Problem Gambling Treatment

The future arrives!

Sean Sullivan PhD

ABACUS

Current challenges for all addictions

• Alcohol abuse and resistance to legislate

• Smoking – risking international sanctions and penalties because of „free trade‟ conflicts with public health

• Legal „party‟ drugs – some initiatives but uncertain outcomes regarding proof of harm and levels for e.g. synthetic cannabis

• Internet addiction – what is „normal‟ use? Longer use becoming the norm

• Gambling – some controls but technology challenges, social acceptance, and attractive taxation source – uncertain growth in problems

PG differences to AOD

• A relatively „pure‟ behavioural addiction (no external drug influence) – often perception the addiction due more to choice

• The reinforcer is a general reinforcer (e.g. money, praise) – it is resistant to satiation

• Solution to problems arising from the behaviour may include continuation in the behaviour (has a built in solution i.e. a win!)

• Money is a powerful reinforcer that most people want (drugs perhaps less so) – gives choice, respect, safety, peace of mind, hope……….

• PG may be less likely to seek help

The old days

• Gambling semi-controlled under Gaming & Lotteries Act 1977

• Lotto introduced 1987

• Gambling machines existed, but not recognised under the Act – became „legal‟ in 1988

• No casinos pre 1994– Committee of Enquiry into casinos 1988-1989

• First casino opens 1994, by 2003, a total of 6 casinos open

Into the new era

• 2003 Gambling Act – no NZ Internet

gambling except Lottery & racing/sports

• Online betting – Racing Board monopoly on

racing and sports betting or Lotto

• Internet gambling – allowed if based

overseas

• Technology and accessibility the challenge –

can be accessed 24 hrs a day

Global online gambling growth Ferguson 2012

Mobile gambling growth

• UK – 20% wagers are via online mobile devices

• Now in NZ: In play betting can prompt gambling– „next try/yellow card?‟

• Estimated world-wide growth of gambling via mobile devices will increase from the $20B in 2011 to $100B in 2017

Juniper Research (May 2012)

An important income

resource for governments

• Because gambling is a substantial source of duty/tax, a large employer, and is part-owned by the state (Lotto), conflict of interest may be perceived when gambling expansion/reduction

• NZ Gambling Act – no „for profit‟ gambling permitted other than casinos

• Monopoly on Internet gambling in NZ given to Lottery Commission and Racing Board

• In Australia, 11% (average) of all State income is raised from gambling

But is problem gambling reducing? Some suggest problem gamblers „adapt‟ &

reduce their harm

The case for PG reducing

„While far from certain, problem gambling

prevalence rates appear to have fallen

somewhat. It is unclear how much this

reflects natural adaptation or the impact of

government policy, though both are likely

to have contributed‟ Productivity Commission 2009

But…..

• The Productivity Commission also

comments

– „Given (the wide influences on PG) reductions

are unlikely to continue without environmental

changes‟

From exposure to adaptation contagion disease model applies?

LaPlante & Shaffer, 2008

The adaptation model

• The assumption that people adapt to novel

forms of gambling, much like a contagion

disease model reacts to an epidemic, may

not apply to an addiction

• If people adapted to gambling machines, one

would expect at least this to occur within a

decade. Between 1988 – 2008 in NZ, no

such adaptation occurred demonstrated by

reduced gambling machine spending (for

same number of machines)

What would we expect if adaptation true?

Less spent on gambling

But assumes due to gambling reducing • The larger proportion (non-problem gamblers) may

be more likely to reduce discretionary spending especially in a recession

• Problem gamblers increase their problems/gambling when under stress (DSM)

• Reduction in amount spent may mask increased problem gambling spending – especially if those financially disadvantaged increase and this group are known to be at higher risk for PG (e.g. during a recession)

Less spending not necessarily reduced

PGs hypothetical example

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Is gambling participation reducing?

Perhaps…

• Abbott et al (1991) – 90% gambled in last 6 months

• Abbott et al (2000) – 87% gambled in last 6 months

• NZ Health Survey 2006/7 – 65% gambled in last 12 months

• Spending in NZ on gambling has remained relatively constant at $2B from 2004-2008

• Is spending per capita increasing (if participation is reducing) or people‟s perception of their gambling, or not, flawed?

