Pathological Gambling Causes, Course and Treatment

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Gambling Addiction: What Every Mental Health Professional Should Know Timothy Fong MD UCLA Gambling Studies Program UCLA Extension February 8, 2008

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Financial Disclosures Speaker Bureau Research Support Reckitt Benckiser NIDA Pfizer OPG (California) Cephalon Ortho-McNeil Forest Somaxon Ortho McNeil

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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 (2005) Gambling (Legal) $83 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 California Scene

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Types of Gambling In California State lottery (1985) Card clubs (97) 1,500 tables Indian casinos (61) (San Diego, Palm Springs, Northern California) Horseracing Proximity of Las Vegas, Reno

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Background Exponential growth of legalized gambling $2.5 billion (1997) to $13 billion (2003) Horse race wagering ($4 billion) Lottery ($3 billion) Card rooms ($1 billion) Tribal casinos ($5 billion) 60% Californians gambled last year

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Recent Events Crackdown on Internet Gambling (2006) New Indian Compacts 20,000 slot machines! Asian Expansion (Macau, Singapore) Little noise from federal level NIH funds (2007) Gambling = 36 Methamphetamine = 199

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World Series of Poker 2007 6,400 Entrants $10,000 Buy-In First Prize $8.25 Million 30-day coverage on ESPN Winner - PhD

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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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Pathological Gambling DSM-IV Criteria

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Consequences of Pathological Gambling

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Similarities to Addictions Loss of control Preoccupation, urges, pathological “wanting” Negative impact on major areas of life Major impacts on mood. Judgment and insight Tolerance/ Withdrawal

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Differences from Addictions No toxicology test to diagnosis it; easier to hide Behaviors are not due to drug effects (thus, makes it more open to shame/guilt) Greater uncertainty of outcome (i.e. anything can happen) Ego Dystonic or Ego Syntonic Mix of impulsive and compulsive

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Economic Burden of Pathological Gambling

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Prevalence Rates: General Population

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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

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Screening Assessment Diagnosis

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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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South Oaks Gambling Screen (SOGS) Identifies patients with gambling problems Self-Scored; “greater than 5 = PG” 16 items 5-10 minutes Psychometrically solid Lesieur, Blume and Zoppa, 1986

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When to screen Intake Waiting room As homework Annually Families and friends

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Improving Assessment Standardized instruments (SCID-PG) Focus on impact, not frequency Legal - Family Functioning Financial - Productivity Social - Mental health Physical 2% rule

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Assessment Tips Note shame, secrecy, stigma Collateral information a MUST Can take several sessions to get the picture Ask for evidence (statements)

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Clinical Questions How much time do you spend on gambling? What is the meaning of gambling? Do you plan trips only to where gambling is available? Do you gamble alone? What kind of problems has gambling caused you?

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Differential Diagnosis Mood Disorders, esp. Bipolar Manic episodes Anxiety Disorders ADHD Substance Use Disorders Timelines and history are the essential

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Etiology

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Biological Causes Genetic contributions Medical Conditions Medications / Toxic Exposures Neurochemicals Neuroanatomy Neurofunctioning

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Neurochemicals Serotonin Dopamine Norepinephrine

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Neurotransmitters in Pathological Gambling

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Neuroanatomy Prefrontal Cortex (OFC, DLPFC, VMPFC) Assessment of reward value, central evaluator, “brakes” Somatic-marker hypothesis Similar performances as those with drug abuse, ADHD, impaired on Gambling Task, Delay Discounting Tasks, Go-No-Go Tasks,

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Neurobiology of PG (Neuroanatomy) Potenza’s Imaging Studies (PG vs Normals) Decreased activity in: Left ventromedial PFC (Decision-making) Orbitofrontal cortex (processing of rewards, dealing with uncertainty, inhibiting responses) Anterior Cingulate (Decision-making) Ventral striatum (NA, Limbic system)

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Risk Factors: Psychological Exaggerated illusion of control Reason for gambling: escape High levels of impulsivity aggressive or hyperactivity NOT a RF

