Problem Gambling Treatment Providers

Monthly Call/WebinarMarch 4, 2015

Facilitated by Greta Coe

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AgendaTime Topic3:00pm-3:10pm Introductions/County Roll Call

 3:10pm-3:15pm AMH Update/Announcements

PG System Improvement Community Forums3:15pm-3:45pm Presentation

•GBIRT Screening Project- Presented by Alicia Bartz (Multnomah County) and David Corse (VOA/InAct- Mult. Co.)

3:45pm-3:55pm Discussion Topics•PGS Treatment Provider Discussion-Updates from the field

3:55pm-4:00pm Wrap UpItems for next meeting?Future agenda items: •Quality Improvement Reports- as statewide look and performance based contracting (April) •MH clinicians not knowing how to refer and screen•Treating gambling addiction and co-occurring disorders•Ideas for increasing enrollments 

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AMH Updates PGS System Improvement Community

ForumsMarch 10, 2015- Lake OswegoMarch 12, 2015- Grants Pass March 13. 2015- Albany March 17, 2015- Bend

Contact Patricia.alderson@state.or.us for registration flyer. Registration closes on Friday, March 6.

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Presentation

GBIRT Screening ProjectPresented by Alicia Bartz

(Multnomah County) and David Corse (VOA/InAct-

Mult. Co.)

1. Evidence of high risk of gambling problems among individuals diagnosed with substance use and mental health disorders.

2. Not addressing gambling issues decreases treatment effectiveness and adds to treatment costs

3. Early intervention and treatment work!

Why bother screening for gambling disorders?

• Per DSM5, those with gambling disorder have high rates of substance use disorders, depressive disorders, anxiety disorders, and personality disorders.

• Up to nearly 1/3 of individuals in SUD treatment identified as problem gamblers (Ledgerwood et al, 2002)

• The more severe the past year’s SUD, the higher the prevalence of gambling problems (Rush et al, 2008)

• Individuals with lifetime history of mental health disorder had 2-3 times rate of problem gambling (Rush et al, 2008)

Comorbidity

OSAM Survey 27.6% gambled more when using alcohol or

other drugs 16.7% used more alcohol or drugs when

gambling 15.6% gambled to buy alcohol or drugs

• What happens in actual clinical practice • Use screen • No one endorses items • What does counselor think?• None of my clients have any gambling

problems • Don’t care about the research, my clients are

different • NIMBY (Not in my back yard (or treatment

program))

Typical results of use of brief screens

Need to define what is meant by gambling – list types of gambling

Use diagnostic criteria Developed to screen for most severe

gambling problemsDiffering ways questions are addressed by

counselors; many factors including counselor workload, length of intake assessments, counselor priorities, and counselor comfort with problem gambling all may contribute to minimizing importance of gambling questions

Issues with brief screens

Counselor thinking: “I can save time on these…That’s not why she is here anyway.”

“ You’ve never lied about gambling or wanted to spend more money on it, have you? “

Client thinking: “Phew! Nobody cares about gambling here! No, that’s not a problem”

PG screening: what often happens

• For the purpose of the next questions, “gambling” means buying lottery tickets, gambling at a casino, playing cards or dice for money, betting on sports games, playing slot machines, video poker or other video gambling, gambling on the internet, betting on horses or dogs, playing bingo or keno.

• During the past 12 months, have you gambled 5 or more times?

• If yes, continue to next 3 questions:

Strategy adapted from IL SBIRT*

*from DSM-5, BBGS, and Elizabeth Hartney, PhD

During the past 12 months:1. Have you tried to hide how much you have

gambled from your family or friends?2. Have you had to ask other people for money to

help deal with financial problems that had been caused by gambling?

3. Have you ever felt restless, on edge or irritable when trying to stop or cut down on gambling?

If yes to any of the above, proceed to next 6 questions:

Screening strategy

4. Have you tried to cut down or stop your gambling?5. Have you increased your bet or how much you would

spend, in order to feel the same kind of excitement as before?

6. Did you think about gambling even when you were not doing it? (Remembering past gambling experiences, or planning future gambling?)

7. Did you go to gamble when you were feeling down, stressed, angry or bored?

8. Did you ever try to win back the money that you had recently lost?

9. Has your gambling caused problems in your relationships or with work?

Total “yes” responses?

