pathological gambling and comorbid substance use

Pathological gambling and comorbid substance use

Fiona Maccallum, Alex Blaszczynski

Objective:

The objective of this study was to determine the rates of substance use problemsin a sample of diagnosed pathological gamblers seeking treatment in a university teachinghospital cognitive behavioural outpatient clinic.

Methods:

A semistructured interview schedule and the composite international diagnosticinterview (CIDI-auto) were administered to assess substance dependence in a sample of 75poker-machine gamblers meeting DSM-IV and South Oaks gambling screen (SOGS) criteriafor pathological gambling. Both the self-reported rates and the proportion meeting criteria fora psychiatric disorder were determined.

Results:

The rates for substance use disorder within a sample of treatment-seekingpathological gamblers is higher as compared to general population figures. Gender differ-ences were found with more current alcohol-abuse problems reported among male thanfemale participants. Non-alcohol-related substance abuse was relatively lower than ratesreported by other studies in the literature.

Conclusions:

Substance abuse is a common comorbid condition of pathological gamblingand therefore should be screened for in routine clinical assessments. Failure to identify andtreat comorbid substance-use disorders in gamblers may lead to higher relapse rates.

Key words:

Australian and New Zealand Journal of Psychiatry 2002; 36:411–415

alcohol dependence, comorbidity, pathological gambling, substance use.

Gambling is a major contemporary public health issuewith approximately 1.5% of the Australian populationmeeting criteria for pathological gambling problems,and a further 2.3% exhibiting significant gambling prob-lems [1]. While there have been a number of attempts toexplain the aetiology of pathological gambling in thecontext of a non-addiction framework, the addictionmodel of gambling remains the predominant paradigm[2–6].

In this context, high rates of comorbidity betweenpathological gambling and substance use have been con-sistently reported in community survey studies [7–9] and

in samples of pathological gamblers attending for treat-ment at drug and alcohol facilities [10,11]. Lifetime andcurrent rates of 47% and 39%, respectively for substanceuse have been reported in samples of pathological gamb-lers attending veteran’s administration or specialistgambling treatment programmes [12,13] with rates of8% to 20% noted among Gamblers Anonymous attendees[14–16].

Conversely, the rate of pathological gambling amongpopulations of substance abusers has also been reportedto be four to 10 times greater than that found in thegeneral population [17,18]. These rates have rangedfrom 6% to 33% subject to the population source anddiagnostic criteria used [19–23]. More recently, Hall

et al

. [24] found rates of 8.0% for lifetime diagnosis and3.8% for current diagnosis of pathological gambling in asample of 313 cocaine-dependent outpatients (200 werealso opiate-dependent) recruited for a treatment outcomestudy.

Alex Blaszczynski, Professor (Correspondence)

Department of Psychology, Transient Building F12, University ofSydney, NSW 2006, Australia. Email: [email protected]

Fiona Maccallum, Clinical Psychologist

Psychological Medicine Program, Liverpool Hospital, Sydney, Australia

Received 29 June 2001; revised 30 October 2001; accepted 26 November2001.

412 COMORBID SUBSTANCE USE AND GAMBLING

Although these data suggest that substance abusersmay be at greater risk for developing gambling prob-lems, and conversely, problem gamblers may be atgreater risk for developing substance-abuse problemsthan the general population, a notable feature of the datais the large variability found in constructs that have beenmeasured. Measured constructs have ranged from use,abuse, and misuse to dependence. Such differences inseverity prevent direct comparisons across studies andlimit generalization to other populations. With respect togambling, measures have inconsistently assessed for thepresence or absence of either lifetime and/or currentdiagnosis of ‘pathological’ or ‘problem’ gambling [25],using either standardized psychiatric interviews or SOGS[26]. There is even less consistency in the assessment ofsubstance use and/or substance problems. A number ofstudies have used standardized interviews to establishpsychiatric diagnoses of ‘dependence’ and ‘abuse’ [27].Others have assessed broader constructs such as ‘prob-lematic use’, or ‘hazardous use’ [7,25]. In addition thetypes of substances used have been classified into broadcategories such as ‘alcohol’ and ‘non-prescription illicitdrugs’ without specifying the type[s] of drug used, orreported in such a way that it is not possible to separatethe rates of alcohol from other drug use. This variabilityhas the potential to lead to confusion and inflated comor-bidity rates.