Hard to measure means uncertainty

• But gambling losses over time is a blunt tool

• Productivity Commission (Australia) estimates

40% total losses on gambling machines and

20% from moderate problem/at risk gamblers

• May mask the possibility that „controlled‟ or non-

problem gamblers do reduce their gambling

during a recession while problem gamblers may

increase their gambling as stress increases (a

recognised influence)

Losses constant during recession (excluding Internet gambling)

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EGM loss ($M) All gambling loss ($M)

Adaptation – do PGs adapt? The Victorian Gambling Study 2011

• N=5003

• Surveyed in 2008 and again 2009 (repeat) using a gambling screen that identified levels of PG: – NT=not a gambler

– NPG= a gambler but not a problem gambler

– LR=low risk for problem gambling

– MR=moderate risk for problem gambling

– PG=problem gambler

• Findings: – 5.6% of gamblers increased their risk for PG

– 4.3% decreased their risk

– PGs were, with Non-PGs, the most stable categories

Transitions between PGSI groups Wave One to Wave Two (n=5003)

The Victorian Gambling Study 2011

But assumption in surveys is that

responders are telling the truth

If data is suspect, can we rely on

prevalence rates or „adaptation‟?

• As only 29% of problem gamblers reported in the 1999 Australian Productivity Commission report stated they would tell the truth about their gambling, surveys specifically on gambling probably strongly under-estimate, and may vary over time

A.C. Nielsen NSW Survey 2007

Some considerations

• Productivity Commission also states:

„the share of spending accounted for by PGs

appears to be very high – with no apparent

downward trend‟

• Higher risks with those with little disposable

income – many within this population

spending all their non-disposable income may

not result in increases in total gambling

losses

The future?

• Problem gambling in its most severe form is

both chronic and persistent

• Many factors suggest increased, rather than

reduced, gambling problems in the future

– New generation gambling machines,

– „improvement‟ in internet gambling sites,

– greater competition between modes of gambling

(e.g. Lotto more often, larger prizes), and

– greater accessibility due to electronic advances

But gambling technology improves

too so difficult to compare years

The total amount lost per poker machine (in

Australia) has risen fivefold from $19,600

in 1992-93 to $101,100 in 2008-09

The Age, July 2012

A hidden, difficult to measure, but

resilient addiction

• Prevalence measures used vary (and no

gold standard)

• Problem gambling is „persistent and

recurrent‟ and almost all prevalence studies

for PG are snapshots rather than

longitudinal assessments

• Stigma high, visual symptoms low or

ambiguous, may mean under-identified

PG prevalence in NZ: stable?

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clie

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F to F intensive F to F all clients Gambling Helpline

PGs are reluctant help-seekers 2011/2012

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New

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Brief intervention Received both Full intervention

Internet gambling The future risk?

Internet gambling

• Online gambling sites typically see

revenues of $300 per paying user

per month

• Asia-Pacific online gambling

expected to grow from $(US)34.4B

to $(US)79.3B in the next few years PriceWaterhouseCooper

Exposure to technology – Internet

Gambling

• Although internet gambling has been available for at least a decade, few problem gamblers present to services with this problem mode

• 2011 Gambling Helpline n=21 clients with Internet gambling problems;

• NZ face to face doesn‟t code by Internet until mid 2012

Reasons for low Internet PG

presentation

• Internet gambling not conducted in a public venue – little harm minimisation controls enforced, less overview (hidden)

• Most clients present under some pressure – PG identified by gambling venue and excluded –

access to services a requirement for re-admission to venue

– Others note the excessive gambling and motivate PG to access treatment

• Remember: few PGs seek help and may be influenced by hope of winning their way out of financial problems

Reasons for low Internet PG

• In past gambling may have been hampered by

– Low Internet speed and/or insufficient computer

power (slow, low level graphics)

– Uncertainty around honesty or reliability of process

– Fear of complexity of the Internet

• Now

– High speed and computer power widely available

– Familiarity with Internet (especially youth)

– New „gaming‟ without money widely accessible and

introduces new Internet gamblers to the process

– Cross-over opportunities between gaming & gambling

Monthly online gambling by 18-22yr olds

Annenberg Survey: U Pennsylvania 2010

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% a

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Males

Females

Internet gambling here

• Health Sponsorship Council 2011: 8.7% of New Zealanders had gambled online in last 12 months (2% overseas sites balance Lotto-Racing-Sports NZ sites)

Press Release

“Proposals to increase internet speed and capacity, patterns of online gambling in overseas jurisdictions and increasing use of online payment methods all combine to suggest that NZ might be approaching a tipping point”

“How do you stop people, in the privacy of their own home, accessing gaming sites?”

