Transcript Pathological Gambling: Insights on an Emerging Addiction

Pathological Gambling and
Alcohol Use Disorders
Timothy W. Fong MD
UCLA Gambling Studies Program
Alcohol Medical Scholars Program
2005-2007
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Introduction
• Lifetime risk
– Pathological gambling (PG)
– Alcohol use disorders (AUD)
~ 2%
13%
• PG + AUD
– Often co-occur
– Worse outcomes
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This lecture will cover
Pathological
Gambling (PG)
Alcohol Use
Disorders (AUD)
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Diagnostic criteria
Epidemiology
Consequences
Screening
Risk factors
Treatment
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Pathological
Gambling
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Gambling in the United States
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85% of Americans gamble
Available in 48 states
Gambling revenue: $72 billion/year
Increasing cultural acceptance
– 80% parents not opposed
(www.americangaming.org)
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Social Gambling
• Similar in meaning to
social drinking
• 85% of gamblers
• No negative impacts
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Pathological Gambling
• Maladaptive use → impairment
Preoccupation
Lying
Tolerance
Withdrawal
Chases
Bailed Out
Can’t stop
Chases losses
Illegal Acts
Gambles to escape
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Epidemiology - USA
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Problem
Pathological
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Petry, in
press
Welte,
2001
Gerstein,
1999
0
Kalick,
1976
%
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Consequences of
Pathological Gambling
Financial
Ave. debt = $45,000
Relationships
Divorce, child abuse
Time
25 hrs/wk
Crime
Non-violent
Substance use disorders
4x risk
Medical
Worse health
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Screening Tools
• South Oaks Gambling Screen
• Lie/Bet Questionnaire
– “Have you lied about your gambling?”
– “Have you ever increased bets to get same
sense of action?”
• No objective tests
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Risk Factors
• Genetic
– 60% risk
• Psychological
– Impulsive
• Social
– Increased access
– Heavy gambling peers
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Treatment:
Social Assistance
• Self-exclusion programs
– Self-bar entrance into casinos
• Financial counseling
• Gambler’s Anonymous
– >1500 chapters
– Similar to Alcoholics Anonymous
– 8% abstinent at 12 months
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Psychosocial Treatment
• Cognitive behavioral therapy
– Addresses cognitive distortions
– 40% stopped gambling
– Long-term data needed
• Helplines
– 24-hour crisis interventions
– No data on effectiveness
– Widely available
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Treatment:
Pharmacotherapy
• Preliminary evidence
– Naltrexone
– Selective Serotonin Reuptake Inhbitiors
(SSRIs)
– Valproic Acid
– Lithium
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Alcohol Use Disorders
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Alcohol Use in the United States
• 63% drank over last 12 months
• Alcohol beverage industry: 2005
– $6 billion gross revenue
• Alcohol use disorders
– Abuse
– Dependence
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Alcohol Dependence
• Maladaptive use → impairment
• ≥ 3 over 12 months
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Tolerance
Withdrawal
Larger amts than intended
Can’t decrease use
Excessive time
Decreased activities
Use despite problems
(American Psychiatric Association, 1994)
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Epidemiology of AUD
• Lifetime prevalence
– Males 15%
– Females 8%
• 15 million meet criteria
• Economic burden: $155 billion
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Consequences
• Medical
– Cardiovascular: hypertension
– Gastrointestinal: fatty liver
– Neurological: peripheral neuropathy
• Work
– ↑lateness, ↓performance, ↑injury
• Family
– >80% spousal violence
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Screening
• Alcohol Use Disorders Identification Test
• Michigan Alcohol Screening Test
• Lab tests
GGT>35
MCV>91.5
CDT>20
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Risk Factors
• Gender
– males > females
• Genetics
– 60% risk
• Co-occurring psychiatric disorders
– 45% lifetime prevalence
• Heavy drinking peers
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Social Assistance
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12-step, Alcoholics Anonymous
– >75,000 groups in US
– Peer support and fellowship
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SMART Recovery (Self-Management
and Recovery Training)
– Self-reliance, personal responsibility
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Psychosocial Treatment
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Cognitive-Behavioral Therapy
– Identify motivations and triggers
– Longer in treatment, better outcome
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Relapse Prevention
– Identify risky situations
– Develop alternative behaviors
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Treatment: Pharmacotherapy
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Disulfiram
– Efficacy:
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Naltrexone
– Efficacy:
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equivocal
↓ drinks, ↓ # drinking days
Acamprosate
–
Efficacy: ↑ tx completion and time to
first drink
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Pathological Gambling
&
Alcohol Use Disorders
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PG and AUD
• More difficult to treat and retain
–2x rate of dropout
• Lower compliance rates
• Other comorbidities likely
• More likely to relapse
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Epidemiology
• PG: ↑rates of AUD (40%)
– ↑severity of PG = ↑risk for AUD
• AUD: ↑rates of PG (10%)
– Lack of screening
• PG or AUD can occur first
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Differences: PG and AUD
• No objective tests
– No intoxicated states
– No physical signs and symptoms
• Financial impact
– PG may win or lose large amount at one
time
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Treatment Considerations
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More data needed
Must treat both disorders
Get collateral information
Periodic drug and alcohol testing
Insurances don’t cover PG
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Conclusions
• PG has serious life consequences
• PG + AUD = common occurrence
• Importance of screening
• Treatments available for both PG and AUD
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