copyright alcohol medical scholars program1 pathological gambling and alcohol use disorders timothy...

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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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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