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Psychological Causes Positive Reinforcement Negative Reinforcement Tension-Reduction / Affective Regulation Cognitive Distortions Vicarious Learning Personality traits Impulsivity, reward-seeking, loss aversion

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Social Causes Accessibility Acceptability Peer behaviors Availability of treatment and prevention Societal portrayal

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Risk Factors: Social Parents that gamble or have substance abuse Gambling peers Unstructured time Lack of parental control Access to money

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Protective Factors Almost no research Clinically, Empathy Capacity for honesty Social capital Problem solving skills Mindfulness

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Vulnerable Populations

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Vulnerable Populations Incarcerated #1 pastime is gambling Substance Use Disorders 10x risk for PG Lower SES Problems develop sooner

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Vulnerable Populations Adolescents 5-6% meet criteria Elderly Harder to recoup financial losses Casino Workers Chicken or the egg?

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How much do adolescents gamble? 60-90% have gambled Similar, internationally Strong pop culture influences No monitoring system Societal, parental acceptance

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Reasons for gambling Win money Social activity Excitement Competition Fantasy Family members

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Asians and Gambling

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History of Gambling in China 3,000 B.C. Many games invented All segments of society Officials of government Gambling as a profession Gambling associated with secret society, corruption and drugs

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History of Gambling and Asia Different story in each country Forbidden, ambivalent, promoted Unique definitions of gambling Mahjong, lottery, stocks vs. casinos Common thread – gambling always part of the social dialogue

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Cultural factors that promote gambling Acceptable way to make money Inquire about one’s destiny “Honoring the Gods” Losses are sacrifice Equate gambling with self-worth and ability to move up classes

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Cultural factors that promote gambling Emphasis on numbers that have power over life events Heavy peer involvement Gambling is family entertainment Gambling as a rite of passage Superstitions

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Asian Gambling Expansion Vietnam: Ho Chi Minh (2009) Singapore: Two casinos (2009) Phillipines: Manila Bay Hong Kong: Horse-racing, lottery, Taiwan / Thailand / Japan: Considering China: Not on the mainland

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Asians in America US Census 2000

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Asians in California 12 % of Californians are AAPIs ~ 4 million Highest rate of growth 1.2 million Los Angeles County State population ~ 35 million (2000 Census)

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Asians in California Largest Asian Groups: Filipino Chinese Vietnamese Korean Asian Indian Japanese Fastest growing Asian Indian, Vietnamese, Hmong

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Asian Communities Monterey Park (64%) Cerritos (61%) Rowland Heights (52%) San Gabriel (51%) San Marino (50%) Alhambra (48%)

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Background Data NICOS (SF) 70% identified gambling as number one social concern (1999) 15 % problem gamblers 21% pathological gamblers

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Asians and Gambling (Los Angeles) 30-40% of casino clientele are AAPIs Casinos market toward AAPIs Significant percentage of casino revenue comes from local AAPI residents Social activity of choice

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Consequences of PG on APIs 20% of child neglect cases (Santa Clara) 30% of API DV cases (SF Chinatown) Numerous bankruptcy reports from Monterey Park Recent cases of family violence (April 2006)

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Case Examples: Bong Joo Lee (April 2006) Fontana, California Unemployed $200,000 in gambling debt. Recent separation Family discord over gambling Past history of assaulting wife End Result: Murder-Suicide

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Case Example: David Lam (2007) Casino Employee Wife seen, not heard Gambling debt (>$50,000) ; bankruptcy Marital discord Lam heads to Singapore 9/18/2005 Body found 9/23/2005 Caught in 11/2007, w/family in Indonesia

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“Impact of Gambling on Los Angeles Asian Communities” To understand the impact of problem gambling on AAPIs. To understand cultural influences which will inform prevention and treatment (Funded by UCLA in LA)

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Surveys

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Prevalence Survey 180 surveys collected over 3 days at Commerce Casino (March 2006) SOGS NODS UCLA Gambling Survey Convenience Sampling $5 Starbucks reimbursement

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Prevalence Survey Objectives: What is the rate of PG among casino patrons? What is the rate of PG of AAPIs vs. Non-AAPIs?