The purpose of this study was to investigate systemat-ically rates of substance-use problems in a sample ofdiagnosed pathological gamblers seeking treatment at aspecialist gambling outpatient clinic in Sydney, Aus-tralia. Structured standardized interviews were used toestablish 12-month diagnoses of substance abuse anddependence. In addition, as there is a growing body ofresearch indicating that non-problematic use of sub-stances such as alcohol can encourage increased gamb-ling [23,28,29], participants were also asked about theirlevels of general substance use.

Method

Participants

Seventy-five poker-machine treatment-seeking gamblers (48 malesand 27 females) took part in this study. All met DSM-IV [30] criteriafor pathological gambling, and the mean score on the SOGS [26]was M = 11.90 (SD = 2.51) indicating that a high level of gambling-related problems were experienced by participants. There was nodifference between males and females on the SOGS. The mean age ofparticipants was M = 37.69 (SD = 10.61), with males M = 35.90(SD = 10.40), significantly younger than females M = 42.56 (SD = 10.61),f (1,74) = 10.30, p < 0.003).

Participants had recognized their gambling to be a problem for amean of 3.70 years (SD = 3.90 years) prior to presentation for

treatment. There was no difference between males and females on thisvariable.

Procedure

Consecutive poker-machine gamblers attending the impulse controlresearch clinic, a specialist treatment service for problem gamblers,completed the SOGS and a semistructured clinical interview assessinggambling history and self-reported substance use. This interview con-tained probe questions for each of the DSM-IV diagnostic criteria forpathological gambling. Participants who met diagnostic criteria wereinvited to participate in a large-scale research project being conductedby the authors. As part of this study they attended a second assessmentinterview during which substance abuse and dependence were system-atically assessed using the clinician-administered computerized com-posite international diagnostic interview (CIDI-auto v2.1, 12 monthversion) [31]. The CIDI-auto v2.1, 12 month version is a standardizedinterview that assesses for the presence of mental disorders during theprevious 12 months and provides psychiatric diagnoses according tothe definitions and criteria of DSM-IV [30].

The South-western Sydney Area Health Service Ethics Committeegranted approval for the study.

Results

The results of this study are presented in two sections. The firstsection presents subjects’ self-reported substance use. The secondsection presents data on rates of substance-use psychiatric diagnosisduring the previous 12 months.

Self-reported substance use

Self-reported estimates for substance use during the previous12 months were obtained from responses to items in the semistructureddemographic interview. Data are presented in Table 1. As may beexpected the legal substances, alcohol (73.3%) and nicotine (65.30%),were the most commonly used substances. However, males (52.08%)were more likely than females (19.23%) to combine alcohol use andgambling (

χ

2

= 7.56, p < 0.007). The majority of participants whosmoked tobacco (85.71%) indicated that they smoked many morecigarettes during a gambling session. Self-reported usage rates foralcohol were similar to recent national estimates for at least semiregu-lar use in the Australian population (81%), while rates of nicotine usewere higher than national estimates (26%) [32]. Just over 13% of thesample reported marijuana use. There was no difference in the percent-age of males and females reporting marijuana use. Reported usage ofother illicit substances was minimal.

Participants were asked to indicate whether they felt their useof substances was problematic. Twelve per cent of clients (12.50% ofmales and 11.11% of females) felt their current use of alcohol wasproblematic, and 8.0% (8.33% of males and 7.41% of females)reported an alcohol problem in the past. Only a small percentage ofclients (5.33%) reported previous drug and alcohol treatment. All ofthese participants were male.

F. MACCALLUM, A. BLASZCZYNSKI 413

Substance-use disorders

Table 2 shows the percentages of male and female participants whomet criteria for a substance use disorder on the CIDI-auto. As this tableindicates, nicotine dependence was the most common substance-related disorder. Thirty-seven per cent of participants (41.67% malesand 29.63% females) met criteria for this disorder. Alcohol abuse wasthe next most common disorder, with 16.00% of the sample meetingcriteria for this disorder during the 12 months prior to assessment.Males (22.92%) were significantly more likely to meet criteria foralcohol abuse than females (3.70%; Fisher’s exact p < 0.03). Rates ofalcohol dependence were somewhat lower (10.42% males, 3.70%females) and there was no sex differences on this variable.

As Table 2 indicates, comparatively few subjects met diagnosticcriteria for abuse and dependence disorders for substances other thanalcohol and tobacco (1.3%–5.3%), and no subject met criteria for a12-month opiate disorder. With the exception of opiate disorders, therates of substance disorders were higher for all substances in thissample than in the general Australian population [33].

