Taking a bet on your Doctoran overdue role for PHOs I gambling

harm minimisation

Sean Sullivan PhDABACUS

Currently few gamblers seek help

• Problem gamblers are reluctant help-seekers (<10%)

• Possible reasons– Solution may be winning – why give up only hope?

Especially as symptoms are hidden– Stigma – gambling and losing money needed for

essentials seen as reprehensible, indulgent, so reluctance to disclose

– Other coexisting health issues may reduce motivation to change behaviour – and, is gambling perceived as a related health issue by PGs?

Even fewer affected family seek help

• One in three clients of gambling treatment services seek help

• Approximately 5-7 family affected by each problem gambler so family even less likely to seek help

• Reasons– Shame, guilt, anger, motivation, fear…..– Uncertain if services cater to them– Is gambling perceived as a health issue?

Are not early help seekers

• Those problem gamblers that seek help are usually affected by severe gambling symptoms

Why?– Stigma, isolation– Financial problems continue– Hereditary drivers – Greater barriers of coexisting health problems including

personality disorders, and – Cognitive distortions and strong learning schedules

(variable ratio reinforcement, not fixed ratio reinforcement of drugs) that retain belief of gambling as both cause and solution of problems

Important clinical aims in problem gambling harm minimisation are– Increasing help seeking for gamblers and their

families affected by gambling problems– Offering help at an earlier stage where possible– Providing a holistic approach that also addresses

coexisting health problems

Enter a possible solution

• Primary health organisations are first points of contact for health issues - primary care

As health specialists – Ability to access public resources– Can address coexisting health problems– May be more acceptable for affected family when

seen as a health issue– Are widely accessed (80%+ access annually)– 32 PHOs and 1029 GP Practices in NZ

Long ago, some NZ research notedSullivan, Arroll, Coster, Abbott, Adams (2000) NZMJ

• 80 GPs surveyed• 85% said PG their role• 72% would be involved in treatment PG• 80% also a role where family member of PGBut:• 53% had confidence raising the topic• 38% knew of any PG resources• 19% felt they had the necessary training

If one in 16 patients may be PGs..

• “International research has shown the prevalence of gambling disorders in primary care attendees to be around 6%”

Sanju 2011 Br J Gen Pract

Add family to this!

PG is a health issue

“Nine in ten (96.6%) problem gamblers had visited a general practitioner in the last 12 months, compared with eight in ten (81.2%*) with no gambling problems”

NZ Health Survey 2006/7(*But in 2012 numbers accessing GPs reduced to 78%)

Also, the survey noted that PGs were significantly more likely to have worse self-rated health after adjusting for age

Overseas acceptance

Australian Medical Association Position Statement ‘The health Effects of Problem Gambling’ 2013• “Medical practitioners should be aware of the potential

adverse impacts of PG on the physical and mental health of individuals and their families. Patients with problem gambling may present with symptoms that appear unrelated to gambling. Other patients may present with health-related concerns arising from a family members gambling problem. Medical practitioners should consider including gambling as part of their systematic lifestyle risk assessment when taking a medical history”

Australia

“Thousands of GPs to help detect problem gamblers: almost 7,000 general practitioners across Victoria will be trained in the early detection and treatment of PG under a new initiative announced today by the Minister for Community Services…The Problem Gamblers Kit (and MI)…”…there are warning signs…stress related symptoms (e.g. headaches, irritable bowel syndrome, lethargy in PGs and family)”

2002 Govt Victoria

South Australia

“Early detection by medical practitioners can lead to effective treatments to reduce the urge to gamble and improvements in mental and physical health. Given the shame and stigma attached to problem gambling, it is rare for patients to volunteer this information. A conversation with a trusted GP who introduces the topic for them might be the breakthrough they need to seek help”

Prof Battersby, Psychiatry, Flinders

Doctors join State Government to tackle problem gambling

Dept for Communities & Social Inclusion, Govt South Australia

“The State Govt is partnering with the Australian medical Association to urge more GPs to screen patients for a gambling addiction” Dec 2013

Tasmania

“The Gambling Assistance Program, an accredited training resource to assist General Practitioners in responding to patients presenting with gambling issues, was launched today Research by the Dept of Health and Human Resources shows there are gaps in knowledge and capacity for GPs to respond to patients who present with problem gambling issues”

Minister for Human Resources Nov 2014

Singapore

• “The Ministry of Health has published clinical practice guidelines on Management of Gambling Disorders to provide doctors and patients in Singapore with evidence-based guidance on the management of gambling disorders”

Ministry of Health Clinical Practice Guidelines: management of gambling disorders, Lee et al, Singapore medical Journal 2011

E-Learning in UK for GPs

• “This Gambling Disorders course enables you to identify and manage patients with problem gambling. The prevalence and impact of problem gambling is grossly underestimated and can range from lottery addictions to pathological internet-based gambling activities.

• It is essential as a GP to be able to identify patients at risk and this course is designed to help you improve the care and support you and your practice can provide by offering practical screening tools and the skills to manage problem gambling in general practice”

elearning.rcgp.org.uk/course/info.php?id=95

Barriers

• Is problem gambling their domain? “Lifestyle, social issues rather than health, not life threatening”

• Time restraints where brief interventions the rule• (Importance) Time that even more acceptable

mainstream addictions take to address• Lack of training to address PG• Lack of incentives to address these marginal

health issues

A Model of primary care intervention for minimisation of gambling harm

Issues to be addressedTime restraints, skill concerns &

incentives

Possible solutions1. Address screening only and refer out– “We know that GPs are busy but screening

patients for problem gambling is a simple exercise”

– Dr Montanaro, AMA SA Branch President– “Your doctor will be able to help refer you to a

recovery programme for counselling”– Family Doctor (NZ) Gambling Addiction – a patient’s guide

2. Practice nurse (in addition to opportunistic screening by GP when symptoms suggest)– Nurse takes responsibility for systematic screening

(annually all patients receive a holistic lifestyle screen CHAT

– Provides brief intervention (education, motivation, referral) and with GP, follow-up at subsequent appointments for other health attendance

– Provides liaison with PG treatment service– 31% of patients visited a Nurse without seeing a

GP in previous 12 months (2012 NZ Health Survey)

What is the CHAT?

