Pathological Gambling 2005: Update on the Hidden Addiction

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Pathological Gambling 2005Update on the Hidden
Addiction

• Timothy W. Fong MD
• UCLA Gambling Studies Program
• Cedars-Sinai Medical Center
• Psychiatry Grand Rounds
• December 15, 2005

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Overview

• Gambling in the United States
• Overview of Pathological Gambling
• Treatment Strategies
• Gambling Treatment in California
• UCLA Gambling Studies Program

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Availability of Gambling, 1975
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Availability of Gambling, 1999
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Gambling Nation

• 600 billion wagered annually
• Revenue Comparisons (2003)
• Gambling (Legal) 72 Billion per year
• DVDs 22 Billion per year
• Cigarettes 19 Billion per year
• NIH Annual Budget 30 Billion per year
• (American Gaming Association, CDC, Hollywood
  Reporter)

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The Range of Gambling Behavior

• Social Gambler (85 of the population)
• Problem Gambler (5-6)
• Pathological Gambler (1)
• (or Compulsive Gambling, Gambling Addict)

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DSM-IV Criteria Pathological Gambling

• Preoccupation with gambling
• Lies about gambling
• Need to increase bets (tolerance)
• Restless when not gambling (withdrawal)
• Gambles to escape
• (American Psychiatric Association, 1994)

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DSM-IV Criteria Pathological Gambling

• Cannot control gambling
• Chases
• Commit illegal acts
• Ongoing gambling despite losing something
  important in life
• Needs others for debt bail-out
• (American Psychiatric Association, 1994)

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Prevalence RatesGeneral Population

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Epidemiology of Pathological Gambling

• Higher adolescents, casino workers incarcerat
  ed, substance use disorders, minorities,lower
  SES
• Lower (traditionally) elderly, women
• (NGISC, 1999, Shaffer 1997)

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Consequences ofPathological Gambling

• Medical poorer health, increased health
  utilization
• Employment time and productivity
• Alcohol/Drug higher use, abuse, dependence
• Legal theft, embezzlement, tax evasion
• Financial money loss, bankruptcy
• Family domestic violence, divorce
• Psychiatric increased depression, anxiety

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Economic Burden of Pathological Gambling
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Pathological Gambling Comparison to Substance
Abuse

• Similarities
• Loss of Control
• Preoccupation
• Continued behavior despite negative impact on
  major life areas
• Tolerance
• Urges / Cravings

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Pathological Gambling Comparison to Substance
Abuse

• Similarities
• Withdrawal symptoms
• Utilization of self-help groups
• Similar psychological drives
• escape, self-medication, avoidance

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Pathological Gambling Comparison to Substance
Abuse

• Differences
• Unpredictable outcome
• Head games
• Fantasy of success and involvement in other
  fantasies
• Cognitive distortions
• No biological tests
• Easier to hide / socially acceptable

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Pathological Gambling Comparison to Substance
Abuse

• Differences
• Gambling is not self-limiting
• Behavior not attributable to intoxication
• Greater denial and shame
• Labile financial situation
• Less public awareness and acceptance

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Treatment Approaches to Pathological Gambling

• Medications
• Psychotherapy
• Gamblers Anonymous
• Family Therapy
• Other Interventions
• Prevention

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Principles of Pharmacotherapy

• Target the urges/impulses to gamble.
• Treats comorbid psychiatric symptoms depression,
  anxiety, obsessions, sleep or concentration
• Medications lay the groundwork for psychosocial
  therapies.
• No magic bullets

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Medications

• Evidence Exists for
• Antidepressants
• SSRIs Paxil, Celexa, Luvox
• Bupropion
• Mood Stabilizers (Depakote, Lithium, Tegretol)
• Antipsychotics (Olanzapine)
• Opiate Antagonists (Naltrexone)
• Others (Topamax)

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Cognitive Behavioral Therapy

• Rework erroneous perceptions/expectations of
  gambling
• (e.g. gambling will solve everything)
• Identify triggers to gambling
• Work on cognitive distortions/ illusion of
  control
• (e.g. Im due to win)

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Cognitive Behavioral Therapy

• Can be manualized
• Usually time-limited
• Data emerging to support efficacy
• Follow-up data and lasting effects need to be
  demonstrated

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Psychodynamic Approaches

• Understand conscious and unconscious motivations
  to gambling
• Interpret meaning of gambling behaviors
• Competition, success, freedom
• Escape
• Independence,
• Rebel against authority

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Psychodynamic Approaches

• Break denial
• Confront maladaptive defenses
• Interrupt chasing behavior
• Increase motivation
• Decrease shame/guilt/stigma
• No formalized studies

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Group Therapy

• Gamblers Anonymous
• www.gamblersanonymous.org
• Founded in Los Angeles (1957)
• Based on the 12-step model 1500 chapters
• Needs more evidence to back it up
• (8 abstinence)
• Gam-Anon support for families

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Practical Points about GA

• Know what the content of the meetings are like
  and what the make-up of is.
• Know where the meetings are
• No known alternative groups
• What about language and social barriers?