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Results

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Results

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Results

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Conclusions High rates of PG inside a casino How many require treatment? No obvious ethnic differences BUT APIs will have more PGs Replication needed Secondary analysis underway (gender, time, health status)

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Treatment Strategies

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Treatment Approaches to Pathological Gambling Medications Psychotherapy Gambler’s Anonymous Family Therapy Brief Interventions Prevention

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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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Principles of Pharmacotherapy Target urges/impulses Treat co-occurring disorder Medications lay the groundwork for psychosocial therapies. No “magic bullets” No FDA-approved meds

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Pharmacotherapy Antidepressants SSRIs OCD-Subtype, co-occurring anxiety Reduce preoccupation? Bupropion Attention enhancer? Negative trial (Hollander, Grant, Black)

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Pharmacotherapy Mood Stabilizers Valproic Acid, Lithium, Carbamazepine Co-occurring bipolar disorder Target impulsivity, mood lability (Hollander, Pallanti)

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Pharmacotherapy Opiate Antagonists Naltrexone (PO) and Nalmefene Block urges, cravings Reduce “euphoria” SE: dysphoria, LFTs No research on IM naltrexone

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Case Reports

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Open Label

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Single Blind

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Double-blind, Placebo-Controlled

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Latest Trials

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Pharmacotherapy: Future Directions Topiramate: Impulsivity Modafanil: Neurocognitive enhancer Amphetamines: Co-occurring ADHD N-Acetyl Cysteine:Improved impulse control

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Psychotherapy Cognitive Behavioral Motivational Psychodynamic Psychoeducational Family Therapy Behavioral

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Cognitive Behavioral Therapy Rework erroneous expectations (e.g. “gambling will solve everything”) Identify triggers to gambling (e.g. “payday = PAYDAY!”) Work on cognitive distortions of control (e.g. “I’m due to win”)

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Psychodynamic Approaches Understand conscious and unconscious motivations to gambling 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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Efficacy of a Self-Help Workbook for Problem Gamblers

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Background: Workbook Many kinds ; few empirically tested Promote self-change Easy to distribute ; wide range of audiences No need for training Cost effective Easy to update

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Objectives : Workbook Create a self-help workbook for PG Test efficacy of workbook for PG Publish workbook Distribute workbook

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Study Participants: Recruited from the community Newspapers, helpline, word-of-mouth, web advertising Inclusion: SOGS > 2 English-speaking Exclusion: Significant psychiatric d/o Active substance abuse

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Study Design Participants randomized to Workbook (alone) Workbook (guided) Study visits Wk 0 : Screening Wk 1,2,4,8,12: Workbook Wk: 20, 52: Follow-up

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Measurements Primary Outcomes Gambling behaviors Gambling urges / cravings Quality of life measures Secondary outcomes Mood / Anxiety symptoms Patient feedback

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Results so far . . Enrollment began in March 2007 First version of workbook created, revised, edited and printed.

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Results 73 participants screened 56 eligible 26 Workbook Alone 28 Workbook Guided 2 dropped out (choice)

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Results

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Follow-up data Most show reductions within second or third visits. Need data to analyze post treatment effects. Enrollment to end in Spring 2008

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Client Feedback No significant complaints Mostly positive Interactive quality of book is most appealing Good for future reference

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Next Steps Target Enrollment: 60 / 60 Expand recruitment Increase visibility of program Complete Enrollment Spring 2008 Continue to revise Workbook Primary and Secondary analyses

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Effectiveness of a Brief Telephone Intervention for PG: “Call to Change”

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Objectives : Helpline Evaluate effectiveness of “Call to Change” Expand helpline services to those likely to respond

