An Overview of Gambling Disorder. Timothy Fong MD UCLA Gambling Studies Program IDAA Annual Meeting August 2018

Transcription

1 An Overview of Gambling Disorder Timothy Fong MD UCLA Gambling Studies Program IDAA Annual Meeting August 2018

2 Financial Disclosures Speaker Bureau Indivior Research Support Constellation Connections in Recovery Onward

3 Definition of Gambling To place something of value on an event of uncertain outcome in the hopes of winning a larger reward

4 Gambling News: 2018 Urban expansion continues Fantasy Sports is gambling Same Day Fantasy Sports Poker Boom over but still popular Internet Gambling persists Emerging Gambling Spaces Loot Boxes Skins Cryptocurrency

5 Gambling in California

6 Types of Gambling In California (2018) State lottery (1985) Card rooms (89) ~1,500 tables total Tribal casinos (58) Total number of slot machines = > 20,000 Horseracing: 5 operating tracks Total number of lottery vendors = > 20,000 Close proximity to Nevada (Las Vegas and Reno) No state-approved Internet gambling

7 Gambling Severity Gambling Disorder Persistent, recurrent and sometimes progressive maladaptive gambling behavior despite the negative consequences Subthreshold Gambling Disorder Encounter gambling related problems but don t reach diagnostic threshold Recreational Gambling No gambling related repercussions

8 Conceptual Framework Ascher M, Levounis P. The Behavioral

9 Gambling Disorder (Formerly Pathological Gambling)

10 DSM-5 : Gambling Disorder Formerly known as: pathological gambling, compulsive gambling, gambling addiction Formerly housed in Impulse Control Disorder Currently housed in Substance Related and Addictive Disorders Copyright AAAP 2016

11 Summary of DSM-5 Changes Renamed to Gambling Disorder Moved from Impulse Control Disorder section to Addictive Disorders section 12-month time frame added Dropped illegal acts criterion Changed N criteria for Dx to 4 or more

12 Summary of DSM-5 Criteria for Gambling Disorder A. Persistent and recurrent maladaptive gambling behavior as indicated by five (or more) of the following: Preoccupation Lying Tolerance Withdrawal Chases Bailed Out Can t stop Lost opportunities Gambles to escape Copyright AAAP 2016

13 Summary of DSM-5 Criteria for Gambling Disorder B. The gambling behavior is not better accounted for by a Manic Episode Copyright AAAP 2016

14 Severity Mild: Exhibit only 4 or 5 of the criteria, with preoccupation with gambling most frequent criteria Moderate: Exhibit more of the criteria (6 or 7). Severe: Individuals with the most severe form will exhibit all or most all of the nine criteria. Jeopardizing relationships or career opportunities due to gambling Relying on others to provide money for gambling losses Copyright AAAP 2016

15 DSM-5 Notes Most Common Symptoms: Preoccupation and Lying Most Severe Symptoms Jeopardizing relationships or career opportunities due to gambling Relying on others to provide money for gambling losses Copyright AAAP 2016

16 California Prevalence Study (2005) n=7,121 respondents, 18 years and older Problem gambling 2.2% Pathological gambling 1.5% ~1,000,000 problem/pathological cases Highest Risk: African-Americans, Disabled, Unemployed

17 According to California Prevalence Data Highest risk for gambling disorder: Disabled Unemployed African Americans Adolescents Elderly (over 60) Co-Occurring Substance or Mental Health Disorders

18 Etiology

19 Neurobiological Risk Factors Neuroimaging studies: activation of vmpfc & ventral striatum in response to gambling cues Twin studies: genetics accounts for 50-60% of risk in developing gambling disorder Dopamine agonists: increase risk of gambling disorder and other behavioral addictions

20 Psychological Risk Factors Co-occurring psychiatric conditions Certain personality traits Reward-seeking Impulsive Conflict Avoidant Degraded stress management skills Decreased loss aversion

21 Social Risk Factors Early onset of gambling Family history of gambling Cultural factors that promote gambling Gambling peers Financial capital / access to money

22 Clinical Characteristics of Gambling Disorder

23 Consequences of GD Individuals Mental Health Physical Health Financial Health Families Dysfunction, Abuse, Neglect, Drama Society Lost time, productivity Economic stagnation Environmental impact

