DISORDERED GAMBLINGin 2015: Trends, Implications & Services

Training Agenda• Introductions & Expectations• Overview, Definitions & Trends• Defining Disordered Gambling• Co-occurring Issues• Screening & Intervention• Problem Gambling Services• Wrap-up

Introductions & Expectations

DEFINITION:

______ something of valuein the _________________

something of greater value.hopes of obtaining

RISKING

Source: American Psychiatric Association - DSM-5 (2013).

A longhistory

1931

Video poker began

1992

Nine tribal casinos opened

1994 - 2004

?

Lottery approved

1984

Gambling in Oregon Lottery Scratch-its Megabucks Powerball Keno Video lottery

Bingo/charitable gaming

Casino gaming

“Social gaming” (e.g., card houses)

Sports bets Horse racing Internet Office pools Poker/card nights Bets among friends Stock market (??)

Local “Social Gaming”

Image sources: Oregon Lottery, Hynes

Image sources: Oregon Lottery, Hynes

2,400 retailers in Oregon

ELECTRONIC GAMBLING:“Video Poker/Slots/Line Games”

Source: Oregon Lottery

$8.60out of

every $10 spent on lottery

Video Lottery:Video Poker / Video Slots / “Line Games”

Source: The OregonianPhoto source: Daniel Berman.

Going Mobile: Real Gambling…

16

…to Free* Apps…

17

And this is where lines in 2015 start to blur…..

Gamingor Gambling?

18

21

Fantasy Sport$

22

23

2424

2525

26

27

Key

“A’s” of the Trends

AVAILABILITY.

Amygdala active

Risk-taking & impulsivity

Source: Ramoski, S., Nystrom, R. (2007). Image source: simpsons.wikia.org

age…

Acceptability.

Advertising.

Pop-up on my kid’s game, Feb 201533

2012 Oregon Student Wellness Survey, Lane County (“ESD”) and Oregon; available at http://oregon.pridesurveys.com/esds.php?year=2012

Awareness (low).

Oregon parent/youth focus groups revealed:

• All parents’ focus group said their kids didn’t gamble

• All of their kids, in their own focus groups, said they did gamble

• Neither sees gambling as risky

ATTITUDES.

More Gamblers ► More Problem Gamblers

Prevalence of gambling problems

is a function of the overall level of gambling participation

“Last Week Tonight with John Oliver” –11/9/14https://www.youtube.com/watch?v=9PK-netuhHA

disordered

PATHOLOGICAL:Persistent and recurrent maladaptive gambling behavior...results in the LOSS OF CONTROL over gambling. (DSM-IV)

Historical Definitions

New language

It’s a“Continuum”

No Gambling Experimentation

Recreational Problem Pathological

Sources: 1. Moore (2006). 2. Volberg, Hedberg, & Moore (2008). 3. Shaffer & Hall (2001). 4. Northwest Survey & Data Services (2007). 5. Moore (2001).

At-Risk“GAMBLING DISORDER”

Electronic Gambling

Electronic Gambling

89% Cards4%

Other7%

Oregon Gambling TreatmentGamblers' Preferences

Source: Oregon Health Authority.

The new DSM-5 (May 2013) definespathological gambling as a

“behavioral addiction,” the first of its kind.

Typical Phases of

Problem Gambling

Source: Custer, R. & Rosenthal, M.

WINNING

LOSING

DESPERATION

HOPELESSNESS

Source: http://www.oregon.gov/oha/amh/gambling/gear-workbook.pdf

THOUGHTS, FEELINGS, ANTICIPATION, FANTASY

(Gambler’s Mind, “Gambling Time/ Gambling Money”)

PLANNING(Removing obstacles

to gambling)

GAMBLING(“Winning & Losing”)

Serotonin Adrenaline

Dopamine

CRASHGuilt, Shame, Anger, Denial, Justification, Restless, Irritable, Depression, Panic or Numb, Suicidal Thoughts Dopamine

REALITY(Self with Others)“Real Time, Real Money”

$32k

85%

90%

24%

$27k$!

IS THE AVERAGE HOUSEHOLD INCOME. Range is from $0 to over $1million/year.

ARE WHITE. 4.4% Hispanic/Latino., 3.4% Asian. People of color are under-represented in treatment.

prefer ELECTRONIC GAMBLING. Video (slots/poker/line games). Cards 4.1%; scratch-its 1.3%; sports 0.9%;

HAVE COMMITTED CRIMES TO FINANCE THEIR GAMBLING. Most crimes are “white collar” (forgery, check fraud, embezzlement.)

IS THE AVERAGE INDIVIDUAL GAMBLING DEBT.

