copyright alcohol medical scholars program1 pathological gambling and alcohol use disorders timothy...
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Copyright Alcohol Medical Scholars Program 1
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
Pathological Gambling (PG)
Alcohol Use Disorders (AUD)
• Diagnostic criteria• Epidemiology• Consequences• Screening• Risk factors• Treatment
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PathologicalGambling
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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
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ick,
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ry, i
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Problem Pathological
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Consequences ofPathological 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