestressEscape stress
c. CognitivedistortionsCognitive distortions
about gambling (50-52)
i. FalseperceptionsFalse perceptions
of ability to control gambling outcomes
ii. FalsebeliefsFalse beliefs
that gambling will solve life problems
3. Social(53, 54) [Slide 16]
i. IncreasedaccessIncreased access
to gambling
ii. LearningtoLearning to
gamble at an earlier age (54)
1. Pharmacotherapy: No
FDA-approved meds;preliminarymeds; preliminary
research evidence for: (55)
a. Naltrexone
i. Opiate
antagonist used for alcoholandalcohol and
opiate dependence
ii. Targets
urges and cravings (56)
iii. Side
effects: dysphoria, elevated LFTs, nausea, problems
controllingpaincontrolling pain
iv. Efficacy:
30% reduction inurgesin urges/craving to gamble (57)
b Selective
serotonin reuptakeinhibitorsreuptake inhibitors
(SSRI)
i. Antidepressants
to target gamblingpreoccupationgambling preoccupation
and obsessions (58, 59)
ii. Side
effects: nausea, sexualdysfunctionsexual dysfunction,
agitation
iii. Efficacy: Mixed results on gambling behaviors (59, 60)
c. Valproic
Acid
i. Anticonvulsant
used for bipolardisorderbipolar disorder
ii. Side
effects: sedation, tremors,nauseatremors, nausea
iii. Efficacy:
reduced gambling in
non-bipolar disorder (61, 62)
d. Lithium
i.
Natural salt used for bipolar disorder
ii. Side
effects: tremor, sedation,nauseasedation, nausea,
thyroid and kidney
impairments
iii. Efficacy: reduced gambling in non-bipolar and
bipolar spectrumdisorderspectrum disorder
PG (61, 63, 64)
2. Social assistanceSocial assistance[AB1]
[Slide
18]
a. Self-exclusion
programs
i. PGs
sign up with casinos to barthemselvesbar themselves
from entering
ii. Potential
gateway into treatment (65)
b. FinancialcounselingFinancial counseling:
i. Debt
relief/consolidation
ii. Bankruptcy
iii. Discharged
casino debts
c. GamblerÕs
Anonymous [AB2](66)
i. >
1500 chapters in U.S.
ii. Modeled
after AA, providesfellowshipprovides fellowship
and peer support
iii. 8%
abstinence rate after 1 year ofparticipationof participation
3. PsychosocialtreatmentsPsychosocial
treatments
[Slide19]
a. CognitivebehavioralCognitive behavioral
therapy (67, 68)
i. FocusesonFocuses on
reworking cognitive distortions about gambling
ii. CanbeCan be
manualized
iii. 40%reduction in gambling behavior after 12 sessions
iv. 50%treatment
retention rate [AB3]
v. Long-term efficacy data needed, especially after therapy ends
b. HelplinesHelp lines
i. 24-hourtelephonehour telephone
counseling
ii. TrainedgamblingTrained gambling
counselor provides crisis intervention, education and referrals
iii. NodataNo data on
effectiveness, yet widely used.
A. Alcohol Use in the United States [Slide 20]
1. 63%percent drank over last 12 months
2. GrossrevenueGross revenue
2005: $6 billion
B. DSM-IVCriteriaIV Criteria (69)
[Slide
21]
d. Social/interpersonalproblemsinterpersonal problems
(e.g. arguments, physical fights)
2. Dependence: >3 in a 12-month period [Slide 22]
a. Tolerance(Tolerance (e.g.
increased amount needed for effect)
1. Abuse/Dependence(70, 71)
a. LifetimeprevalenceLifetime prevalence
- abuse/dependence :dependence:
15-20%
b. 15 million individuals meeting criteria
2. EconomicburdenEconomic burden:
$155 billion
D. Consequences [Slide24]
1 Medical
a. Cardiovascular:hypertensionCardiovascular:
hypertension, cardiomyopathy, MI.