Discussion

This study investigated the rates of substance use andsubstance-use disorders in a sample of pathological gam-blers seeking treatment at a specialist gambling treat-ment. Although direct comparison of comorbidity rateswith previous literature is hampered by lack of consist-ency in measurement of substance-use problems, therates of alcohol dependence in this sample appear some-what lower than reported elsewhere in the literature [11].The rate of alcohol abuse in this sample is comparableto the rate of lifetime ‘alcohol problems’ reported byToneatto and Skinner [25]. However, in contrast to theseauthors, who found no differences between males andfemales in lifetime rates of alcohol problems for treat-ment seeking gamblers, the present findings indicatedthat recent or current alcohol-abuse problems are more

Table 1. Self-report estimates for substance use and alcohol problems

Substance Totaln = 75n (%)

Malesn = 48n (%)

Females n = 27 n (%)

Alcohol use* 55 (73.3) 36 (75.0) 19 (70.4)Alcohol (while gambling) 30 (40.0) 5 (52.1) 5 (18.5)Self report of alcohol problem 15 (20.0) 10 (21.1) 5 (18.5)Nicotine use 49 (65.3) 33 (68.8) 16 (59.3)Increase smoke rate while gambling 42 (85.7)

†

29 (87.9)** 13 (81.3)**Cannabis use 10 (13.3) 6 (12.5) 4 (14.8)Amphetamine use 1 (1.3) 1 (2.1) 2 (2.9)Ecstasy use 1 (0.5) 1 (2.1) 0Multi-drug 2 (1.1) 2 (4.2) 0Previous drug and alcohol treatment 4 (5.5) 4 (8.5) 0

* Subjects were rated as ‘using alcohol’ if they indicated that they had consumed more than 12 standard drinks in the last 12 months.

†

Percentage figures expressed as percentage of tobacco smokers not total sample.

Table 2. Rate of DSM-IV substance use disorders

Substance use disorders Totaln = 75n (%)

Malesn = 48n (%)

Females n = 27 n (%)

Nicotine withdrawal 10 (13.3) 9 (18.8) 1 (3.7)Nicotine dependence 28 (37.3) 20 (41.7) 8 (29.6)Alcohol abuse 12 (16.0) 11 (22.9) 1 (3.7)Alcohol dependence 6 (8.0) 5 (10.4) 1 (3.7)Cannabis abuse 4 (5.3) 4 (8.3) 0 (0.0)Cannabis dependence 4 (5.3) 3 (6.3) 1 (3.7)Amphetamine abuse 1 (1.3) 1 (2.1) 0 (0.0)Inhalant abuse 1 (1.3) 1 (2.1) 0 (0.0)

414 COMORBID SUBSTANCE USE AND GAMBLING

prevalent among male treatment seeking pathologicalgamblers than females.

There is little data on rates of comorbidity betweengambling and substances other than alcohol. It is there-fore difficult to make comment on the rates of non-alcohol substance disorders observed in this study withrates found in other settings. Compared to available datait appears that rates of non-alcohol problems were alsolower in the current sample than previous literature.For example, while high rates of comorbidity betweengambling and opiate use have been reported elsewhere[24], no participant in this sample reported opiate useduring the 12 months prior to assessment. Rates ofsubstance use and substance-use disorders were alsolower than reported by Toneatto and Skinner [25].

These differences between rates of comorbidity foundin this sample and in previous research may reflectactual differences in comorbidity of substance use andgambling across the different settings. Pathological gam-blers in treatment may not be representative of the totalpopulation pool of gamblers with problems with lessthan 10% of ‘cases’ identified in community-basedsamples reporting that they received treatment [1]. Patho-logical gamblers in treatment represent the more severeend of the spectrum of gambling and exhibit higher ratesof psychopathology, notably antisocial personality disor-der, mood and anxiety disorders [34,35]. In the currentsample, participants were attending a specialized gamb-ling treatment clinic. Many of the previous studies havebeen undertaken in veteran administration drug andalcohol treatment centres. However, as there has beenlittle consistency in the constructs that have been meas-ured in the literature, higher rates found in previousstudies may reflect less stringent assessment criteria orless ‘serious’ categories of substance use, for example,abuse versus dependence.

