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Pathological Gambling Insights on an Emerging Addiction

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Pathological Gambling Insights on an Emerging Addiction Powered By Docstoc
					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)                         ~ 2%
  – Alcohol use disorders (AUD)                        13%


• PG + AUD
  – Often co-occur
  – Worse outcomes


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      This lecture will cover
                                     •   Diagnostic criteria
Pathological                         •   Epidemiology
  Gambling (PG)                      •   Consequences
                                     •   Screening
Alcohol Use                          •   Risk factors
  Disorders (AUD)
                                     •   Treatment




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Pathological
 Gambling




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Gambling in the United States

•   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
            Problem                Pathological
    10
     8
     6
%
     4
     2
     0
         Kalick,




                                       Welte,
                       Gerstein,




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                                       2001
          1976




                                                        press
                        1999




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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
  –   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

•   12-step, Alcoholics Anonymous
    – >75,000 groups in US
    – Peer support and fellowship


•   SMART Recovery (Self-Management
    and Recovery Training)
    – Self-reliance, personal responsibility

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      Psychosocial Treatment
•   Cognitive-Behavioral Therapy
    – Identify motivations and triggers
    – Longer in treatment, better outcome


•   Relapse Prevention
    – Identify risky situations
    – Develop alternative behaviors


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    Treatment: Pharmacotherapy

•    Disulfiram
     – Efficacy:       equivocal
•    Naltrexone
     – Efficacy:       ↓ 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

•   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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