Oregonians in gambling treatment, 2012:

The “Addiction” Connection

• Loss of control• Denial• Depression/mood swings• Progressive• Tolerance• Use as an escape• Preoccupation• Similar “highs”• Self-help groups• Family involvement• Use of rituals

Differences?Similarities? Defining “use” (gambling) Behavior not attributable to

chemical ingestion No biological test More intense sense of shame and

guilt (anecdotal) Unpredictable outcome Fantasies of success /quitting is

giving up hope Easier to hide

Effects on Children• Higher abuse & neglect

• Higher levels of tobacco, alcohol & drug use, overeating & gambling among their children

Sources: 1. National opinion research center (1999). 2. Darbyshire, oster, & carrig (2001). 3. Gupta & derevensky (1997); jacobs (2000); wallisch & liu (1996). 4 volberg et al. (2008; ibid).

Some Key Risk FactorsOther

addiction issues

Starting early in life

Friends / family favorable

Community laws & norms

Mental health issues

53

People with other

addictions issues

People with other mental health issues

Military/ Veterans

Young people

Incarcerated persons

People of color

Older adults

WomenPeople of lower SES

People with history of

traumaMen

Vulnerable Populations

54

>70%are current

tobacco users

24%have current

alcohol problems

5%actually attempt

suicide

Source: Oregon Health Authority, 2013

27%experience

suicidal ideation

Use illicit drugs

5.6% college age (18-24)

2.7 % all adults (18+)

4% teens (13-17)

This is the first generation of widely available electronic gambling. We really don’t know the effects yet.

1.2 % older adults (65+)

Adolescent Behavior & Brain Development

• Preference: ↑excitement and ↓ effort activities

• Prefer novelty• Poor planning & judgment• Minimal consideration of

negative consequences • More risky, impulsive

behaviors

Source: Grant, J (2008, October). The Adolescent Brain & Impulsive Behaviors. Healthy Brain Development: Key Impacts & Interventions Conference.

Age 65+• Rate of problem gambling lower (1.2%) 1

• BUT living close to gambling facility ↑↑risk– six times more likely to be problem

gamblers• ↑ risk factors 2

• Gambling = most frequently identified social activity 2

• Challenges in problem acceptance

Sources: 1. Moore (2001, ibid). 2. McNeilly & Burke (2000). Late life gambling: The attitudes and behaviors of older adults. Journal of Gambling Studies, 16, 393-415.

People of Color

• Higher proportion of problem gamblers (except Asians)

• Spend 2.5x more on gambling in a typical month

Source: Moore, Jadlos, & Carlson, 2000

Incarcerated Persons• One in three offenders

meet criteria for PG 1

– Highest rate in any population

• Gambling common in prison culture

• Resources limited to investigate crime & gambling 2

Sources: 1. Williams, Roysten & Hagen. (2005). Gambling and Problem Gambling Within Forensic Populations, A Review of the Literature 2. Myers, H. (2006). Organized crime in Oregon.

Military & Veterans• All four branches operate

slot machines overseas• Service members at higher

risk– Male, younger, racial/ethnic minorities– Marine corps highest rate of PG

• Alcohol & gambling connected

• Further article of interest: http://www.cnn.com/2007/US/05/22/military.gambling/index.html

Source: Department of Defense (2002). Survey of Health Related Behaviors Among Military Personnel Washington, DC: Author. Report information available at http://www.tricare.mil/main/news/dodsurvey.htm

Co-Occurrence with Mental Health & Addictions

Thought processes & distortionsNeurobiology & addiction connections

Similarities & differences

Mental Health & Addictions Connections

• Depression/mood disorders 1

– Depression – in one study, 76% of PGS had depression– Bipolar disorder – correlations with BPD & PG

• PTSD (studies of military veterans)– PTSD among problem gamblers estimated between 12.5 – 29% 2,3

• ADHD• Alcohol & other substance abuse disorders

Sources 1. Ledgerwood & Petry (2006). 2. Kausch et al. (2006). 3. Biddle et al. (2005). 4. Oregon DHS (2009).

brain

The PREFRONTAL CORTEX is the LAST PART to develop.

The brain is still

developinguntil

Neurotransmitter

Serotonin

Norepinephrine

Opioids

Dopamine

Role in Impulse Control

Behavior Initiation/Cessation

Arousal, Excitement

Pleasure, Urges

Reward, Reinforcement

⇓ Serotonin -- ⇑ risk taking

Gambling - ⇑ β-endorphin

PGs - ⇑ NE levels

PGs - ⇑ dopamine response

Potential Neurotransmitter Roles in Disordered Gambling

Dopamine: most studied neurotransmitter in problem gambling

Source: Brain Briefings (2007, October), Society for Neuroscience, Washington, DC

Gambling & Dopamine

Dopamine not released when expecting a loss.Flooded with dopamine when expecting a win!

It’s not about the money – it’s about the action of the game and the hope of winning.