Assoc Minister of Health 11th August 2012

Growing concern

• “There is a huge flood of new gamblers (2% population currently addicted)…some 100,000 more Swedes become addicted to gambling each year…women most likely to be addicted, with slot machines and online games being the most common”

Swedish National Institute of Public Health August 2012

But this could only be the beginning -growth areas for gambling are online

a) Mobile gambling

b) Social gambling sites

Growth in online gambling -Australia

• “Betting on Australia‟s two largest football codes is set to double over the next 5 years driven by strong growth in online gambling on sports”

Deloites

• “Mobile gambling is the biggest shift in online gambling, greater than offline to online. Tabcorp says 20% of their online revenue is through mobile…Sportsbet revenue is up 241% in the last year and 40% use their mobile to place bets”

Dr Sally Gainsbury, Centre for Gambling Education Research, Southern Cross University

Growth in online gambling

• Paddy Power is launching social media

gambling and mobile casino products

following a record year (up 47% in Australia,

79% Eire, online up 36%)

• New online forms of online gambling payment

solutions enable confidential bank to casino

transfers (UseMyFunds) in addition to many

other such as Visa and Mastercard

Social gaming sites targeted

• “Convergence of casino gaming and social media will be „the next big thing‟ in our industry”

Chairman MGM Resorts

• Will ellipse all land-based casinos in USA

• 800 million users (20 times Las Vegas tourists)

Earning Power of Zynga Poker

In July 2012, Zynga announced that it will be

providing real-money gaming outside of United

States in 2013

In July 2012 Zynga's games had over 306

million monthly active users

Listed on the American Stock Exchange

Zynga has quarterly revenue earnings in

excess of US$300 million and is experiencing

annual growth of 19 percent annually

The mobile version of the game is available in

18 languages

7 of top 20 Facebook earners Gambling Apps “Play and challenge your friends to fun and addicting games..”

Ranking $ Game Players

1 Zynga Texas HoldEm

Poker

33 million

4 DoubleDown Casino 4.8 million

7 Slotmania 6.2 million

11 Games by GSN 4.3 million

13 Zynga Slingo 12 million

17 Best Casino 1.6 million

19 Zynga Bingo 5.5 million

Zynga – Buy Chips – 50% off !

Zynga “this game requires 800,000 chips to join”

Zynga – Buy Chips – Prepaid Cards

Online Poker the player has $390, the Queen of Spades and the 10 of Hearts,

they call the game to start with $4

So what are we going to do?

Lets not be reactive or do nothing

But we can do something

• May be hard to control access to the Internet

But can:

• Increase education of gambling risk (very little public education currently)

• Can increase research into risk areas

• Can provide interventions online

• Can consider novel online approaches to therapy

Using technology in treatment

• Stage 1: phone counselling, manuals for self-

directed programmes

• Stage 2: text counselling, email counselling

• Stage 3: counselling with Skype & others, smart

phones/tablets, - mobile counselling

• Stage 4: virtual world/avatar programmes, more

self-directed on-line programmes, stepped

programmes, increased mobile counselling

PGs may prefer self-directed help

• N=106 affected by PG and/or PTSD (commonly coexists with treatment seeking PGs -12.5%-29%) were recruited from the community and asked their treatment preferences

• Treatment preferences for (only) PG identified that the preferred therapy was self-help, while (only) PTSD preferred psychotherapies – coexisting also preferred psychotherapies

Gainsbury & Blaszczynski (2011a)

Internet may be both problem &

solution!

• Internet-based treatment may better meet the needs of some PG clients because

– May increase uptake & retention

– Enquiries can be less stressful

– CBT & MI easily adapted

– Cost effective

– Accessibility, especially when geographical/time restraints

Gainsbury & Blaszczynski (2011a)

Some support for this

• Small numbers of PGs seek formal treatment

• Review of 24 randomised Internet health/mental health programmes identified these have equal to or greater effectiveness than face-to-face therapy

• Some therapist interaction in online programmes indicated some greater effectiveness but mixed

• Younger PGs may relate better to online therapy

• Concluded: online PG programmes an alternative rather than a replacement for face to face therapy and an adjunct for those waiting for or exiting treatment

Gainsbury & Blaszyznski (2011b)

Proteus effect: Patricia & Baji

The future

• More than any other addiction (with the possible exception of pornography addiction), problem gambling is, and will be even moreso in the future, be impacted by technology

• Even if there is an underlying common substrate for addictions, and only objects may differ (such as alcohol, other drugs, pornography, compulsive buying, and problem gambling), treatment is often driven by these differences

• Adaptation, if alive and well, may provide an answer in the long term but still require a focus on minimising harm during the short-term duration of problem gambling

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