Gambling Disorders:What Addiction Professionals Need to Know

Wednesday, March 23, 20112 – 3 p.m. EST

Co-Sponsored by:

Glenn ChristensonChairmanNational Center for Responsible Gaming

Welcome

www.ncrg.org• Webinar Series – new sessions will be scheduled soon!• Gambling Disorders 360° blog• Connect via facebook and slideshare

ModeratorShirley Beckett Mikell, NCAC II, CAC II, SAPDirector of Certification and Education, andNational Certification Commission Staff LiaisonNAADAC

Today’s Session

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Organizational Memberships

www.naadac.org/education

The Basics of Addiction Counseling: Desk Reference and Study Guide

Integrating Treatment for Co-occurring Disorders: What Every Addiction Counselor Needs to Know

Conflict Resolution in Recovery Kit

New Innovations with Opioid Treatment: Buprenorphine

New Horizons: Integrating Motivational Styles, Strategies and Skills with Pharmacotherapy

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Independent Study Courses

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– Substance Abuse Professional (SAP)

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National Certification Opportunities

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Jon Grant, J.D., M.D., MPHProfessor of Psychiatry University of Minnesota

Today’s Presenter

FPO

WebinarWebinarProblem/Pathological Problem/Pathological

GamblingGambling

Jon E. Grant, JD, MD, MPHJon E. Grant, JD, MD, MPHProfessorProfessor

University of Minnesota University of Minnesota School of MedicineSchool of MedicineMinneapolis, MNMinneapolis, MN

Nature and PrevalenceNature and Prevalence

Core FeaturesCore Features

Repetitive or compulsive engagement in Repetitive or compulsive engagement in gambling despite adverse consequencesgambling despite adverse consequencesDiminished control over the problematic Diminished control over the problematic behavior behavior An appetitive urge or craving state prior to An appetitive urge or craving state prior to gambling gambling A hedonic quality during gambling.A hedonic quality during gambling.

Common Core QualitiesCommon Core Qualities

ToleranceTolerance

WithdrawalWithdrawal

Repeated unsuccessful attempts to cut back Repeated unsuccessful attempts to cut back or stopor stop

Impairment in major areas of life functioningImpairment in major areas of life functioning

CharacteristicsCharacteristics

Age: usually begins in early adulthoodAge: usually begins in early adulthoodGender: 32% female, 68% maleGender: 32% female, 68% maleMales tend to start at an earlier age Males tend to start at an earlier age Telescoping phenomenon Telescoping phenomenon Triggers: Triggers: –– External External ––AdvertisementsAdvertisements–– Internal Internal -- Boredom, Stress Boredom, Stress

Social/Personal ConsequencesSocial/Personal Consequences

Family dysfunction and domestic Family dysfunction and domestic violenceviolence

Depression and suicide Depression and suicide

Financial problemsFinancial problems

Criminal behaviorCriminal behavior

Legal ConsequencesLegal Consequences

FraudFraudStealingStealingEmbezzlementEmbezzlementForgeryForgeryRobberyRobberyBlackmailBlackmailProstitutionProstitution

Other Health IssuesOther Health Issues

–– Heart diseaseHeart disease

–– Liver diseaseLiver disease

–– HypertensionHypertension

National Comorbidity Study National Comorbidity Study Past Year Rates Past Year Rates (%) for All (%) for All AgesAges

Anorexia 0.1Schizophrenia / schizophreniform 1.1Panic Disorder 1.3Anti-social Personality 1.5Social Phobia 1.7Obsessive Compulsive 2.1Dysthymia 2.5Drug Use Disorder 2.9Cognitive Impairment 2.9Gambling addiction 4.0Major Depression 5.8Alcohol Use Disorder 7.3Any Phobia 11.0Any Anxiety 12.7Any NCS disorder 28.0

ComorbidityComorbidity

CoCo--Occurring Disorders in Occurring Disorders in Pathological GamblingPathological Gambling

0

10

20

30

40

50

60

70

Substance Use

Affective

Anxiety

Impulsedisorders

Smoking and GamblingSmoking and Gambling-- Cigarette Smoking Associated with Cigarette Smoking Associated with Increased Gambling Severity in TreatmentIncreased Gambling Severity in Treatment--Seeking Problem Gamblers Seeking Problem Gamblers

-- Among HelpAmong Help--Seeking Problem Gamblers, Seeking Problem Gamblers, Current Daily Smoking Associated with More Current Daily Smoking Associated with More Psychiatric Problems Psychiatric Problems

-- Among Gambling Subjects, Daily Smokers Among Gambling Subjects, Daily Smokers Report Stronger Gambling UrgesReport Stronger Gambling Urges