Image source: http://www.drugabuse.gov/pubs/teaching/largegifs/slide-2.gif

Survival Reward Pathway

Dopamine levels and behavioral pattern resulting from learned audiovisual cue (Figure from Self, 2003)

Source: Biology, Addiction & Gambling (http://www.basisonline.org/backissues/2003/vol8pdf/wager838.pdf)

"Monetary reward in a gambling-like experiment produces brain activation very similar to that observed in a cocaine addict receiving an infusion of cocaine.” -Hans Breiter, MD, co-director of the Motivation & Emotion Neuroscience Center, Massachusetts General Hospital

Sources: Tonneato, T. (1999). Cognitive psychopathology of problem gambling. Subst Use Misuse. Sep;34(11):159Anecdotal reports from problem gamblers in treatment and recovery.

Image source: Anheuser-Busch

Cognitive Distortions

• Lucky #’s• Favorite shirt• “My” machine

Superstition

Rituals/habits that are believed

to affect the outcome.

Cognitive Distortions

• Example (win): “Yeah buddy! I was just waiting on my card. I know this game inside and out.”

• Example (loss): “I would’ve won if that idiot didn’t get lucky and draw an ace.”

Biased EvaluationAttributing wins to one’s special skill or luck, while losses are blamed on external circumstances.

Image source: Anheuser-Busch

Cognitive Distortions

Forgetting about losses, only remembering wins.

Selective Memory

Cognitive Distortions

Failure to see each event as independent. Examples:• Trying to see patterns in coin flips.• “This slot machine is DUE to hit!”

Gambler’s Fallacy

Have you ever experienced a

cognitive distortion? What was the

experience like?

Reflect: cognitive distortions.

Creating conditions in families, schools, and communities that

promote the wellbeing of people

Emotional and behavioral health Physical health

Addressing the “A’s”

1. Awareness Building: Focusing on Brain Development & Technology

2. Education: Making Evidence-Based Connections with Other Problem Behaviors

3. Policy: Systems level, implementing “Big P” & “little p”

Current special emphasis:• Brain development.• Technology.

• Supporting evidence-based programs.• Curriculum integration.• Training integration.

Identification & Treatment

InterventionHelpline

emergence 24/7:

1.877.MY.LIMITReferred to provider for

assessmentFamily members come in;

later bring gambler in

Treatment Options in Oregon

• Minimal intervention: GEAR (Gambling Education and Reduction)

• Outpatient treatment (46)• Crisis respite (1)• Residential treatment (1)

Assessment Tools• “Valid and Reliable”

– DSM-V – South Oaks Gambling Screen (SOGS)

• Frequently Used– Gamblers Anonymous 20 Questions (GA-20)

Screening: The “Lie-Bet”

• Two questions to rule out pathological gambling behavior– 1) Have you ever felt the need to bet more and more

money?– 2) Have you ever had to lie to people important to

you about how much you gambled?• One or both “yes” answers indicate further

assessment needed– Further evaluation can be made by calling

1-877-MY-LIMIT (877-695-4648)

DSM Criteria Revisited1. Preoccupation with

gambling2. Increases amount of

money gambled3. Unsuccessfully tries to

quit4. Restless or irritable when

trying to cut down/stop5. Gambles as an escape

6. “Chases” losses7. Lies to others to conceal

gambling8. Has jeopardized

relationships9. Relies on others to bail

him/her out

Gambling Disorder = Four or more of above, AND: The gambling behavior is not better accounted for by a Manic Episode.

Mild (4-5) / Moderate (6-7) /Severe (8-9)

Treatment is Free IN OREGON.

24 hrs: 1-877-My-limitOnline: www.opgr.org

Emergence Gambling Treatment ProgramTreatment is gender-specific

Multimodal treatment - Individual sessions - Family therapy- Group sessions - Recreational counseling- Didactic lectures - Audiovisual education

Suggest to explore 12-step program

System Evaluation Results

• Treatment is working– 50% successful completion rate

– 64% of clients reported either no gambling or reduced gambling at 6-months post-treatment

• 97.3% of the completers at six-month follow-up and 93.9% of those at 12-month follow-up indicated strong endorsement regarding recommending the program to others

1. Oregon Health Authority, T.L. Moore (2014)

Wrapping it All Up• The lines of gaming and gambling have blurred, and

it’s become much more popular• This popularity doesn’t come without cost• Gambling problems often mimic other disorders in

manifestation, consequences, & co-occurrence• Problem gambling services are free, confidential,

available and effective• Important to assess for issue & make your clients

aware of services

Revisiting OurExpectations,Q&A

Anything lingering?

Evaluations

Thank You!!Julie Hynes

Prevention SpecialistLane County Public Health

Prevention Program

541.682.3928Julie.Hynes@co.lane.or.us

preventionlane.org

Michele Tantriella-ModellProgram Director

Emergence Meridian Gambling Treatment Program

541.741.7107mtmodell@4emergence.com

4emergence.com