Massachusetts Council on Compulsive Gambling

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Transcript Massachusetts Council on Compulsive Gambling

Problem Gambling:
The Hidden Addiction
Victor Ortiz, MSW, LADC I, CADC II
Presentation for:
Residential Substance Abuse Treatment (RSAT)
December 17, 2014
o Harvard Medical School Division on Addiction
o National Center for Responsible Gaming
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.
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
o Another 4-6 million (2-3%) would be considered
problem gamblers.
Source: National Council on Problem Gambling , Retrieved from
Stores with past Powerball winners lure crowds
Worcester T&G-2013
Gambling Risk Factors
Emotional difficulties
Distorted expectations
about winning
Social pressure to
Risky gambling
Attention deficits
Illusion of control over
Addiction history
Family history of
gambling problems
Gambling Disorders
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
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
Failure to resist an impulse, drive, or temptation that is
harmful to the person or to others.
Onset in adolescence and young adulthood – more men
than women.
Occurrence of an urge or craving state prior to initiating the
Pathological Gambling &
Drug and Alcohol Disorders
Resulting “high” – need to increase the intensity of the
behavior to achieve the same high.
Financial and marital problems.
Criminal behavior to fund addictive behavior or cope with
consequences of it.
Source: Grant, J.E. J.D. Potenza, M. MD, Weinstein, A. PhD., Gorelick, D. MD, PhD. (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
There is no substance
Bail out by family or friends
There is no obvious signs: slurred speech,
blood shot eyes, or odor
Neurological Similarities between Gambling & Drug
and Alcohol Abuse
o Multiple neurotransmitter systems are implicated in the
pathophysiology of behavioral addictions and substance use
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
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.
Source: Grant, J.E. J.D. Potenza, M. MD, Weinstein, A. PhD., Gorelick, D. MD, PhD. (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, PhD, CAS,, 2004
Clinical Practice
Gambling Disorders
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)
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%)
(McCormick 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).
What comes First, PG or Other Disorder?
PG First
Disorder First
Onset at Same
Any Mood Disorder*
Any Anxiety
Any Impulse Control
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 aChanging Landscape.”
Columbus, Ohio.
Medical Problems
Among Pathological Gamblers
o Depression
o Allergies
o Intestinal Disorders
o Respiratory Problems
o Cardiovascular
o Oral-Dental Disease
o Nerve-Sensory System
o High Blood Pressure
o Migraines
o Stress-related
Gambling Disorders and Suicide
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.
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.
Gambling Disorders
Do people with Gambling Problems
commit crimes?
Gambling Disorders and Corrections
 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
Gambling Disorders and Corrections
 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
DSM-IV and DSM-5
Gambling Disorders
According to DSM-IV criteria, gambling is
considered an impulse control disorder and
the criteria include three areas often
associated with addictive disorders:
 compulsion or craving;
 loss of control;
 and continuing behavior, despite the
presence of adverse consequences.
Challenges- Pathological Gambling
Mental Health or Addiction
Barriers within Recovery Community
Third Party Billing
Treatment Challenges
Data and Research
Gambling Disorders: 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
o Change reflects research findings that indicate that GD is
similar to substance-related disorders in clinical expression,
brain origin, comorbidity, physiology, and treatment.
Reclassification of Gambling
o Placement in “Substance-Related and Addictive
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
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
 Needs to gamble with increasing amounts of money in
order to achieve the desired excitement
 Is restless or irritable when attempting to cut down or
stop gambling
 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).
 Often gambles when feeling distress (e.g., helpless,
guilty, anxious, depressed).
Gambling Disorder DSM-5 Criteria Cont.
 After losing money gambling, often returns another day
to get even (“chasing” one’s losses).
 Lies to conceal the extent of involvement with
 Has jeopardized or lost a significant relationship, job, or
educational career opportunity because of gambling.
 Relies on others to provide money to relieve desperate
financial situations caused by gambling.
Differences in DSM-4TR and DSM-5
 “Is preoccupied with
 Gambles as a way to
escape from problems”
 “Is often preoccupied with
 Gambles when feeling
Differences in DSM-4TR and DSM-5 Cont.
 The omitted criterion reads, “Has committed
illegal acts such as forgery, fraud theft or
embezzlement to finance gambling.”
The DSM-5 Work Group felt that any illegal acts
would fall under “Lies to conceal the extent of
involvement with gambling
National Council on Problem Gambling
Massachusetts Council on Compulsive Gambling
Harvard School Division on Addiction
National Center for Responsible Gaming
Massachusetts Council on Compulsive
Victor Ortiz, MSW, LADC I, CADC II
Sr. Director of Programs and Services
[email protected]
Twitter- @Victor_Ortiz21
Work Cited
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. PhD., Gorelick, D. MD, PhD. (2010) The
American Journal of Drug and Alcohol Use, Early Online 1-9. DOI:
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, PhD, CAS, Debi A. LaPlante, PhD, Richard A. LaBrie, EdD, 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
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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
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
American Psychiatric Association. DSM-IV: Diagnostic and Statistical Manual of Mental
Disorders. 4th ed. Washington, DC: American Psychiatric Association; 1994
American Psychiatric Association. Diagnostic and Statistical Manual
of Mental Disorders. 5th 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.