Family historyFamily history

•• 50% of pathological gamblers had a 50% of pathological gamblers had a parent with alcohol abuseparent with alcohol abuse

•• 33% of first33% of first--degree relatives of degree relatives of pathological gamblers had an alcohol use pathological gamblers had an alcohol use disorderdisorder

•• FirstFirst--degree relatives more likely to have degree relatives more likely to have gambling problems (odds ratio 3.36)gambling problems (odds ratio 3.36)

Relation to Alcohol UseRelation to Alcohol UseRate of substance abuse 7Rate of substance abuse 7--fold greater in fold greater in pathological gamblers than among nonpathological gamblers than among non--gamblers. gamblers.

44% of those with disordered gambling 44% of those with disordered gambling behavior also have lifetime history of behavior also have lifetime history of Alcohol use disorder.Alcohol use disorder.

Severity of gambling increases with Severity of gambling increases with increase alcohol consumption.increase alcohol consumption.

Relationship Between Gambling and Relationship Between Gambling and Alcohol Use DisordersAlcohol Use Disorders

High Rates of CoHigh Rates of Co--OccurrenceOccurrence

Similar Clinical CoursesSimilar Clinical Courses

Similar Clinical CharacteristicsSimilar Clinical Characteristics

Similar BiologiesSimilar Biologies

Mesocorticolimbic PathwayMesocorticolimbic Pathway

Ventral tegmental area

Nucleus accumbens

Anterior cingulate

Prefrontal cortex

Cognition in Problem GamblingCognition in Problem Gambling

Executive function deficits, including Executive function deficits, including planning, cognitive flexibility, and planning, cognitive flexibility, and inhibition greater compared to controls. inhibition greater compared to controls.

Individuals with gambling problems Individuals with gambling problems discount rewards rapidly oer timediscount rewards rapidly oer time

Vulnerable PopulationsVulnerable Populations

Vulnerable PopulationsVulnerable Populations

IncarceratedIncarcerated–– #1 pastime is gambling#1 pastime is gamblingSubstance Use DisordersSubstance Use Disorders–– 7x risk for Problem Gambling7x risk for Problem GamblingLower SocioLower Socio--economic statuseconomic status–– Problems develop soonerProblems develop sooner

Vulnerable PopulationsVulnerable Populations

AdolescentsAdolescents

ElderlyElderly

Casino WorkersCasino Workers

Adolescent GamblingAdolescent Gambling

How much do How much do adolescents gamble?adolescents gamble?

6060--90% have gambled90% have gambledSimilar, internationallySimilar, internationallyStrong pop culture influencesStrong pop culture influencesNo monitoring systemNo monitoring systemSocietal, parental acceptanceSocietal, parental acceptance

Consequences Consequences

FinancialFinancialLost Time Lost Time Illegal ActivitiesIllegal ActivitiesSchool ProblemsSchool ProblemsFamily problems (lying, trust)Family problems (lying, trust)Lost activitiesLost activitiesLost sleepLost sleep

Estimates of Problem Estimates of Problem GamblingGambling--LifetimeLifetime

PercentageGroup Range Median

Adult <1 - 3% 1.5%

College 3 - 11% 5%

Adolescent 1 - 7% 2.9%

Known Risk Factors for Known Risk Factors for Adolescent Problem GamblingAdolescent Problem GamblingMale Male Substance Use DisordersSubstance Use DisordersDeviant PeersDeviant PeersFamily history of gamblingFamily history of gamblingImpulsive behaviorsImpulsive behaviorsDeclining school performanceDeclining school performance

SeniorsSeniors

Gambling often starts as a social activity.

Gambling can become a coping mechanism after a life change (death of spouse, loss of friends, etc.)

Harder to recoup losses

Stigma of gambling

Casino EmployeesCasino Employees

Employees tend to be at greater risk to develop gambling problems

– Warning Signs Are Similar to Alcohol and Drug Abuse

– Excessive Sick/Late Time– Decreased Productivity– Extreme Mood Changes

Screening, Diagnosis, Screening, Diagnosis, and Treatmentand Treatment

Screening ToolsScreening Tools

Structured Clinical Interview for DSMStructured Clinical Interview for DSM--IV IV South Oaks Gambling Screen South Oaks Gambling Screen GamblerGambler’’s Anonymouss Anonymous--2020Lie/Bet QuestionnaireLie/Bet Questionnaire

