“The Gambler”

1. “The Gambler”

2. a Gambler?

3. Gambling Brief Intervention & Referral (GBIRT) GBIRTGambling Screening, Brief Intervention & Referral to Treatment

4. Goals of Training • Discuss the connections between gambling and Mental Health &Substance Use Disorders • Learn about the cost of gambling problems to individuals, families and the community • Learn how to open a conversation about gambling with individuals who are being treated for Substance Use Disorders and do primary prevention • Learn how to refer interested individuals to Problem Gambling Treatment

5. Consumer Warning!!!! This slideshow contains subliminal messages

6. Free help for individuals with Gambling Disorder and their families!!!!!!! • STATE WIDE: Call: 1-877-MY-LIMIT Web: www.opgr.org

7. Why Treatment Staff Should Care About Problem Gambling • Individuals who have Substance Use & MH Disorders are the most vulnerable population to develop a future Gambling Disorder. • Research suggests that more gambling = less likely to succeed in MH and SUDs Treatment. • Gambling can be a relapse trigger for alcohol and drugs, and a stressor towards decompensation for MH disorders.

8. Substance use and gambling go hand in hand

9. Social Cost of Gambling Disorder • More ED visits for domestic violence related to gambling than to alcohol (Muellerman et al, 2002) • Suicide rate higher for Gambling Disorder than Alcohol Disorder, although confounded by co-morbidity • In counties where there are tribal casinos 8.6% property crime and 12.6% violent crime attributable to gambling (Grinols, 2006) • Each individual with a Gambling Disorder in U.S. costs (Grinols, 2011): • $4334 a year in crime • $3060 a year in lost productivity and employment costs • $530 a year in social services

10. Connections between Substance Use disorders & Gambling Disorder • 5% - 20% of SUD clients have a gambling disorder, average 15% (Petry, 2014) • The more severe the past year SUD, the higher the prevalence of gambling problems (Rush et al, 2008) • Individuals in medication assisted treatment who have GD twice as likely to drop out early and more likely to have positive UAs for cocaine (Ledgerwood, 2002)

11. Connections between Mental Health Disorders & Gambling Disorder (Zimmerman et al., 2006)

12. Tectonic shift in addictions field DSM-5 and new ASAM Criteria reflect: Gambling Disorder seen as addiction Convergence of SUDs and GD in tx SUDs workforce trained to skillfully refer and/or assess and/or treat GD

13. Why do dice have dots instead of numbers?

14. Definitions of gambling Gambling can be defined as placing something of value at risk in the hopes of gaining something of greater value. (Potenza 2006)

15. Another definition of gambling Gambling is the wagering of money or something of material value (referred to as "the stakes") on an event with an uncertain outcome with the primary intent of winning additional money and/or material goods. Typically, the outcome of the wager is evident within a short period. (Wikipedia, 2012)

16. Gamblers Anonymous (GA) definition of gambling Gambling,for the compulsive gambler is defined as follows: Any betting or wagering, for self or others, whether for money or not, no matter how slight or insignificant, where the outcome is uncertain or depends upon chance or "skill“ constitutes gambling.

17. What behaviors do you call “gambling?”

18. 49% of those with lifetime pathological gambling reported receiving treatment for mental health or substance abuse problems. NONE reported treatment for gambling problems. Kessler et al., 2008 National Co-morbidity Survey Replication

19. In the U.S. slot machines grossed more than $1 billion a day in 2012. That’s more than the gross of McDonald’s, Burger King, Wendy’s and Starbucks combined (Johnson, 2013)

20. Impact on U.S. life • For every ATM in the U.S. there are two electronic gambling machines • More spent on gambling machines than on movies, professional baseball and theme parks combined • http://www.cbsnews.com/news/slot-machines-the-big-gamble-07-01-2011/

21. Gambling Machine of the Present & Future

22. Free help for individuals with Gambling Disorder and their families!!!!!!! 1-877-my-limit www.opgr.org

23. Anti-Gambling Laws – 3000-4000 BC

24. MAHABHARATA – 800-900 BC

25. Public Health Approach Gambling Continuum

26. Social/Recreational Gambling

27. Problem Gambling/GamblingDisorder

28. DSM-5 diagnostic differences . . .

29. Problem Gambling vs. Gambling Disorder • DSM-5: 4 symptoms needed to make a Gambling Disorder Dx • Treatment & Research community: 2-3 symptoms = Problem Gambling