Although rates of substance-use problems were lowerin this sample than found in previous studies, they werehigher than found in the general Australian population[33]. This finding supports previous research suggestingthat pathological gamblers may be at higher risk fordeveloping substance-use problems than the general pop-ulation. However, research into the relationship betweengambling and substance misuse is in its infancy and thecausal relationship between gambling and alcohol andother drug use remains at best a complex and littleunderstood issue. The literature to date has focusedmainly on identifying comorbidity rather than offeringconceptual models explaining its aetiology.

Pathological gambling is conceptualized as an addic-tive disorder on the grounds that it exhibits many phe-nomenological similarities to substance-abuse disorders.Without entering into any discourse on the validity of the

addiction model of pathological gambling, a number ofexplanations for the association between gambling andsubstance use can be offered without necessary referenceto the presence of an inherent underlying addiction pro-cess. It could be argued on the basis of joint probabilitiesthat poker-machine gambling and alcohol coexist insome individuals simply because both are offered in thesame licensed venues. This increases the chance thatgamblers will be exposed to opportunities for alcoholconsumption, and alcoholics to gambling behaviour.Alternatively, alcohol may be used by the gambler as away of coping with the guilt and depression following abig loss, or an alcohol user may use gambling as a meansof trying to win money to buy alcohol [18]. Furtherresearch is needed to investigate these issues.

Identifying comorbidity is not only of conceptual andtheoretical importance. Recognizing and assessing theassociation between gambling and substance use is alsoimportant from a clinical standpoint as empirical evi-dence is emerging to suggest that alcohol use and gamb-ling is interrelated and that comorbidity places anindividual at greater risk for relapse [18]. Within gamb-ling sessions, alcohol is known to impair rational judge-ment and control and increase risk-taking among gamblers[23]. Baron and Dickerson [28] found that the ingestionof alcohol prior to gambling reduced resistance to beginand end a session of gambling, while Kyngdon andDickerson [29] demonstrated that even in regular uses asmall amount of alcohol during a session prolonged theduration and intensity of gambling. Alcohol use maythus precipitate a gambling lapse in a pathological gamblerby impairing judgement, increasing risk-taking and self-confidence in their ability to control their gambling.Alternatively persistence at gambling after cessation orcontrolled alcohol consumption may precipitate family,work, financial and/or emotional problems, that may inturn trigger a return to drinking, particularly where gam-bling is undertaken in a licensed venue.

Despite the potential impacts, current evidence indi-cates that many problem gamblers are not receivingassistance for concurrent substance problems [1] andmany substance abusers are not being routinely assessedfor the presence of a comorbid pathological gamblingdisorder [18]. Screening for gambling problems shouldbe included in standard approaches in the assessment ofsubstance users and appropriate interventions offered toidentified cases of problem gambling.

Acknowledgements

Financial assistance for this project was provided bythe NSW government from the Casino CommunityBenefit Fund.

F. MACCALLUM, A. BLASZCZYNSKI 415

References

1. Productivity Commission.

Australia’s gambling industries.

Draft report. Canberra: Commonwealth of Australia, July 1999.

2. Jacobs D. A general theory of addictions: a new theoretical model.

Journal of Gambling Behavior

1986; 2:15–31.3. Custer RL. Gambling and the addictions. In: Craig R, Baker S,

eds.

Drug dependent patients: treatment and research.

Springfield, Ill: Thomas, 1982:367–381.

4. Ferris J, Wynne H, Single E.

Measuring problem gambling in Canada.

Draft final report of the Inter-provincial task force on problem gambling. Edmonton: Canadian Centre on Substance Abuse, 1998.

5. Peele S. Is gambling an addiction like drug and alcohol addiction? Developing realistic and useful conceptions of compulsive gambling.

Electronic Journal of Gambling Issues

(serial online) [cited 3 February 2001.] Available from URL. http://www.camh.net/egambling

6. Shaffer HJ. The most important unresolved issue in the addictions: conceptual chaos.

Substance Use and Misuse

1997; 32:1573–1580.

7. Abbott M, Volberg R.

Gambling and problem gambling in New Zealand.

A report on phase one of the national survey. Wellington:

Wellington Department of Internal Affairs

, 1991.8. Dickerson M, Allcock C, Blaszczynski A, Nicholls B, Williams R,

Maddern R.

An examination of the socio-economic effects of gambling on individuals’ families and the community including research into the costs of problem gambling in New South Wales.

Sydney: University of Western Sydney (Macarthur), Australian Institute of Gambling Research, 1995.

9. Becona E. The prevalence of pathological gambling in Galicia (Spain).

Journal of Gambling Studies

1993; 9:353–370.10. Ciarrocchi J, Richardson R. Profile of compulsive gamblers in

treatment: update and comparisons.


