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

II.                Pathological gambling                                                                                               

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 “social drinking”

b.         GamblingdoesGambling does not meaningfully impact life

c.         ~85% of gamblers

                        2.         ProblemgamblingProblem gambling         (1)                                                        [Slide 7]

                                    a.         SimilartoSimilar to “substance abuse”

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  ≥5 = 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 “yes” 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)

G.        TreatmentofTreatment of PG                                                                                   [Slide 17]

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


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.         Gambler’s 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.

III.       AlcoholUseAlcohol Use Disorders: The second diagnosis                                            

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]

1.         Abuse:  significant impairment/distress in>1 over 12 months

                                    a.         FailuretoFailure to fulfill major obligations

                        b.         PhysicallyhazardousPhysically hazardous (e.g. driving while intoxicated)

                        c.         LegalproblemsLegal problems (e.g. disorderly conduct, DUIs)

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)

b.         Withdrawal(Withdrawal (e.g. increased autonomic hyperactivity, tremor)

                        c.         LargeramountsLarger amounts/longer period than intended

                        d.         PersistentdesirePersistent desire/unsuccessful attempts to cut down

e.         ExcessivetimeExcessive time spent with alcohol

f.          ActivitiesgivenActivities given up due to alcohol

g.         ContinueduseContinued use despite problems

            C.                                              Epidemiology                                                                                                                                                  [Slide23]

                        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:    Korsakoff’s and Wernicke’s syndrome (opthalmoplegia, ataxia, and encephalopathy), peripheralneuropathyperipheral neuropathy, cerebellar degeneration, cognitive deficits

2.         Work: unemployment; lateness; injury; weeks of employment; and


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.


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


IV.       AlcoholuseAlcohol use disorders and pathological gambling (81, 82)               [Slide29]

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 “common-sense practices”

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

III.             Conclusions                                                                                                    [Slide 34]

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


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 [AB1]Tim, are these really“treatments”? Treatment usually refers to a clinical interaction that isfacilitated by a clinical professional. Maybe better to call them “socialprograms for PG” or “social assistance for PG”

 [AB2]Tim, 12 step programs are nottreatment. (12step facilitation is.) Treatment occurs when a trainedprofessional provides it. I would consider this a “social program” or“assistance” and put it in that section. Then, you can do the same for AUD(i.e., have a section entitled “social programs/assistance”.

 [AB3]Tim, this reference is a casereport. I would say this is pretty preliminary evidence. It’s not just thatlong term data are needed—it’s that more methodologically rigorousstudies need to be done before you can say this is efficacious. It’s fine tohave prelim evidence if that’s the state of the literature. It’s just that it’simportant 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, you’ll need to have >1 treatment(i.e., CBT). Feel free to use the summaries and references in my chapter tomention other tx’s –like relapse prevention therapy or 12 stepfacilitation, for example.