SelfSelf--exclusionexclusion

In Canada 0.4% to 1.5% problem In Canada 0.4% to 1.5% problem gamblers use exclusion programsgamblers use exclusion programsNo way of knowing how many individuals No way of knowing how many individuals rere--enter casino during time of exclusion enter casino during time of exclusion Does not apply to other forms of Does not apply to other forms of legal/illegal gambling legal/illegal gambling 30% of participants completely stopped 30% of participants completely stopped gambling once excludedgambling once excluded

PsychotherapyPsychotherapy

Cognitive therapyCognitive therapy

Behavioral therapyBehavioral therapy

Imaginal desensitizationImaginal desensitization

Family/couples therapyFamily/couples therapy

Cognitive Behavioral TherapyCognitive Behavioral Therapy

Cognitive Cognitive -- psychoeducation, increased psychoeducation, increased awareness of irrational cognitions, and awareness of irrational cognitions, and cognitive restructuring. cognitive restructuring.

Behavioral Behavioral -- identification of gambling identification of gambling triggers and development of nontriggers and development of non--gambling gambling behaviors. behaviors.

15 published randomized trials of CBT for 15 published randomized trials of CBT for PG. PG.

Brief InterventionsBrief InterventionsWorkbook Workbook

Workbook plus a single inWorkbook plus a single in--depth interview. depth interview.

Workbook plus a telephone motivational Workbook plus a telephone motivational enhancement intervention. enhancement intervention.

Motivational InterviewingMotivational Interviewing

Miller and Rollnick (2002)Miller and Rollnick (2002)–– CollaborationCollaboration–– EvocationEvocation–– AutonomyAutonomy

1) Positive aspects of gambling (what are the positive things gambling gives me?)

2) Negative aspects of quitting (what do I lose if I stop gambling?)

3) What are the negativeconsequences of gambling (current and future?)

4) What are the advantagesof quitting gambling (what do I have to gain?)

Motivation to Quit Gambling

Imaginal DesensitizationImaginal DesensitizationCue exposure therapy (CE) based on Cue exposure therapy (CE) based on classical conditioning. classical conditioning. The learned response decreases to a The learned response decreases to a manageable level through repeated manageable level through repeated exposure to a stimuli. exposure to a stimuli. Urges or cravings can be activated using Urges or cravings can be activated using exposure to triggering events via actual exposure to triggering events via actual and imaginal exposure exercises. and imaginal exposure exercises.

Relapse PreventionRelapse Prevention

Learn how to manage situations in the Learn how to manage situations in the future that trigger urge for gamblingfuture that trigger urge for gambling

Practice the strategies Practice the strategies

Continue to work on and develop new Continue to work on and develop new goals goals

Addressing Financial/Legal IssuesAddressing Financial/Legal Issues

Debtors Anonymous/Financial CounselingDebtors Anonymous/Financial Counseling

Cognitive issues Cognitive issues –– finances not solved by finances not solved by gamblinggambling

Cognitive/emotional issues Cognitive/emotional issues –– gambling is gambling is an escape from finances/legal issues only an escape from finances/legal issues only in short termin short term

Legal aid clinicsLegal aid clinics

1212--Step ProgramsStep Programs

Gamblers AnonymousGamblers Anonymous

Medication TreatmentsMedication Treatments

NaltrexoneNaltrexone

NN--Acetyl CysteineAcetyl Cysteine

LithiumLithium

Antidepressants?Antidepressants?

Outcomes and Symptom Outcomes and Symptom MonitoringMonitoring

Treatment participationTreatment participationCollateral historyCollateral historyAssessment of overall functioningAssessment of overall functioningPreoccupation, urgesPreoccupation, urgesOngoing screening for addiotnal Ongoing screening for addiotnal disordersdisorders

ConclusionsConclusionsPathological gambling is common and Pathological gambling is common and disabling disabling Social and personal consequences are large Social and personal consequences are large and farand far--reachingreachingEmerging data suggest that medications and Emerging data suggest that medications and psychotherapy are effective treatmentspsychotherapy are effective treatmentsIndustry, society and government need to Industry, society and government need to address the problem in a collaborative address the problem in a collaborative fashionfashion

Questions and Answers

Continuing Education Approvals

This session has been approved for one hour of continuing education by:

• NAADAC, the Association for Addiction Professionals (provider # 737)• The California Foundation for Advancement of Addiction Professionals

(provider # OS-02-26-1111)• The California Board of Behavioral Sciences (for MFT and LCSW licensure

requirements in California) (Approval # PCE 4619)• The National Board for Certified Counselors (Provider 6474)

Confirmed attendees will be e-mailed a Certificate of Participation fromChristine Reilly at the National Center for Responsible Gaming within one weekof the live event.