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Financial Counseling

• Know bankruptcy laws
• Limit credit cards and access to ATMs
• Tell families to separate accounts
• Debt consolidation / relief
• No formal studies

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Other Interventions

• Helpline Services
• 1-800-GAMBLER (National)
• 1-800-522-4700 (CA)
• Internet treatment
• Self-help workbooks

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Natural Recovery

• Numbers / percentages are unknown but thought to
  be high
• Those who quit were able to
• avoid gambling stimuli
• engage in alternate activities
• Less precipitating life events and more positive
  events during recovery
• Less severe PG
• (Hodgins 2000)

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How effective is gambling treatment?

• 30-60 abstinence at 6-12 months after completion
  of treatment
• Similar rates as compared to heart disease,
  addictions, diabetes
• (Stinchfield 2001)

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Prevention

• Primary
• Casinos and advertisers to target underage
  gambling
• Screenings at school, primary care visits
• Parental Education / Social Norms
• Secondary
• Screenings in mental health systems
• Responsible Gaming Programs

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Whats happening in California?
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Types of Gambling In California

• State lottery (1985)
• Card clubs (102)
• Indian casinos (53)
• (San Diego, Palm Springs, Northern California)
• Horseracing (7 tracks 9 county/state fairs 20
  OTBs)
• Proximity of Las Vegas, Reno
• Gambling Dens

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Background

• Exponential growth of legalized gambling
• From 2.5 billion in 1997 to 13 billion in 2003
• Horse race wagering (4 billion)
• Lottery (3 billion)
• Card rooms (1 billion)
• Tribal casinos (5 billion)
• Into the future

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California Prevalence Study (1990)

• Prevalence rate of 1.2
• 240,000 lifetime pathological gamblers
• An additional 577,000 lifetime problem gamblers
• 2003 census translates to 418,000 pathological
  gamblers
• Volberg (1994), Amer J Publ Health,
  84(2)237-241.

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Other States

• Oregon, Minnesota, Connecticut and Iowa are
  exemplary programs
• Most are in substance abuse programs and use
  abstinence model and 12-step.
• Most programs do not see multicultural groups,
  teens, older adults or families.

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California Funding and Gambling Treatment

• Office of Problem Gambling (2003)
• California Department of Alcohol and Drug
  Programs
• (Prevention Services Program)
• 3 million budget for prevention and possibly,
  treatment and research

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Treatment Options in California

• Inpatient Treatment Programs
• Outpatient Treatment Programs
• Gamblers Anonymous
• Individual Providers
• Helpline
• www.calproblemgambling.org

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Gambling Treatment in California (2005)

• Gamblers Anonymous
• Fee-for-service inpatient / outpatient programs
• Certified Compulsive Gambler Counselors (CCGC)
  provided by California Council on Problem
  Gambling

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Certifications

• National Certified Gambling Counselor
  Certification Board,
• American Compulsive Gambler Counselor
  Certification Board
• Requirements 60 gambling training hours, 100
  hours patient hours, supervision, examination

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Who is responsible for treatment?

• Alcohol and Drug Programs
• Department of Mental Health
• Criminal Justice
• Casino Industry
• Private programs / concerned citizens?

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Resources

• Gamblers Anonymous and GamAnon
• [phone]
• www.gamblersanonymous.org
• California Department of Drug and Alcohol
• www.adp.cahwnet.gov
• (Office of Problem Gambling)
• California Council on Problem Gambling
• www.calproblemgambling.org
• National Council on Problem Gambling
• 800-522-4700 www.ncpgambling.org

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The UCLA Gambling Studies Program
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• Our vision for the UCLA Gambling Studies Program
  is to set the national standard in pathological
  gambling research, treatment, prevention and
  education. The direct result of this work will
  be to reduce the individual and societal damage
  caused by pathological gambling.

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The Mission

• Investigate causes and courses
• Develop effective interventions
• Move treatment into mainstream application
• Support public health policy that lessen
  consequences from pathological gambling

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Building Blocks

• Research
• Treatment
• Training
• Prevention

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PubMED Citations (2005)
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Research

• Neuroscience
• How do stress/ alcohol impact gambling behaviors?
• What are the neurobiological consequences of
  pathological gambling?
• How does impulsivity relate to PG?
• Understanding the dopamine link (Parkinsons and
  gambling)
• Risk and Protective Factors

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Research

• Epidemiology
• Understanding the impact of gambling on APIs
  
• Treatment studies
• Medication and psychotherapy
• Gamblers Anonymous
• How to measure outcomes and tx effectiveness

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Treatment

• Impulse Control Disorders Clinic
• Provide specialty care
• Develop into a teaching clinic
• Proving ground for new therapies

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Training

• Focus on professional development
• UCLA Staff and Faculty
• Psychiatry residents, medical students
• Create a Fellowship in Gambling Studies

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Prevention

• Populations of interest
• College Students
• Minority Groups
• (Asians)
• Substance Abusing Populations
• Elderly

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Contact Information Timothy Fong MD Richard
Rosenthal MD310-825-4845tfong_at_mednet.ucla.eduga
mblingstudies.npih.ucla.edu