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Participants Problem Gamblers calling the California Helpline Offered to enroll in “Call to Change”; administered by BDA Inclusion: NODS >2 English Speaking Data collected by BDA

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Study Design Week 0: Intake and Enrollment Week 1: Counseling Week 2: Counseling Week 4 Counseling Week 8 Counseling Week 12 Counseling Week 24: Follow-up Week 52: Follow-up

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Measurements Primary Outcomes Gambling behaviors Gambling urges / cravings GA Attendance Transition to formal treatment Secondary outcomes Mood / Anxiety symptoms Patient feedback

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Results Enrollment began March – June 2007 Target: 40 Currently enrolled: 40 Program Retention: 33/40 Follow-up and effectiveness data to be sent by BDA very soon

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Next Steps Preliminary analyses Comparison groups with California How to get CA program funded? For whom does it work for?

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Gambler’s Anonymous www.gamblersanonymous.org Founded in Los Angeles (1957) Based on 12-step model; 1500 chapters nationally Needs more research Gam-Anon for families

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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) Self-Exclusion Programs Internet assistance Online chat rooms Internet treatment manuals

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Working with Families Educate Reduce enabling behaviors Support self-efficacy and therapy Minimize negative situations Encourage time together Protect family’s financial interests Recommend formal family therapy

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Behavioral Measures Limit access to money and transportation Cut-up credit cards Increase structured time Self-exclusion programs No monitoring systems available, yet

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Case study #1 47 year-old white male $250,000 per year income 50% of income lost to gambling last year Consequences Divorce, no retirement savings, depressed, doesn’t see a way out, drinking and sex control issues

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Treatment Plan GA 90/90 Weekly therapy No alcohol or gambling No meds after intake Bring ex-wife in next time Plan time out

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Case study #2 54 yo Chinese Female Lives with husband, 2 kids Housewife, 1st-generation, English – poor Drives or buses to casinos > $45,000 in debt Kids bring her to treatment

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Treatment Plan GA: Chinese GA Individual Therapy: APCTC No meds Family meeting for history and decrease enabling Alternative socializing plan needed.

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Prevention

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Primary Prevention Casinos and advertisers to target underage gambling Addressing parental education Responsible Gaming Programs School-based programs

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Secondary Prevention Screenings at school, primary care, mental health settings, alcohol and drug programs Self-Help Workbooks Brief Interventions (1,2 sessions) Telephone Counseling

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Tertiary Prevention Self-Exclusion Programs “Gateway to Treatment” Gambling Courts / Forensic Care Does Harm Reduction apply? Managing co-occurring disorders

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Natural Recovery Percentages are unknown but thought to be high among those who avoid gambling stimuli engage in alternate activities less precipitating life events more positive events during recovery less severe PG (Hodgins 2000)

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Outcomes and Symptom Monitoring Treatment participation Collateral history Assessment of overall functioning Preoccupation, urges Time analysis Ongoing screening for add’l disorders

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Treatment Options in California (2008) Inpatient Treatment Programs Outpatient Treatment Programs UCLA Impulse Control Disorders Clinic UCLA Addictions Medicine Clinic Gambler’s Anonymous Private Practitioners Helplines

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California Funding and Gambling Treatment California Department of Alcohol and Drug Programs Office of Problem Gambling (2003) $3 million per year 2/2007: $0 State-Funded Treatment 7/1/07: $150,000 per year UPAC: San Diego County

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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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Treatment Summarized History and collateral information GA Therapy (go with what’s familiar) Address co-occurring disorders Supervision, if needed Motivate, motivate

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Resources Gamblers Anonymous and GamAnon (213) 386-8789 www.gamblersanonymous.org California Department of Drug and Alcohol (Office of Problem Gambling) www.adp.cahwnet.gov California Council on Problem Gambling www.calproblemgambling.org National Council on Problem Gambling www.ncpgambling.org

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Contact Information Timothy Fong MD Richard Rosenthal MD 310-825-4845 tfong@mednet.ucla.edu uclagamblingprogram.org

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