1. Drugs, Alcohol, and Mental Health: Where and How Does Gambling Fit?
Victor Ortiz, MSW, LADC I, CADC II

2. Disclosure
Neither I nor any member of my immediate family has a financial relationship with commercial entities producing, marketing, re-selling, or distributing health care good or services consumed by, or used on, patients relevant to the content I am presenting.
My content will not include discussion/reference to commercial products or services.
I do not intend to discuss an unapproved/investigative use of commercial products/devices.

3. U.S. Gambling History and Expansion3

4. U.S. Gambling History and Expansion
According to noted gambling law expert I. Nelson Rose, gambling has gone through three waves of expansion in the US.
The first wave of gambling, before the US was founded, was when lotteries were used to finance the settlement of the first colonies.
The second happened during the 1800s when gambling was often tolerated (though not always legal) as we began to “go west.”
And the third wave began when Nevada legalized casinos (again) during the Great Depression in 1931.

5. U.S. Gambling History and Expansion
During the 1930s, 40s, and 50s, several forms of gambling were legalized in various regions of the country. These included horse tracks, charity bingo and other social games.
Then, in 1963, New Hampshire legalized a state lottery. Over the ensuing decade and a half, 11 more states (for a total of 12) legalized lotteries; however, Nevada remained the only state with legalized casino-style gambling until New Jersey began to allow it in Atlantic City in 1976 (with the first casino opening in 1978).
Then, in 1988, the Indian Gaming Regulatory Act (IGRA) was passed by the federal government - See more at:

6. U.S. Gambling History and Expansion
1988- The Indian Gaming Regulatory Act (IGRA) was passed
48 out of 50 states have legalized gambling (Utah, Hawaii)
Gambling revenues in the United States leisure economy in 1996 grossed over $47 billion, which was greater then the combined revenues of almost $41 billion from film box office, recorded music, cruise ships, spectator sports, and live entertainment
According to various reports, over $100 billion dollars per year in total revenue
Then, in 1988, the Indian Gaming Regulatory Act (IGRA) was passed by the federal government - See more at:

7. of new destinations for entertainment and leisure; and the rise of
U.S. and Gambling
Korn & Shaffer noted three primary forces have encouraged the growth of gambling throughout North America: the desire of governments to identify new sources of revenue without invoking new or higher taxes; development by tourism entrepreneurs
of new destinations for entertainment and leisure; and the rise of
new technologies and forms of gambling [e.g., video lottery terminals (VLTs),Powerball TM mega-lotteries, and Internet offshore gambling].
Then, in 1988, the Indian Gaming Regulatory Act (IGRA) was passed by the federal government - See more at:

8. The Field of Gambling Disorders
It was not until 1972 that Dr. Robert Cluster, a physician working at the Veterans' Administration hospital in Brecksville, Ohio, first proposed a clinical entity, which he termed compulsive gambling.
In 1980, the American Psychiatric Association incorporated "pathological gambling" into its diagnostic and statistical manual (American Psychiatric Association, 1980) and thus legitimated this entity within the mainstream mental health field.

9. The Gambling Environment is Evolving
Gambling has become more convenient and accessible.
Gambling is coming out of gambling environments and is converging with other technologies.
Gambling is becoming more anonymous and "asocial”.
Gambling is perceived as an ever more important source of public revenues.

10. Gambling in the U.S.
Approximately 85% of U.S. adults have gambled at least once in their lives; 60% in the past year.
2 million (1%) of U.S. adults are estimated to meet criteria for pathological gambling in a given year.
Another 4-6 million (2-3%) would be considered problem gamblers.

