Problem Gambling The Hidden Addiction Victor Ortiz MSW

Problem Gambling: The Hidden Addiction Victor Ortiz, MSW, LADC I, CADC II Presentation for: Residential Substance Abuse Treatment (RSAT) December 17, 2014

Acknowledgement o Harvard Medical School Division on Addiction o National Center for Responsible Gaming

Agenda o Provide an Overview of Gambling Disorders o Gambling Disorders and Substance Abuse o Gambling Disorders and Mental Health o Gambling Disorders and Corrections o Discuss DSM IV and DSM-5 - Gambling Disorders o Review Resources

What is Gambling? ` “… risking something of value on the outcome of an event when the probability of winning is less than certain. ” Korn, D. A. & Shaffer, H. R. (1999). Journal of Gambling Studies, 15(4), p. 292. 4

Gambling in the U. S. o Approximately 85% of U. S. adults have gambled at least once in their lives; 60% in the past year. o 2 million (1%) of U. S. adults are estimated to meet criteria for pathological gambling in a given year. o Another 4 -6 million (2 -3%) would be considered problem gamblers. Source: National Council on Problem Gambling , Retrieved from http: //www. ncpgambling. org/i 4 a/pages/index. cfm? pageid=3314#widespread

Stores with past Powerball winners lure crowds n Worcester T&G-2013

Gambling Risk Factors n n n Emotional difficulties Stress Distorted expectations about winning Social pressure to gamble Risky gambling behavior n n n Attention deficits Impulsivity Illusion of control over outcomes Addiction history Family history of gambling problems 7

Gambling Disorders and Substance Abuse

National Epidemiologic Survey on Alcohol and Related Conditions The 2008 NESARC study reported that: o 73. 2 percent of pathological gamblers had an alcohol use disorder (73. 2%), o 38. 1 percent had a drug use disorder, o 60. 4 percent had nicotine dependence,

Gambling and Alcohol o Problem gamblers with frequent alcohol use have greater gambling severity and more psychosocial problems resulting from gambling than those without alcohol use histories. o Adolescents who are moderate to high frequency drinkers are more likely to gamble frequently than those who are not. (Grant, Potenza, etal, 2010) o For individuals with alcoholism and gambling disorders, addressing both problems simultaneously leads to better outcomes. (Hodgins and el-Guebaly, 2002)

Gambling and Drugs o Research indicate that cocaine-addicted individuals are nearly two times more likely to have serious gambling problems than those who are not cocaine-dependent. o Cocaine may artificially inflate a gambler’s sense of certainty of winning and skill, contributing to increased risk behaviors. o Pathological gamblers may use cocaine to maintain energy levels and focus during gambling and sell drugs to obtain gambling money. o Research also suggests a positive correlation between methamphetamine abuse and pathological gambling.

Pathological Gambling & Drug and Alcohol Disorders Common features between pathological gambling and drug and alcohol use disorders o Failure to resist an impulse, drive, or temptation that is harmful to the person or to others. o Onset in adolescence and young adulthood – more men than women. o Occurrence of an urge or craving state prior to initiating the behavior.

Pathological Gambling & Drug and Alcohol Disorders o Resulting “high” – need to increase the intensity of the behavior to achieve the same high. o Financial and marital problems. o Criminal behavior to fund addictive behavior or cope with consequences of it. o Source: Grant, J. E. J. D. Potenza, M. MD, Weinstein, A. Ph. D. , Gorelick, D. MD, Ph. D. (2010) The American Journal of Drug and Alcohol Use, Early Online 1 -9. DOI: 10. 3109/00952990. 2010. 491884

Differences of Gambling Disorder and Substance Abuse Disorders o o There is no substance Bail out by family or friends There is no obvious signs: slurred speech, blood shot eyes, or odor Reward 14

Neurological Similarities between Gambling & Drug and Alcohol Abuse o Multiple neurotransmitter systems are implicated in the pathophysiology of behavioral addictions and substance use disorders. o Serotonin and dopamine, in particular, may contribute to both sets of disorders. • Serotonin is involved with inhibition of behavior. • Dopamine is involved with learning, motivation, stimuli, and rewards. o Alterations in dopaminergic pathways in the brain are thought to underlie reward-seeking (gambling, drugs, alcohol) that triggers the release of dopamine and produces feelings of pleasure. n. Source: Grant, J. E. J. D. Potenza, M. MD, Weinstein, A. Ph. D. , Gorelick, D. MD, Ph. D. (2010) The American Journal of Drug and Alcohol Use, Early Online 1 -9. DOI: 10. 3109/00952990. 2010. 491884