b. GastrointestinalsystemGastrointestinal :system: Mallory
Weiss tear, gastric
bleeding, fatty
liver, cirrhosis.
c. Neurological: KorsakoffÕs and WernickeÕs syndrome
(opthalmoplegia, ataxia, and encephalopathy), peripheralneuropathyperipheral neuropathy,
cerebellar degeneration, cognitive deficits
2. Work: ↑unemployment; ↑lateness; ↑injury; ↓weeks of employment; and
↓ performance
3. Family
a. > 80% of cases of spouse-to- spouse violence
b. 25% of heavydrinkersheavy drinkers
abuse children
E. Screening [Slide25]
1. AlcoholUseAlcohol Use
Disorder Inventory Test (AUDIT) (72)
a. 10 items
b. Self-administeredoradministered or
interview
c. 2 minutes to complete
d. IncludesquestionsIncludes questions
on quantity/frequency and alcohol use problems
e. OriginallydevelopedOriginally developed
as screening instrument for primary care setting
2. Michigan Alcohol Screening Test (MAST) (73)
a. 25 items (also a 10 item version)
b. Self-administeredoradministered or
interview
c. 10 minutes to complete
3. StatemarkersState markers: ↑GGT, ↑ MCV, ↑CDT
F. RiskFactorsRisk Factors
[Slide26]
1. Gender
(femalestendfemales tend to
have less body water, more body fat)
2. Genetics
(differential risk for level of intoxication,diseasesintoxication, diseases,
alcohol
dependence)
3. Body
weight (smaller size achieves higher bloodlevelsblood levels)
4. Metabolism
(less activity ofalcoholof alcohol
dehydrogenase results in slower metabolism, higher levels and longerdurationlonger duration
of sustained alcohol levels)
5.
Medical
illness (e.g. liverdiseaseliver disease,
diabetes, hepatitis C, etc.)
6.
Pregnancy
(risk for fetalalcoholfetal alcohol syndrome,
spontaneous abortion, low
birthbabybirth baby,
developmental delays, etc)
G. TreatmentofTreatment of AUD
(74)
[Slide
27]
1. Pharmacotherapy
a. Disulfiram
(75)
i. Inhibits
aldehydedehydrogenase;
ii. Aversive
effect if ETOH consumed;
Disulfiram-Ethanol Reaction (flushing, nausea, tachycardia)
iii. Side
effects: metallic taste, nausea, hepatitis, psychosis.
neuropathy
iv. Efficacy:
equivocal forabstinentfor abstinent
rates, best for highly motivated, directly observed patients
b. Naltrexone(76)
i. Opiate
antagonist to blockurgesblock urges/cravings
ii. Side
effects: nausea, dysphoria,
increased LFTs
iii. Efficacy:
reduces number ofdrinksof drinks and number of drinking days
c. Acamprosate (77)
i. Taurine
derivative, restores NMDA receptor tone in the glutamate system,
also impacts GABA
neurotransmission.
ii. Side
effects: diarrhea, rash
iii. Efficacy:
greater treatmentcompletiontreatment completion,
increased time to first drink
2. SocialassistanceSocial assistance
for AUD (73, 78)[AB4]
[Slide28]
a. 12-Step,AlcoholicsStep, Alcoholics
Anonymous
i. PeersupportPeer support and
fellowship
ii. 75,000 groups in the United States
iii. DifficulttoDifficult to
study empirically
b. SMART Recovery (Self-Management and Recovery Training)
i. Self-reliance
ii. Discussion groups
iii. No sponsors
iv. Essentially no empirical data
3. PsychosocialTreatmentsPsychosocial
Treatments
a. CognitivebehavioralCognitive behavioral
therapy (79, 80)[AB5]
i. IncreasemotivationIncrease motivation
for abstinence
ii. IdentifymotivationsIdentify motivations
for drinking and develop alternatives
iii. SimilartechniquesSimilar techniques
used for PG
iv. Efficacy:longerEfficacy: longer
in treatment, better the outcome
b. Relapse Prevention Therapy
i. Identify high-risk situations
ii. Develop new coping behaviors
iii. Effective in reducing frequency of relapse
A.