11. The gambling environment is evolving
The 4th Wave
The gambling environment is evolving
Technologies initiatives and creations are growing
Fantasy sports and social games (gaming vs gambling)
Gambling is perceived as an ever more important source of public revenues
Marginalized communities and health disparities
Complexities and association to other related issues
Then, in 1988, the Indian Gaming Regulatory Act (IGRA) was passed by the federal government - See more at:

12. Stores with past Powerball winners lure crowds
Worcester T&G-2013

13. Gambling Disorders and Substance Abuse13

14. National Epidemiologic Survey on Alcohol and Related Conditions
The 2008 NESARC study reported that:
73.2 percent of pathological gamblers had an alcohol use disorder (73.2%)
38.1 percent had a drug use disorder
60.4 percent had nicotine dependence

15. Gambling and Alcohol
Problem gamblers with frequent alcohol use have greater gambling severity and more psychosocial problems resulting from gambling than those without alcohol use histories.
Adolescents who are moderate to high frequency drinkers are more likely to gamble frequently than those who are not. (Grant, Potenza, etal, 2010)
For individuals with alcoholism and gambling disorders, addressing both problems simultaneously leads to better outcomes. (Hodgins and el-Guebaly, 2002)

16. Gambling and Opioid
The prevalence of opioid abuse worldwide is 0.4%, while the standardized problem gambling prevalence rate varies from 0.5% to 7.6%.
Among misusers, however, the prevalence of GD is considerably higher varying from 8% to 21% and even higher (17% to 27%) among patients in methadone maintenance treatment (MMT).

17. Gambling and Drugs
Research indicate that cocaine-addicted individuals are nearly two times more likely to have serious gambling problems than those who are not cocaine-dependent.
Cocaine may artificially inflate a gambler’s sense of certainty of winning and skill, contributing to increased risk behaviors.
Pathological gamblers may use cocaine to maintain energy levels and focus during gambling and sell drugs to obtain gambling money.
Research also suggests a positive correlation between methamphetamine abuse and pathological gambling.

18. Pathological Gambling & Drug and Alcohol Disorders
Common features between pathological gambling and drug and alcohol use disorders
Failure to resist an impulse, drive, or temptation that is harmful to the person or to others.
Onset in adolescence and young adulthood – more men than women.
Occurrence of an urge or craving state prior to initiating the behavior.

19. Pathological Gambling & Drug and Alcohol Disorders
Resulting “high” – need to increase the intensity of the behavior to achieve the same high.
Financial and marital problems.
Criminal behavior to fund addictive behavior or cope with consequences of it.
Source: Grant, J.E. J.D. Potenza, M. MD, Weinstein, A. PhD., Gorelick, D. MD, PhD. (2010) The American Journal of Drug and Alcohol Use, Early Online DOI: /

20. Neurological Similarities between Gambling & Drug and Alcohol Abuse
Multiple neurotransmitter systems are implicated in the pathophysiology of behavioral addictions and substance use disorders.
Serotonin and dopamine, in particular, may contribute to both sets of disorders.
Serotonin is involved with inhibition of behavior.
Dopamine is involved with learning, motivation, stimuli, and rewards.
Alterations in dopaminergic pathways in the brain are thought to underlie reward-seeking (gambling, drugs, alcohol) that triggers the release of dopamine and produces feelings of pleasure.
Source: Grant, J.E. J.D. Potenza, M. MD, Weinstein, A. PhD., Gorelick, D. MD, PhD. (2010) The American Journal of Drug and Alcohol Use, Early Online 1-9. DOI: /

21. Gambling Disorders: DSM-5
In May the DSM 5 was issued.
It moved what was called Pathological or Compulsive gambling from Impulse control Disorders under Substance Related and Addictive disorders– Non-Substance Related Disorders and now refers to it as Gambling Disorders.
Officially changing the name to “Gambling Disorder” is a welcome revision for many researchers and clinicians who have expressed concern that the label “pathological” is a pejorative term that only reinforces the social stigma of being a problem gambler.
It is the sole behavioral addiction in the new DSM. The words pathological and compulsive can no longer be diagnostically used to describe problem gambling
This give providers a better chance to diagnose PG

22. DSM-5 Reclassification of Gambling
Contains significant changes to “Substance-Related and Addictive Disorders”.
Places “Gambling Disorder” in “Substance-Related and Addictive Disorders”, under “Non- Substance-Related Disorders”
Change reflects research findings that indicate that GD is similar to substance-related disorders in clinical expression, brain origin, comorbidity, physiology, and treatment.

