What is gambling, and how common is it? Problem Gambling: A Hidden Addiction in the Asian American Community. Background. Michael S.

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1 NICOS Chinese Health Coalition Problem Gambling: A Hidden Addiction in the Asian American Community Michael S. Liao, MSW Mission: To Enhance the Health and Well-Being of San Francisco's Chinese Community. Founded in 1985 Located in SF Chinatown Public-private-community partnership of 30+ groups North East Medical Services IPA (Chinese Community Health Case Association) Chinese Hospital On-Lok Lifeways Self-Help for the Elderly Background Chinese Community Health Study (NICOS/ Four Winds, 1997) Telephone Survey of 1,808 Chinese American adults in San Francisco Purpose: Health profile 70% identified gambling as a problem What is gambling, and how common is it? 1

2 Gambling refers to any game of chance or skill that involves a financial risk Types of Gamblers Social/Casual Source: California Prevalence Study (Volberg et al. 2006) 社交賭博 At-Risk 高危賭博 Problem 問題賭博 Gambling Disorder 賭博性疾患, 嗜賭症, 賭癮 16.9% 70% 9,5% 2.2% Gambling Disorder 1.5% American Psychiatric Association: DMS-5 Criteria DSM-5: Gambling Disorder Substance-Related and Addictive Disorders Persistent and recurrent problematic gambling behavior leading to clinically significant impairment or distress, as indicated by the individual exhibiting four (or more) of the following in a 12 month period: 2

3 Signs of Gambling Disorder 1. Tolerance: Gambles with increasing amounts of money to achieve excitement. 2. Withdrawal: Is restless or irritable when attempting to cut down or stop gambling. 3. Inability to Stop: Repeated unsuccessful efforts to control, cut back, or stop gambling. 4. Preoccupation: Thinking about gambling all the time. Signs of Gambling Disorder 5. Escape: Often gambles when feeling distressed. 6. Chase: After losing money gambling, often returns another day to get even. 7. Lies to conceal the extent of involvement with gambling. 8. Neglect: Jeopardized/ lost significant relationships, job, or other opportunities because of gambling. 9. Bail Out: Relies on others to provide money. ONE+ FOUR+ Seeing Signs? Exhibiting any one of these signs may indicate that gambling has become a problem Exhibiting four or more signs means that a licensed mental health professional could make a diagnosis of gambling disorder Asian Americans & Problem Gambling 3

4 Problem Gambling among Asian Americans Higher rates of problem gambling and addicted gambling found: - Chinese community members % problem gambling; 21% pathological gambling (Wong and Toy, 1999) - API University Students % probable gambling disorder (Zhao, Lee, Kuwatani, 2016) - API high school students 11% probable pathological gambling (Chiu & Woo, 2012) Risk Factors: - Being male, younger, earlier onset of gambling, more recent immigrant, experience of trauma Immigration-Related Issues Cultural Acceptance Target Marketing Challenges Environmental Prevalence Stigma / Help-seeking Behavior Lack of culturally & linguistically appropriate resources Health Impacts of Problem Gambling Problem Gambler Medical Utilization, Help Seeking Patterns Evans and Delfabbro (2005) found that PGs did not view treatment services as an option, but rather as a last resort Morasco et al. (2006) found that PGs are more likely to be treated in the ER in the past year 4

5 Symptoms Physical Health Issues Potential Causes Tachycardia (Morasco et.al, 2006) Hypertension (Lorenz & Yaffee, 1986) Angina (Morasco et.al, 2006) Headaches (Bergh & Kuhlhorn, 1994, Lorenz & Yaffee, 1986) Insomnia (Lorenz & Yaffee, 1986) Skin Problems Gastrointestinal problems such as nausea, ulcers, and colitis (Bergh & Kuhlhorn, 1994, Lorenz & Yaffee, 1986) Cirrhosis and other liver diseases (Morasco et.al, 2006) Alteration of heart rhythms Decreased blood flow to the heart Increased body tension Exacerbation of skin conditions Irritation and disruption of the digestive system Increased prevalence of alcohol abuse Neurobiological Basis of Gambling Addiction This Is Your Brain on Gambling Are brains of problem gamblers different? fmri of subject anticipating a small amount of cocaine fmri of subject anticipating a monetary win in simulated game NAc Controls Pathological Gamblers Breiter et al., 2001 Reuter et al.,

6 Are brains of problem gamblers different? Pathological Gamblers exhibit lower activity in prefrontal cortex compared to Non-PGs In performing neuro-cognitive tests, PGs showed similar dysfunctions in prefrontal cortex as Methamphetamine addicts Potenza et al., 2003 What Can I do? Assess! Ask the right questions: (Brief Biosocial Gambling Screen BBGS) 1) During the past 12 months, have you become restless irritable or anxious when trying to stop/cut down on gambling? 當您嘗試減少或停止賭博時,您是否感到渾身不自在或脾氣暴躁呢? 2) During the past 12 months, have you tried to keep your family or friends from knowing how much you gambled? 是否曾經對家人或朋友隱瞞自己參與賭博的程度? 3) During the past 12 months did you have such financial trouble as a result of your gambling that you had to get help with living expenses from family, friends or welfare? 是否曾經應因為賭博帶來的經濟絕境而需要倚靠家人, 朋友或社會福利組織來提供金錢? Educate! Provide information. To avoid gambling excessively, learn the facts: - Randomness 隨機性 - Independence of Events 事件的獨立性 - House Advantage 莊家優勢 Set a money limit Set a time limit Leave credit/debit cards at home Avoid borrowing money Have a plan, win or lose The HOUSE (gambling operator) ALWAYS wins! (in the long run) 6