24 Percentage of GDs with Co-Occurring Disorders Petry et al., 2005

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26 Health Impact of Gambling Disorder Increased likelihood of stress-related physical problems: migraines, tension headache, IBS, ulcers, insomnia & sexual dysfunction GD more likely to have had a physical injury GD more likely to have needed ER visit (Grant) 36% of GD reported poor/fair physical health (CALGETS database)

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28 UCLA Gambling Sleep Study - Results National Epidemiological Survey: (N=3412) GDs were almost 3.5 times more likely to experience a sleep problem compared to individuals who did not have a gambling problem Community Survey: (N=120) GDs experience significantly poorer sleep quality and increased daytime sleepiness relative to those that recreationally gamble. Parhami, Iman, et al. "Pathological gambling, problem gambling and sleep complaints: An analysis of the National Comorbidity Survey: Replication (NCS-R)." Journal of Gambling Studies 29.2 (2013): Parhami, Iman, et al. "Sleep and gambling severity in a community sample of gamblers." Journal of addictive diseases 31.1 (2012):

29 What is the most effective screening tool?

30 Open-ended Screening Techniques Tell me about your relationship with gambling How often have you gambled for money? Is gambling part of your regular lifestyle? How do you spend your entertainment budget? How would you describe your current financial health?

31 Lie-Bet Questionnaire Have you ever felt the need to bet more and more money? Have you ever had to lie to people important to you about how much you gambled? Johnson, Hamer, Nora et al., 1997

32 Screening For Gambling 32

33 Biopsychosocial Treatment Planning 33

34 Brief Interventions

35 Brief Interventions for Gambling Disorder Self-Help Workbooks Single, one time interventions Brief, 1-3 office visits Mainly motivational interviewing Online experiences Helpline experiences

36 Freedom From Problem Gambling Workbook

37 Where to Get the Workbook California Department of Alcohol and Drug Programs Office of Problem Gambling

38 Evidence-Based Treatments for Gambling Disorder Medications (No FDA-Approved) Brief Interventions Self-Help, Helplines, Single Sessions Psychotherapy CBT, MI, Psychodynamic, Mindfulness Gambler s Anonymous Sponsor + Commitments 38

39 Medications For Gambling Disorder Comprehensive review published by Jon Grant and colleagues: Pharmacological treatments in pathological gambling (British Journal of Clinical Pharmacology 2014) Antidepressants Opioid antagonists Mood stabilizers Atypical antipsychotics Other Agents 39

40 Gambler s Anonymous and Gam-Anon

41 GA Overview GAMBLERS ANONYMOUS is a fellowship of men and women who share their experience, strength and hope with each other that they may solve their common problem and help others to recover from a gambling problem.

42 Gambler s Anonymous GA founded in Los Angeles (1957) GA considers gambling the problem Medical disease model Meeting styles vary (e.g. closed /open) Sponsorships and commitments are critical Research much limited than AA Wide range of published outcomes (6-65%)

43 Notes about Recovery As many as 1/3 of those with gambling problems recover on their own Usually through a combination of avoiding gambling triggers and engaging in new, nongambling related behaviors

44 Focus on Areas of Recovery Home Secure, safe base of operations Health Physical (sleep, nutrition, exercise) Emotional (resiliency, stress management) Purpose Structure and meaning Community Social capital and meaningful relationships 44

45 California Gambling Education and Treatment Services (CALGETS) problemgambling.ca.gov 45

46 1-800-GAMBLER

47 Gambling Disorder Primary Prevention Media Campaign, Enforcement of Underage Gambling, Responsible Gambling Programs Secondary Prevention Self-Exclusion, Screening of at-risk populations, Helplines Tertiary Prevention Self-exclusion (lifetime); financial counseling;

48 CALGETS SERVICES No-Cost Helpline Outpatient Visits (8 session) IOP Residential (SF, LA) Self-Help Materials Gamblers and Affected Individuals

49 UCLA Gambling Studies Program (UGSP) UGSP examines the causes, course and impact of pathological gambling while developing evidence-based treatment strategies Funded by NIDA, Office of Problem Gambling, Annenberg Foundation Lab Space available for pre and post-docs

50 uclagamblingprogram.org

51 Summary: Take Home Message Gambling constantly evolving Gambling Disorder is prevalent but hidden Constantly screen and make connections Know about local gambling venues Become familiar with CALGETS Recovery is a team approach and works but it takes resources, skills and knowledge 51

52 Contact Information Timothy Fong MD UCLA Gambling Studies Program (office) uclagamblingprogram.org

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