23. DSM-5 Reclassification of Gambling
Placement in “Substance-Related and Addictive Disorders” could open the door to coverage under MH/SUD-related provisions of health reform.
Improve diagnostic accuracy and screening efforts.
Support more appropriate treatment and services.
Facilitate integration/bundling of services and payment processes with MH/SUDs services and primary care (e.g., SBIRT).
Increase public health awareness, and raise visibility among health care providers, insurers, and policy makers.
Accelerate research and development of more robust, evidence-based practices.

24. Gambling Disorder and DSM-5
According to DSM-5 criteria, gambling is considered a persistent and recurrent problematic gambling behavior leading to clinically significant impairment or distress, as indicated by the individual exhibiting four (or more) of the following in a 12-month period:
The chapter also includes gambling disorder as the sole condition in a new category on behavioral
addictions. DSM-IV listed pathological gambling but in a different chapter. This new term and its location in the new manual reflect research findings that gambling disorder is similar to substance-related
disorders in clinical expression, brain origin, comorbidity, physiology, and treatment.
Recognition of these commonalities will help people with gambling disorder get the treatment and
services they need, and others may better understand the challenges that individuals face in overcoming this disorder.
While gambling disorder is the only addictive disorder included in DSM-5 as a diagnosable condition,

25. Gambling Disorder DSM-5 Criteria
Needs to gamble with increasing amounts of money in order to achieve the desired excitement
Is restless or irritable when attempting to cut down or stop gambling
Has made repeated unsuccessful efforts to control, cut back, or stop gambling
Is often preoccupied with gambling (e.g., having persistent thoughts of reliving past gambling experiences, handicapping or planning next venture, thinking of ways to get money with which to gamble).
Often gambles when feeling distress (e.g., helpless, guilty, anxious, depressed).
Internet gaming disorder will be included in Section III of the manual. Disorders listed there require
further research before their consideration as formal disorders. This condition is included to reflect the
scientific literature on persistent and recurrent use of Internet games, and a preoccupation with them,
can result in clinically significant impairment or distress. Much of this literature comes from studies in
Asian countries. The condition criteria do not include general use of the Internet, gambling, or social
media at this time.

26. Gambling Disorder DSM-5 Criteria Cont.
After losing money gambling, often returns another day to get even (“chasing” one’s losses).
Lies to conceal the extent of involvement with gambling.
Has jeopardized or lost a significant relationship, job, or educational career opportunity because of gambling.
Relies on others to provide money to relieve desperate financial situations caused by gambling.

27. A Clinical Perspective
People with gambling disorders are hesitant to enter treatment.
None of the participants in the National Comorbidity Survey Replication (Kessler & Merikangas 2004) with a PG diagnosis ever received treatment for a gambling problem; however, 49% were treated for other mental disorders (Kessler et al. 2008).These studies indicate that about half of the PGs received treatment for other psychiatric disorders. However, neither they nor their treatment providers recognized that their disordered gambling required treatment 27

28. Screening Tools SOGS-South Oak Gambling Screen
MAGS- Massachusetts Gambling Screen
Lie/Bet Screening Tool
BBGS- Brief Biosocial Gambling Screen 28

29. Screening Tools LIE/BET
Have you ever felt the need to bet more and more money?
Have you ever had to lie to people important to you about how much you gamble?
Gambling disorders can be hard to spot. What is working for some clinicians is including this 2 questions screening in psychosocial or on intake forms. I have a stack of these – I bring them to every agency I go to. Clinicians I have talked to put them in the waiting room – along with the 4 question version – and find they disappear.