1989; 5:53–65.

11. Lesieur HR, Blume SB. Evaluation of patients treated for pathological gambling in a combined alcohol substance abuse and pathological gambling treatment unit using the addiction severity index.

British Journal of Addiction

1991; 86:1017–1028.12. Ramirez LF. Patterns of substance abuse among pathological

gamblers undergoing treatment.

Addictive Behaviors

1983; 8:425–428.

13. McCormick RA, Russo AM, Ramirez LF, Taber JI. Affective disorders among pathological gamblers seeking treatment.

American Journal of Psychiatry

1984; 141:215–218.14. Rosenthal RL, Lesieur HR. Self-reported withdrawal symptoms

and pathological gambling.

American Journal on Addictions

1992; 1:150–154.

15. Lesieur HR.

The chase.

Rochester, VT: Schenkman, 1984.16. Ladouceur R, Boisvert J-M, Pepin M, Loranger M, Sylvian C.

Social cost of pathological gambling.


1994; 10:399–409.17. Lesieur HR, Blume SB, Zoppa RM. Alcoholism drug abuse and

gambling.

Alcoholism. Clinical and Experimental Research

1986; 10:33–38.

18. Spunt B, Dupont I, Lesieur H, Liberty HJ, Hunt D. Pathological gambling and substance misuse: a review of the literature.

Substance Use and Misuse

1998; 33:2535–2560.

19. Lesieur HR, Heineman M. Pathological gambling among youthful multiple substance abusers in a therapeutic community.

British Journal of Addiction

1988; 83:765–771.20. Lejoyeux M, Feuche N, Loi S, Solomon J, Ades J. Study of

impulse control disorders among alcohol dependent patients.

Journal of Clinical Psychiatry

1999; 60:302–305.21. Ciarrocchi J. Severity of impairment in dually addicted

gamblers.

Journal of Gambling Behaviour

1987; 3:6–26.22. Shepherd RB. Clinical obstacles in administering the South Oaks

gambling screen in methadone and alcohol clinic.


1996; 12:21–32.23. Daghestani A, Elenz E, Crayton JW. Pathological gambling in

hospitalised substance abusing veterans.

Journal of Clinical Psychiatry

1996; 57:360–362.24. Hall G, Carriero NJ, Takushi RY, Montoya ID, Preston KL,

Gorelick DA. Pathological gambling among cocaine-dependent outpatients.


2000; 157:1127–1133.

25. Toneatto T, Skinner W. Relationship between gender and substance use among treatment-seeking gamblers.

Electronic Journal of Gambling Issues

(serial online) [cited 1 March, 2000.] Available from URL: http://www.camh.net/egambling/research/index.html

26. Lesieur HR, Blume SB. The South Oaks gambling screen: a new instrument for the identification of pathological gamblers.


1987; 144:1184–1188.27. Cunningham-Williams R, Cottler LB, Comptom WM,

Spitznagel EL. Taking chances: problem gamblers and mental health disorders. Results from the St Louis epidemiological catchment area study.

American Journal of Public Health

1998; 88:1093–1096.

28. Baron E, Dickerson M. Alcohol consumption and self-control of gambling behaviour.


1999; 15:3–16.

29. Kyngdon A, Dickerson M. An experimental study of the effect of prior alcohol consumption on a simulated gambling activity.

Addiction

1999; 94:697–707.30. American Psychiatric Association.

Diagnostic and statistical manual

, 3rd edn. Washington, DC: American Psychiatric Association, 1994.

31. World Health Organization.

Composite international diagnostic interview – auto 2.1.

Geneva: WHO, 1997.32. Australian Institute of Health and Welfare.

1998 national drug strategy household.

First results. AIHW cat no. PHE15 drug statistic series. Canberra: Australian Institute of Health and Welfare, 1999.

33. Andrews G, Hall W, Teeson M, Henderson S.

The mental health of Australians.

Canberra: Commonwealth Department of Health and Aged Care, April 1999.

34. Slutske WS, Eisen S, Xian H

et al.

A twin study of the association between pathological gambling and antisocial personality disorder.

Journal of Abnormal Psychology

2001; 110:297–308.

35. Crockford DN, el-Guebaly N. Psychiatric morbidity in pathological gambling: a critical review.

Canadian Journal of Psychiatry

1998; 43:43–40.

pathological gambling and comorbid substance use

Documents