7 彩票號碼 Lottery Tickets 2, 10, 18,,, 以下哪三個號嗎最適合用來填滿以上彩票空位來贏得大獎? Which of the following three numbers would best complete the lottery ticket section to provide us with the greatest chance of winning the jackpot? A) 19, 20, 21 B) 27, 39, 44 C) 23, 33, 43 D) 20, 30, 40 E) 任何以上的選擇 Any of the Above Educate! Provide information. To avoid gambling excessively, learn the facts: - Randomness - Independence of Events - House Advantage Set a money limit Set a time limit Leave credit/debit cards at home Avoid borrowing money Have a plan, win or lose The HOUSE (gambling operator) ALWAYS wins! (in the long run) Tips for family members DON T Give gambler money directly Enable / rescue / fix Create more drama Take on burden by yourself DO Seek resources for financial planning and stress management Limit gambler s access to $$ Find support Refer! Provide information about available community resources: Helplines GAMBLER California Council on Problem Gambling English, Cantonese, Mandarin, Spanish, 24/7, statewide NICOS Chinese Health Coalition - Statewide Chinese Problem Gambling Helpline English, Chinese (Mandarin, Cantonese, other dialects), 24/7, SF Bay Area Includes referrals to mental health as well as financial and legal counseling 7

8 California Problem Gambling Resources Training & outreach Problem Gambling Technical Assistance & Training (PGTAT) Project CalGETS Treatment Initiative Bilingual face-to-face counseling Available throughout CA in over 30 languages/ dialects Telephone counseling 8 Asian languages/ dialects: Cantonese, Mandarin, Teo-Chow, Taiwanese, Korean, Hindi, Punjabi, Vietnamese Intensive Outpatient + Residential SoCal & NorCal locations Referrals & resources Signing up for self-exclusion programs, finding GA meetings, free brochures & booklets, linking to state-sponsored treatment services, referrals to other legal/ financial resources, etc. All services are cost-free! Treat! Medications can help as an adjunct to conventional talk therapy: Medication Study Duration Results Mood Stabilizers: AI Subtype; high-impulsivity & low planning Lithium (796 mg) Valproate (847 mg) Carbamezapine (600 mg) Pallanti et al Haller & Hinterhuber weeks 12 weeks 65% completed Lithium arm 84% completed Valproate arm Gambling week 2 Serotonergic System: SRIs & SSRIs: EV Subtype; Comorbid Depression, Obsessive Thoughts Clomipramine (125 mg) Citalopram (35 mg) Nefazodone (346 mg) Paroxetine (57 mg) Paroxetine (10-60 mg) Fluvoxamine (220 mg) Fluvoxamine (195 mg) Fluvoxamine (200 mg) Hollander et al Zimmerman et al Pallanti et al Kim et al Grant et al Hollander et al Hollander et al Blanco et al weeks 12 weeks 8 weeks 1 wk; 8 wks 1 wk; 16 wks 8 weeks 1 wk; 8 wks 24 weeks 90% reduction vs. 24% placebo 53% reduction (86% complete) 62% reduction (75% complete) 12% placebo; 60% red. vs 23% p 8% placebo; 59% red. vs 49% p 70% reduction vs 42% placebo 70% reduction vs 46% placebo 73% reduction vs 59% placebo Opioid Receptor Antagonists: EV/AI Subtypes; Comorbid substance addiction; urge or craving is strong characteristic Naltrexone (100 mg) Naltrexone (50 mg)+ Naltrexone (157 mg) Naltrexone (188 mg) Kim 1998 Crockford et al Kim & Grant, 2001 Kim et al weeks 4 weeks 6 weeks 1 wk; 12 wks No gambling urges or behaviors Decreased urges to gamble & drink Decreased gambling beh & urges 27% placebo; 75% red vs 24% p Norepinephrine & Dopamine Reuptake Inhibitor Bupropion ( mg) Dannon et al weeks 75% rated as full responders Treat! Prescribe diets and lifestyle changes that will improve physical health: - Low blood sugar can increase cravings for addictive behaviors - Low blood sugar can also produce withdrawal-like symptoms and lead to relapse - Exercise training increases serotonin levels in turn improving sleep, reducing depression & stress - Research shows mindfulness practices integrated into conventional treatment significantly reduces relapse and increases ability to cope with stress NICOS Chinese Health Coalition Tel: Helpline: (Chinese & English) michaelliao@nicoschc.org 8