31. Ranked Treatment Interventions
Strong Evidence
·    Cognitive Behavioral Therapy
·    Behavioral Therapy
Moderate Evidence
·     Relapse Prevention
Weak Evidence
·     Psychodynamic Psychotherapy
·     Self Exclusion
·     Gamblers Anonymous
GA studies report first year: dropouts rates as high as 70% (Stewart & Brown, 1988)
abstinence rates of 8% (Brown, 1985).
Rosenthal and Rugle provide clinicians and interested readers with a comprehensive review and treatment approach for gambling problems based on psychodynamic principles (Rosenthal, 1997; Rosenthal & Rugle, 1994).
(Rosenthal, 1997; Rosenthal & Rugle, 1994).

32. Gambling and Mental Health32

33. National Epidemiologic Survey on Alcohol and Related Conditions
The 2008 NESARC study reported that:
49.6 percent had a mood disorder,
41.3 percent had an anxiety disorder,
60.8 percent had a personality disorder.

34. Gambling and Mood Disorders
The major mood disorders include major depression and mania, plus milder versions of each.
Not the usual “ups-and-downs” or occasional “blues” that we all experience as part of life.
Forms of a “chemical imbalance” that result for various biological and/or environmental reasons 34

35. What comes First, PG or Other Disorder?
PG First
Other Disorder First
Onset at Same Time
Any Mood Disorder*
23%
65%
12%
Any Anxiety Disorder*
13%
82% 5%
Any Impulse Control Disorder
100%
Any SUD*
36%
57% 6%
* These disorders more common among PGs compared to rest of US population
© Source: Henry Lesieur (2014, March). Using best practices in treatment of dual diagnosis and pathological gambling. Workshoppresentation to 2014 Problem Gambling Conference: “Ohio’s Response to aChanging Landscape.” Columbus, Ohio.

36. Gambling Disorders and Suicide
The DSM-5 states that up to half of individuals in treatment for a gambling disorder have suicidal ideation and about 17% have attempted suicide.
According to the World Health Organization, factors such as mood disorders, stressful life events or circumstances and a history of physical or sexual abuse in childhood put people at increased risk for harming themselves (World Health Organization, 2002). All of these factors are common among those experiencing problems related to gambling.
1 in 5 – higher than any other addictive disorder;
DSM 5 says up to half of individuals in treatment have had suicide ideation.
And about 17% have attempted suicide.
I work closely with suicide Prevention agencies to get this information out so they are aware of this high rate and can recognize and PG and refer them to our Helpline. 36

37. Medical Problems Among Pathological Gamblers
Depression
Intestinal Disorders
Cardiovascular Problems
High Blood Pressure
Migraines
Stress-related Disorders
Allergies
Respiratory Problems
Oral-Dental Disease
Nerve-Sensory System Disorders

38. A Public Health Perspective
Problem Gambling:
A Public Health Perspective 38

39. Gambling and Public Health
Gambling studies has predominantly focused on the individualized characteristics of problem gamblers; there is an increase interest in exploring gambling from a public health perspective. 39

40. Gambling and Public Health
Contemporary public health perspectives are not limited to the biological and behavioral dimensions related to gambling and health, but also can address socioeconomic determinants such as income, employment, and poverty.
A public health view point can lead to the design of more comprehensive and effective strategies for preventing, minimizing, and treating gambling- related pathologies and encourages public policy makers to distinguish acceptable from unacceptable risks. 40

41. Gambling and Public Health
It promotes an epidemiological examination of gambling and gambling- related disorders to better understand the distribution and determinants of gambling as well as the factors that influence a transition to disordered states 41

42. Range of Gambling Problems Range of Interventions
Framework for Public Health Action
Range of Gambling Problems
none
mild
moderate
severe
Non
Gambling
Healthy
Gambling
Unhealthy
Range of Behaviors
intensive
Treatment
brief
Harm Reduction
Health Promotion
Primary prevention
Secondary prevention
Tertiary prevention
Range of Interventions

43. Mental Health/ Addiction
Gambling
Mental Health/ Addiction

44. Mental Health/ Addiction Social Determinants of Health
Gambling
Mental Health/ Addiction
Social Determinants of Health