30. GA 20 Questions Did you ever lose time from work or school due to gambling? Has gambling ever made your home life unhappy? Did gambling affect your reputation? Have you ever felt remorse after gambling? Did you ever gamble to get money to pay debts or otherwise solve financial difficulties? Did gambling cause a decrease in your ambition or efficiency? After losing did you feel you must return as soon as possible and win back your losses? After a win did you have a strong urge to return and win more? Did you often gamble until your last dollar was gone? Did you ever borrow to finance your gambling? Have you ever sold anything to finance gambling? Were you reluctant to use "gambling money" for normal expenditures? Did gambling make you careless of the welfare of yourself or your family? Did you ever gamble longer than you had planned? Have you ever gambled to escape worry or trouble? Have you ever committed, or considered committing, an illegal act to finance gambling? Did gambling cause you to have difficulty in sleeping? Do arguments, disappointments or frustrations create within you an urge to gamble? Did you ever have an urge to celebrate any good fortune by a few hours of gambling? Have you ever considered self-destruction or suicide as a result of your gambling?

31. But gambling disorder isn’t a “real” addiction like an SUD, is it? • Brain imaging studies show GD pathways are same pathways involved in substance addiction (Nathan, 2014; Grant et al., 2011) • Similar natural history (Petry, 2014) • Similar symptoms (APA, 2013) • Very high co-morbidity • Similar anthropological & social history • DSM 5 classifies as an addiction, brain disorder

32. Mental Health and Addictions Staff are powerful prevention agents • HIV Prevention • Sorenson, J.L. & Copeland, A.L. (2000) • NIDA (2012) • HCV Prevention • NIDA (2012) • Kresina, T.F et al (2006) • Domestic Violence Prevention • O’Farrell T.J. et al., (2003) • Stuart, G.L. et al., (2002)

33. How Mental Health & Addictions Staff can be problem gambling prevention agents • Can treatment itself be a preventive factor? • Open an informed conversation • Know how to refer interested individuals to PG treatment

34. Oregon snapshot* 81,000 Oregon adults need treatment The socio-economic cost of these 81,000 individuals is estimated to be $508M annually System in 2013 treated 1,214 problem gamblers Oregon’s Helpline received over 64,000 hits in the month of August, 2014 *Moore, T. (2013). Oregon gambling treatment programs evaluation update 2013. Salem, OR: Oregon Health Authority, Addictions and Mental Health Division

35. Prevalence in A&D Tx It’s reasonable to expect that 1 out of every 7 A&D clients has a gambling problem 2013 Meta-analysis (Cowlishaw, S. et al., 2013) • Gambling Disorder – 14% • Problem Gambling – 23%

36. What, me gamble?

37. 49% of those with lifetime pathological gambling reported receiving treatment for mental health or substance abuse problems. NONE reported treatment for gambling problems. Kessler et al., 2008 National Co-morbidity Survey Replication

38. Brief Screening Tools Tools work well in research settings but not well in practice (Rugle, 2014) • Insufficient staff training & staff beliefs about gambling • Insufficient staff time • Client dishonesty with self & others • Clients overwhelmed just trying to address SUD

39. If you work on Prevention,it will lead to Intervention

40. Free help for individuals with Gambling Disorder and their families!!!!!!! 1-877-my-limit www.opgr.org

41. GBIRT Goals • Educate clients about gambling risks to prevent problem gambling • Early intervention for individuals who seem to have a developing gambling problem • Referral to treatment for those who need it

42. Framework for understanding risk Traditional: Drug, Set, Setting* More useful: Drug, Brain, Set, Setting *Zinberg, 1986

43. Gambling, especially machine or internet gambling, can be a “drug” withpowerfuladdictive properties

44. SUD brain primed for Gambling Disorder Brain imaging studies show GD pathways are same pathways involved in substance addiction (Nathan, 2014; Grant et al., 2011)

45. Set: Why people gamble Lori Rugle’s 5 E’s: Excitement Entertainment Escape Economics Ego

46. Setting

47. Individuals addicted to or in recovery from alcohol or other drugs

48. Educate About Risks • SUD’s and MH condition effected brain is hard-wired to become addicted to gambling. Find other ways to have fun. • Gambling machines and online games are engineered and constantly updated to manipulate players to Play Until Extinction and increase Time on Machine. • Always start with a time limit and money limit and stick to it. • Never play to win money. All regulated gambling is designed so that the more you play the more you lose.

49. Let’s practice!!

50. GBIRT ProcessAdapted by Illinois SBIRT from DSM5, BBGS, and Elizabeth Hartney, PhD