A. Co-occurringPGoccurring PG and
AUD associated with worse treatment outcomes (83-85)
1.
MoredifficultMore difficult
for treatment engagement and retention
2. LowercomplianceLower compliance
rates with treatment recommendations
3. MorelikelyMore likely to
have other co-occurring disorders such asdepressionas depression,
anxiety disorders or antisocial personality disorder
4. MorelikelyMore likely to
relapse as compared to persons with only PG or AUD
B. Epidemiology (84, 86, 87) [Slide30]
1. PG have higher rates of AUD (88)
a. AUD in PG: 40%
b. IncreasedseverityIncreased severity
of PG = increased risk for AUD
2. AUD have higher rates of PG (4, 89)
a. PG in AUD: ~10%
b. Most AUD providers do not screen for PG
3. Neither PG or AUD more likely to emerge first (90)
C. SimilaritiesbetweenSimilarities between
PG and AUD (4)
[Slide31]
1. Preoccupation:intensePreoccupation: intense
urges and cravings
2. Tolerance;gamblingTolerance; gambling
more to achieve desired affect
3. Lying:coverLying: cover-up
debt and extent of involvement
4. OngoinggamblingOngoing gambling
despite negative consequences
D. DifferencesbetweenDifferences between
PG and AUD (91)
[Slide
32]
1. NoobjectiveNo objective
tests
a. Nointoxicated states
b. NophysicalNo physical
signs and symptoms
2. FinancialimpactFinancial impact
a. PG may lose large amounts at one time
b. PGmayPG may win large
amounts of money at one time
E. TreatmentconsiderationsTreatment
considerations for co-occurring PG and AUD (87, 92)
[Slide 33]
1. MuchmoreMuch more data
needed; use Òcommon-sense practicesÓ
2. For co-occurring
AUD + PG, use similar treatments as for AUD or PG, alone.
3. IftreatIf treat only
one disorder, the other disorder will persist (84)
4. GetcollateralGet collateral
information from relatives and friends
5. PeriodicurinePeriodic urine
drug toxicology testing, breathalyzers, LFTs
6. NoobjectiveNo objective
test available to monitor gambling behavior
7. InsurancedoesInsurance does
not cover PG treatment
A. PG is a psychiatric disorder with serious negative consequences
B. PG and AUD commonly co-occur
C. PhysiciansmustPhysicians must
screen for PG and AUD in order to intervene early
D. TreatmentsandTreatments and
interventions are available for both disorders
[AB1]Tim, are these reallyÒtreatmentsÓ? Treatment usually refers to a clinical interaction that isfacilitated by a clinical professional. Maybe better to call them Òsocialprograms for PGÓ or Òsocial assistance for PGÓ
[AB2]Tim, 12 step programs are nottreatment. (12step facilitation is.) Treatment occurs when a trainedprofessional provides it. I would consider this a Òsocial programÓ orÒassistanceÓ and put it in that section. Then, you can do the same for AUD(i.e., have a section entitled Òsocial programs/assistanceÓ.
[AB3]Tim, this reference is a casereport. I would say this is pretty preliminary evidence. ItÕs not just thatlong term data are neededÑitÕs that more methodologically rigorousstudies need to be done before you can say this is efficacious. ItÕs fine tohave prelim evidence if thatÕs the state of the literature. ItÕs just that itÕsimportant to let the audience know this.
[AB4]Tim, see my AA comments abovere AA and treatment.
[AB5]If you want to have a separatesection of psychosoc treatments for EtOH, youÕll need to have >1 treatment(i.e., CBT). Feel free to use the summaries and references in my chapter tomention other txÕs Ðlike relapse prevention therapy or 12 stepfacilitation, for example.