Evidence supporting a broader conceptualization of addiction is emerging. For example, neurobiological research suggests that addictive disorders might not be independent: each outwardly unique addiction disorder might be a distinctive expression of the same underlying addiction syndrome. Howard J. Shaffer, Ph. D, CAS, , 2004 16

Clinical Practice Drugs Alcohol Addiction Gambling Smoking 18

Gambling Disorders and Mental Health

National Epidemiologic Survey on Alcohol and Related Conditions The 2008 NESARC study reported that: o 49. 6 percent had a mood disorder, o 41. 3 percent had an anxiety disorder, o 60. 8 percent had a personality disorder.

Gambling and Mood Disorders o Roughly one-third of pathological gamblers have a biological parent or sibling with a major mood disorder (Roy et al. , 1988; Linden et al. , 1986) o Close to 20% of formerly diagnosed pathological gamblers were still depressed in follow-up after stopping gambling and improving their other functions (Taber et al. , 1987) 21

Gambling and Mood Disorders o Pathological gamblers in inpatient treatment setting have depression rates as high as 50%-75% (far above the population average of 10 -25%) (Mc. Cormick et al. , 1984; Linden et al. , 1986). o Gamblers’ own reports show that they gamble to forget troubles, to avoid feelings of loneliness, depression, and stress — evidence that gambling serves as a way for gamblers to modify their internal state (Corless & Dickerson, 1989). 22

What comes First, PG or Other Disorder? Disorder PG First Other Disorder First Onset at Same Time Any Mood Disorder* 23% 65% 12% Any Anxiety Disorder* 13% 82% 5% 0 100% 0 36% 57% 6% Any Impulse Control Disorder Any SUD* * These disorders more common among PGs compared to rest of US population © Source: Henry Lesieur (2014, March). Using best practices in treatment of dual diagnosis and pathological gambling. Workshoppresentation to 2014 Problem Gambling Conference: “Ohio’s Response to a. Changing Landscape. ” Columbus, Ohio.

Medical Problems Among Pathological Gamblers o Depression o Allergies o Intestinal Disorders o Respiratory Problems o Cardiovascular o Oral-Dental Disease Problems o Nerve-Sensory System o High Blood Pressure Disorders o Migraines o Stress-related Disorders

Gambling Disorders and Suicide o The DSM-5 states that up to half of individuals in treatment for a gambling disorder have suicidal ideation and about 17% have attempted suicide. o According to the World Health Organization, factors such as mood disorders, stressful life events or circumstances and a history of physical or sexual abuse in childhood put people at increased risk for harming themselves (World Health Organization, 2002). All of these factors are common among those experiencing problems related to gambling. 25

Gambling Disorders and Corrections

Question? Do people with Gambling Problems commit crimes?

Gambling Disorders and Corrections n Contrary to conventional wisdom, most individuals with a gambling disorder do not engage in criminal behavior. However, a small number resort to theft, embezzlement, fraud or other criminal activity to support their gambling. Some of these cases make the headlines, which in turn shape the conventional wisdom. People with gambling disorders might end up in court because of domestic violence, child support and custody issues — all of which might relate to their gambling problem NCRG, 2013 28

Gambling Disorders and Corrections n A complex relationship exists between illegal behavior and pathological gambling, and this relationship has significant implications in both the legal and clinical domains. Despite the importance of this relationship, relatively little research has examined illegal behavior in pathological gambling, particularly within a current gambling climate that has seen dramatic expansion over recent years. Although the article by Ledgerwood and colleagues provides additional insight into the relationship between pathological gambling and illegal behavior, many questions remain unanswered and warrant further investigation. J. Grant, M. Potenza, 2007 29

DSM-IV and DSM-5 & Gambling Disorders

DSM IV According to DSM-IV criteria, gambling is considered an impulse control disorder and the criteria include three areas often associated with addictive disorders: n compulsion or craving; n loss of control; n and continuing behavior, despite the presence of adverse consequences.

DSM IV Challenges- Pathological Gambling Mental Health or Addiction Barriers within Recovery Community Third Party Billing Treatment Challenges Data and Research

Gambling Disorders: DSM-5

DSM-5 Reclassification of Gambling o Contains significant changes to “Substance-Related and Addictive Disorders”. o Places “Gambling Disorder” in “Substance-Related and Addictive Disorders”, under “Non-Substance-Related Disorders” o Change reflects research findings that indicate that GD is similar to substance-related disorders in clinical expression, brain origin, comorbidity, physiology, and treatment.