Screening strategy, continued

A “yes” response to any of questions 1, 2, or 3 results in asking all the questions (4-9) and Gambling Brief Intervention.

•A “yes” response to a total of 4 questions (out of 9) results in a Gambling Brief Intervention and Referral to Gambling Treatment

Brief intervention

• Give feedback on personal gambling • Define levels of gambling and gambling disorder • Go over risk factors for problem gambling/gambling

disorder (i.e., being in recovery, dealing with grief or loneliness, or immediate financial pressures)

• Offer steps to keep gambling fun and problem-free: set a time and money limit and stick to it; learn how the games work and what they cost to play; balance with other leisure activities

• “If you gamble and spend more time and money than you can afford, a good strategy is to take a break and look at your gambling. Consider seeking help if this is a concern.”

Brief advice on reducing gambling

The key to this approach is to raise the issue of gambling and its role in your client’s recovery in multiple contexts and repeatedly over time.

It is also key to include the topic of gambling in a non-judgmental or labeling manner, in order to minimize defensiveness or resistance.

Integrated assessment

What we’re doingGBIRT

Utilize previously-described gambling screening techniques with clear routes to referral

Peer mentorsEducate A&D (alcohol and drug) providers

and conduct outreach to A&D clients with gambling issues to provide support and link to treatment

Planning and evaluationTwo of our providers have both gambling

and A&D branches in their organizationsThe issue: minimal overlap/communication

Piloting GBIRT and mentors at one organization (VOA), not the other (Cascadia, control group)

Also piloting mentors at A&D-only organizations

Examining the needConducted gambling attitude and knowledge

surveys at VOA among all consenting staff and clients to establish baseline, Dec. 2014Questionnaire adapted and expanded from Lori

Rugel’s GBIRT evaluation, available online.Similar baseline conducted at Cascadia, Mar.

2015, for comparison (data forthcoming)Both organizations tracking the number of

identifications and referrals for gambling issues discovered among A&D clients each month

The need31 staff and 83 clients participated at VOA, with a

median time in treatment of 3 to 6 monthsResults

Nearly 90% of clinical staff indicated that they had spoken with clients about gambling problems before; however, only 34% of clients recalled their counselor ever mentioning it.Clients for whom this would not be relevant may have

difficulty remembering; however, this also held for active gamblers—one-third of those who gambled at least once a month reported never having been asked about it before.

Nearly 22% of clients gambled at least once a month; 10% gambled weekly or more.Games of choice: in-person machine games (such as

slots and video poker) and lotteries (such as PowerBall and scratch tickets) were the top two games among weekly to daily gamblers.

The needResults, continued

Knowing where to get help for gambling problems: while 100% of staff reported of available resources they could access if they needed help, only 60% of clients did (despite receiving treatment at an organization with a gambling program).

Ready to help: staff were near-neutral on their self-perceptions of their ability to help clients with gambling issues, as well as on if a client would feel comfortable coming to them with such an issue. There was some agreement that their department needed to do more to address gambling, as well as acknowledgment that they had heard leadership address gambling as an issue.

The needResults, continued

Community impact: over 90% of staff acknowledged that at least one form of gambling had a negative impact on their community; only 35% of clients believed this to be true.In-person machine games, such as slots, keno, or video poker,

was identified as the number one problematic type of game.Personal beliefs: clients and staff strongly believed

gambling to be as addictive as alcohol or drugs and that it was important to provide professional help, although clients were more neutral on the origins of gambling problems than staff (whether it is a simple result of greed/lack of self-control), and on whether addressing gambling addictions should be as high a priority as A&D addictions.

In summaryThis baseline shows receptiveness to

learning more about gambling and improving outreach, but a lack of comfort among staff with addressing gambling issues, a lack of knowledge among clients as to how harmful it can be, and a disconnect between client and staff knowledge of what assistance is available

Thus, room to grow!

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Questions

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Future Agenda Items

APRIL: Quality Improvement Reports- as statewide look and performance based contracting

MH clinicians not knowing how to refer and screen

Treating gambling addiction and co-occurring disorders

Ideas for increasing enrollments

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