“eCHAT is an acceptable and feasible means of systematic screening patients for unhealthy behaviours and negative mood states and is easily integrated into the primary care health record”

Goodyear-Smith et al 2013 Ann Fam Med

“(Using the CHAT, patients who were positive for gambling problems) also responded positively to questions about depression, anxiety and anger control”

Goodyear-Smith et al 2006 BMC Family Prac

3. GP Practice plus PG treatment service– Embed a PG counselor in the GP Practice either at

specific times/days, or in large practices daily– PG counselor becomes a de facto member of the

practice, opportunistic discussions and training with staff, enhancing screening, destigmatising

– An “Addiction Counselor” who provides specialist help for PG and AOD

4. CME or professional points– CME can be provided for approved training

programmes e.g. Tasmania– Nurses also can benefit from Nursing Council

approval of training programmes– Will also enhance acceptance of PG as a serious

health issue“..suicide risk is strongly elevated for problem gamblers. The Victorian coroner’s report analysed 128 gambling related suicides in Victoria”

– Prof Thomas, Australian Family Physician 2014

5. Contractual incentives– Requirement to screen for ‘lifestyle issues’ which

include gambling in a systematic manner– As part of the PG intervention workforce

additional payment from PG Levy for positive PG screens and referral/intervention

6. Awareness raising– Posters in Primary services– Advertising – TV, radio, online (currently entire budget for

PG prevention, harm minimisation, treatment, research and operational costs is less than 1% of annual gambling losses

– “While governments assert they are using the public health tools of prevention, harm minimisation and treatment in their problem gambling strategies, frequently these activities are not integrated with the mainstream health system and in fact have somewhat tokenistic resourcing”

Prof Thomas, Australian Family Physician RACGP 2014

Arrange incentives

PG training for Primary

staff

PG services embed in Primary

practice or close liaison

Systematically screen all

patients annually

TV and online awareness

programme

Summary

• Estimated access sites for PG treatment services at present less than 50

• Incorporation of over 1,000 GP practices increases availability substantially

• Focusing on health may increase acceptability and reduce stigma for PG and family of PGs

• Opportunity to address high coexisting issues• Funding may be a critical barrier but can be addressed

by increasing hypothecated levy which may have benefits for Vote: Health presently carrying hidden PG costs

Lifestyle Assessment form (CHAT)(Case Finding and Help Assessment Tool)What we do and how we feel can sometimes affect our health. To help us assist you to reach and maintain a

healthy and enjoyable lifestyle, please answer the following questions to the best of your ability

How many cigarettes do you smoke on an average day? none less than 1 a day 1-10 11-20 21-30 31 or moreDo you ever feel the need to cut down or stop your smoking? (tick no if you don’t smoke) no yes if yes, do you want help with this? no yes but not today yes

Do you ever feel the need to cut down on your drinking alcohol? (if you don’t drink alcohol, just tick no) no yesIn the last year, have you ever drunk more alcohol than you meant to? no yes if yes to either or both of these questions, do you want help with this? no yes but not today yes

Do you ever feel the need to cut down on your non-prescription or recreational drug use? (if you do not use other drugs, just tick no) no yesIn the last year, have you ever used non-prescription or recreational drugs more than you meant to? no yes if yes to either or both of these questions, do you want help with this? no yes but not today yes

Do you ever feel unhappy or worried after a session of gambling? (if you do not gamble, just tick no) no yesDoes gambling sometimes cause you problems? no yes if yes to either or both of these questions, do you want help with this? no yes but not today yes

During the past month have you often been bothered by feeling down, depressed or hopeless? no yesDuring the past month have you often been bothered by having little interest or pleasure in doing things? no yes if yes to either or both of these questions, do you want help with this? no yes but not today yes

During the past month have you been worrying a lot about everyday problems? no yes if yes, do you want help with this? no yes but not today yesWhat aspects of your life are causing you significant stress at the moment? none relationship work home life money health study other (specify)__________________

Is there anyone in your life whom you are afraid or who hurts you in any way? no yesIs there anyone in your life who controls you and prevents you doing what you want? no yes if yes to either or both of these questions, do you want help with this? no yes but not today yes

Is controlling your anger sometimes a problem for you? no yes if yes, do you want help with this? no yes but not today yes

As a rule, do you do more than 30 minutes of moderate or vigorous exercise (such as walking or a sport) on 5 days of the week? yes no if no, do you want help with this? no yes but not today yes

© Department of General Practice & Primary Health Care The University of Auckland

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Brief Family/Affected Other Screen

1. Do you think you have ever been affected by someone else’s gambling?□ No, never (you need not continue further) □ I don’t know for sure if their gambling affected me□ Yes, in the past□ Yes, that’s happening to me now

2. How would you describe the effect of that person’s gambling on you now? (tick one or more if they apply to you)

□ It doesn’t affect me anymore□ I worry about it sometimes□ It is affecting my health□ It is hard to talk with anyone about it□ I am concerned about my or my family’s safety□ I’m still paying for it financially□ It affects me but not in any of these ways

3. What would you like to happen? □ I would like some information □ I would like to talk about it in confidence with someone □ I would like some support or help □ Nothing at this stage