45. Social Determents of Health

46. Social Determents of Health
The social determinants of health are the conditions in which people are born, grow, live, work and age. These circumstances are shaped by the distribution of money, power and resources at global, national and local levels

47. 1 in 5 – higher than any other addictive disorder;
DSM 5 says up to half of individuals in treatment have had suicide ideation.
And about 17% have attempted suicide.
I work closely with suicide Prevention agencies to get this information out so they are aware of this high rate and can recognize and PG and refer them to our Helpline. 47

48. Social Determents of Health
Economic Stability
Poverty
Employment
Food Security
Housing Stability
Education
High School Graduation
Enrollment in Higher Education
Language and Literacy
Early Childhood Education and Development
Social and Community Context
Social Cohesion
Civic Participation
Discrimination
Incarceration
Health and Health Care
Access to Health Care
Access to Primary Care
Health Literacy
Neighborhood and Built Environment
Access to Healthy Foods
Quality of Housing
Crime and Violence
Environmental Conditions

49. In 2012, 26% of Boston children ages 0-17 lived in households where their parent/caregiver felt that his or her child was unsafe in their neighborhood. Higher percentages of Asian, Black, and Latino children compared to White children lived in households where their parent/caregiver felt his/her neighborhood was unsafe.
*Health of Boston :Boston Public Health Commission Research and Evaluation Office Boston, Massachusetts 2015

50. Victor Ortiz, MSW, LADC I, CADC II
Thank You
Victor Ortiz, MSW, LADC I, CADC II 50

51. Work Cited
American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th ed. Arlington, VA: American Psychiatric Publishing; 2013
Castrén et al.: Past-year gambling behaviour among patients receiving opioid substitution treatment. Substance Abuse Treatment, Prevention, and Policy :4.
Grant, J.E. J.D. Potenza, M. MD, Weinstein, A. PhD., Gorelick, D. MD, PhD. (2010) The American Journal of Drug and Alcohol Use, Early Online 1-9. DOI: /
Grant JE, Potenza MN. Commentary: illegal behavior and pathological gambling. J Am Acad Psychiatry Law. 2007;35(3):302–305.
Howard J. Shaffer, PhD, CAS, Debi A. LaPlante, PhD, Richard A. LaBrie, EdD, Rachel C. Kidman, BA, Anthony N. Donato, MPP, and Michael V. Stanton, BA; Toward a Syndrome Model of Addiction: Multiple Expressions, Common Etiology, Harv Rev Psychiatry 2004;12:367–
Kessler, R. C., Hwang, I., Labrie, R., Petukhova, M., Sampson, N. A., Winters, K. C., & Shaffer, H. J. (2008). DSM-IV pathological gambling in the National Comorbidity Survey Replication. Psychological Medicine, 38(9), 1351–1360. doi: /S
Korn D., Shaffer HJ. (1999) Gambling and the Health of the Public: Adopting a Public Health Perspective. Journal of Gambling Studies Vol. 15, No. 4,
Petry, NM, et al. (2005) Comorbidity of DSM-IV pathological gambling and other psychiatric disorders: Results from the national epidemiologic survey on alcohol and related conditions. Journal of clinical Psychiatry. 66:
Petry, NM, et al. (2013). An Overview of and Rationale for Changes Proposed for Pathological Gambling in DSM-5. J Gambl Studies.
Shaffer HJ, Martin R. Disordered gambling: etiology, trajectory, and clinical considerations. Annu Rev Clin Psychol. 2011; 7:
Shaffer HJ, Korn DA. Gambling and related mental disorders: A public health analysis. Annu Rev Public Health. 2002;23:171–212
Shaffer HJ. The most important unresolved issue in the addictions: conceptual chaos. Subst Use Misuse 1997;32:1573–80.
Shaffer HJ. Rethinking addiction: how gambling and other behavioral addictions are changing the concept and treatment of alcohol and substance use disorders. Acad News 2003(2):1,3,7.