DSM-5 Reclassification of Gambling o Placement in “Substance-Related and Addictive o o o Disorders” could open the door to coverage under MH/SUD-related provisions of health reform. Improve diagnostic accuracy and screening efforts. Support more appropriate treatment and services. Facilitate integration/bundling of services and payment processes with MH/SUDs services and primary care (e. g. , SBIRT). Increase public health awareness, and raise visibility among health care providers, insurers, and policy makers. Accelerate research and development of more robust, evidence-based practices.

Gambling Disorder and DSM-5 According to DSM-5 criteria, gambling is considered a 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:

Gambling Disorder DSM-5 Criteria n Needs to gamble with increasing amounts of money in order to achieve the desired excitement n Is restless or irritable when attempting to cut down or stop gambling n Is often preoccupied with gambling (e. g. , having persistent thoughts of reliving past gambling experiences, handicapping or planning next venture, thinking of ways to get money with which to gamble). n Often gambles when feeling distress (e. g. , helpless, guilty, anxious, depressed).

Gambling Disorder DSM-5 Criteria Cont. n After losing money gambling, often returns another day to get even (“chasing” one’s losses). n Lies to conceal the extent of involvement with gambling. n Has jeopardized or lost a significant relationship, job, or educational career opportunity because of gambling. n Relies on others to provide money to relieve desperate financial situations caused by gambling.

Differences in DSM-4 TR and DSM-5 DSM-IV n “Is preoccupied with gambling” n Gambles as a way to escape from problems” DSM-5 n “Is often preoccupied with gambling” n Gambles when feeling distressed”

Differences in DSM-4 TR and DSM-5 Cont. n The omitted criterion reads, “Has committed illegal acts such as forgery, fraud theft or embezzlement to finance gambling. ” n The DSM-5 Work Group felt that any illegal acts would fall under “Lies to conceal the extent of involvement with gambling

Resources 41

National Council on Problem Gambling www. ncpg. org Massachusetts Council on Compulsive Gambling www. masscounciloncompuslivegambling. org Harvard School Division on Addiction www. divisiononaddiction. org National Center for Responsible Gaming www. ncrg. org 42

Massachusetts Council on Compulsive Gambling Victor Ortiz, MSW, LADC I, CADC II Sr. Director of Programs and Services victor@masscompulsivegambling. org Twitter- @Victor_Ortiz 21 617 -426 -4554 43

Work Cited n n n Petry, NM, et al. (2005) Comorbidity of DSM-IV pathological gambling and other psychiatric disorders: Results from the national epidemiologic survey on alcohol and related conditions. Journal of clinical Psychiatry. 66: 564 -574 Grant, J. E. J. D. Potenza, M. MD, Weinstein, A. Ph. D. , Gorelick, D. MD, Ph. D. (2010) The American Journal of Drug and Alcohol Use, Early Online 1 -9. DOI: 10. 3109/00952990. 2010. 491884 Petry, NM, et al. (2013). An Overview of and Rationale for Changes Proposed for Pathological Gambling in DSM-5. J Gambl Studies. Howard J. Shaffer, Ph. D, CAS, Debi A. La. Plante, Ph. D, Richard A. La. Brie, Ed. D, Rachel C. Kidman, BA, Anthony N. Donato, MPP, and Michael V. Stanton, BA; Toward a Syndrome Model of Addiction: Multiple Expressions, Common Etiology, Harv Rev Psychiatry 2004; 12: 367– 374. 2004 Shaffer HJ, Martin R. Disordered gambling: etiology, trajectory, and clinical considerations. Annu Rev Clin Psychol. 2011; 7: 483 -510. Shaffer HJ. On the nature and meaning of addiction. Natl Forum 1999; 79(4): 10– 4. 67

Work Cited n n n Shaffer HJ. The most important unresolved issue in the addictions: conceptual chaos. Subst Use Misuse 1997; 32: 1573– 80. Shaffer HJ. Rethinking addiction: how gambling and other behavioral addictions are changing the concept and treatment of alcohol and substance use disorders. Acad News 2003(2): 1, 3, 7. American Psychiatric Association. DSM-IV: Diagnostic and Statistical Manual of Mental Disorders. 4 th ed. Washington, DC: American Psychiatric Association; 1994 American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5 th ed. Arlington, VA: American Psychiatric Publishing; 2013 Grant JE, Potenza MN. Commentary: illegal behavior and pathological gambling. J Am Acad Psychiatry Law. 2007; 35(3): 302– 305. .