1. Copyright Alcohol Medical Scholars Program1 Pathological Gambling and Alcohol Use Disorders Timothy W. Fong MD UCLA Gambling Studies Program Alcohol Medical Scholars Program 2005-2007

2. Copyright Alcohol Medical Scholars Program2 Introduction Lifetime risk –Pathological gambling (PG) ~ 2% –Alcohol use disorders (AUD) 13% PG + AUD –Often co-occur –Worse outcomes

3. Copyright Alcohol Medical Scholars Program3 This lecture will cover Pathological Gambling (PG) Alcohol Use Disorders (AUD) Diagnostic criteria Epidemiology Consequences Screening Risk factors Treatment

4. Copyright Alcohol Medical Scholars Program4 Pathological Gambling

5. Copyright Alcohol Medical Scholars Program5 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)

6. Copyright Alcohol Medical Scholars Program6 Social Gambling Similar in meaning to social drinking 85% of gamblers No negative impacts

7. Copyright Alcohol Medical Scholars Program7 Pathological Gambling Maladaptive use → impairment Preoccupation Lying ToleranceWithdrawal ChasesBailed Out Can’t stopChases losses Illegal ActsGambles to escape

8. Copyright Alcohol Medical Scholars Program8

9. 9 Consequences of Pathological Gambling FinancialAve. debt = $45,000 RelationshipsDivorce, child abuse Time25 hrs/wk CrimeNon-violent Substance use disorders4x risk MedicalWorse health

10. Copyright Alcohol Medical Scholars Program10 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

11. Copyright Alcohol Medical Scholars Program11 Risk Factors Genetic –60% risk Psychological –Impulsive Social –Increased access –Heavy gambling peers

12. Copyright Alcohol Medical Scholars Program12 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

13. Copyright Alcohol Medical Scholars Program13 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

14. Copyright Alcohol Medical Scholars Program14 Treatment: Pharmacotherapy Preliminary evidence –Naltrexone –Selective Serotonin Reuptake Inhbitiors (SSRIs) –Valproic Acid –Lithium

15. Copyright Alcohol Medical Scholars Program15 Alcohol Use Disorders

16. Copyright Alcohol Medical Scholars Program16 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

17. Copyright Alcohol Medical Scholars Program17 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)

18. Copyright Alcohol Medical Scholars Program18 Epidemiology of AUD Lifetime prevalence –Males 15% –Females 8% 15 million meet criteria Economic burden: $155 billion

19. Copyright Alcohol Medical Scholars Program19 Consequences Medical –Cardiovascular: hypertension –Gastrointestinal: fatty liver –Neurological: peripheral neuropathy Work –↑lateness, ↓performance, ↑injury Family –>80% spousal violence

20. Copyright Alcohol Medical Scholars Program20 Screening Alcohol Use Disorders Identification Test Michigan Alcohol Screening Test Lab tests GGT>35 MCV>91.5 CDT>20

21. Copyright Alcohol Medical Scholars Program21 Risk Factors Gender –males > females Genetics –60% risk Co-occurring psychiatric disorders –45% lifetime prevalence Heavy drinking peers

22. Copyright Alcohol Medical Scholars Program22 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

23. Copyright Alcohol Medical Scholars Program23 Psychosocial Treatment Cognitive-Behavioral Therapy –Identify motivations and triggers –Longer in treatment, better outcome Relapse Prevention –Identify risky situations –Develop alternative behaviors

24. Copyright Alcohol Medical Scholars Program24 Treatment: Pharmacotherapy Disulfiram –Efficacy: equivocal Naltrexone –Efficacy: ↓ drinks, ↓ # drinking days Acamprosate – Efficacy: ↑ tx completion and time to first drink

25. Copyright Alcohol Medical Scholars Program25 Pathological Gambling & Alcohol Use Disorders

26. Copyright Alcohol Medical Scholars Program26 PG and AUD More difficult to treat and retain –2x rate of dropout Lower compliance rates Other comorbidities likely More likely to relapse

27. Copyright Alcohol Medical Scholars Program27 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

28. Copyright Alcohol Medical Scholars Program28 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

29. Copyright Alcohol Medical Scholars Program29 Treatment Considerations More data needed Must treat both disorders Get collateral information Periodic drug and alcohol testing Insurances don’t cover PG

30. Copyright Alcohol Medical Scholars Program30 Conclusions PG has serious life consequences PG + AUD = common occurrence Importance of screening Treatments available for both PG and AUD