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Gambling and Substance Abuse
The DO Magazine December 2006 Gambling and substance abuse
GAMBLING ADDICTS
Hidden addiction: Identifying
and treating pathological gamblers
Barbara Greenwald
Staff Editor
In the gambling capital of the world, it was only fitting that Michael S. Levy, DO, gave a presentation titled “Substance Abuse and Gambling” as part of the didactic program of the American Osteopathic Academy of Addiction Medicine.
“I never imagined that I would end up practicing in ‘Sin City,’ ” said Dr Levy, a Las Vegas-based addiction medicine specialist.
Despite the ever-growing number of casinos in Nevada offering access to gambling and alcohol, Dr Levy said he is the only outpatient physician in the state who specializes in addiction medicine. “I would certainly welcome anyone who wants to come to Vegas and open an addiction medicine practice because there’s enough business to go around,” he joked.
Pathological gambling is becoming a nationwide problem partly because gambling centers are no longer confined to Las Vegas and Atlantic City, NJ, Dr Levy pointed out. Utah and Hawaii are the only two states in the United States where gambling is illegal, he added.
In addition, state lotteries, Internet gambling, day trading and televised poker tournaments have chipped away at the stigma associated with gambling, Dr Levy observed. “Hollywood stars are now major poker players on TV,” he said. As more gambling centers spring up, the number of adults addicted to gambling is going to increase, Dr Levy warned. Currently, 1-3% of the adult population in the United States are pathological gamblers, he noted, and 25-63% of all pathological gamblers are also substance abusers. A frequent pattern of addiction is alcohol abuse followed by a gambling problem.
“Gambling is going to be something that addiction medicine physicians are going to have to start talking about when they evaluate patients for substance abuse,” Dr Levy said. “There is a direct relationship between pathological gambling and substance abuse, and it is important to identify the triggers for each addiction.”
Pathological gamblers exhibit a number of behaviors that are associated with substance abuse, Dr Levy pointed out. For example, members of both groups often have low self-esteem and seek immediate gratification.
Unlike substance abuse, however, gambling is a “hidden addiction,” Dr Levy observed. Gambling does not require the ingestion of chemicals and cannot be identified by a physical screening test. Gamblers are not physiologically affected by their behavior in the same way as substance abusers, so they can often function at work. By the same token, there is no perceived saturation point for gambling—gamblers can’t overdose. And there are significantly fewer resources available for evaluating and treating a gambling addiction, Dr Levy said.
Spotting the signs:
The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text
Revision (DSM-IV-TR) categorizes pathological gambling as an impulse control disorder. The nationally accepted definition of pathological gambling, Dr Levy said, is “a chronic and progressive failure to resist the impulse to gamble, and such gambling behavior compromises, disrupts or damages personal, family and vocational pursuits.”
According to the DSM-IV-TR, maladaptive gambling behavior is indicated by a patient who exhibits five or more of the following characteristics:
●___ is preoccupied with gambling.
●___ spends increasing amounts of money to achieve the desired excitement.
●___ repeatedly and unsuccessfully tries to control, cut back or stop gambling.
●___ is restless or irritable when attempting to cut down or stop.
●___ uses gambling to escape from problems or relieve a dysphoric mood.
●___ “chases” losses and attempts to “get even.”
●___ lies to others to conceal the extent of involvement with gambling.
●___ commits illegal acts to finance gambling.
●___ jeopardizes or loses a relationship, job or opportunity because of gambling.
●___ relies on others to provide money to relieve a desperate financial situation.
Among the assessment tools available to physicians who want to screen their patients for compulsive gambling behavior are the South Oaks Gambling Screen and the Gamblers Anonymous 20 Questions, Dr Levy told attendees. A more informal tool is the lie-bet assessment: “Have you ever had to lie to people important to you about how much you gambled?” “Have you ever felt a need to bet more money?” If your patient answers “yes” to both questions, there is a good chance that he or she is a pathological gambler, he said.
Taking a family history can also help physicians identify a gambling problem. Just as the children of alcoholic parents have a greater risk of alcohol addiction, the children of pathological gamblers are more at risk for compulsive gambling behavior, Dr Levy said, noting that research is under way to find a molecular genetic basis for pathological gambling.
In addition, just as researchers have pinpointed the primary brain receptors for every major class of abused drug, they are also beginning to identify the neural circuits associated with gambling. For Dr Levy, this means that pathological gambling is a treatable disease of the brain.
“I predict that when the DSM-Vcomes out, it will categorize pathological gambling as a
‘nonsubstance’ substance abuse disorder instead of a compulsion,” Dr Levy said.
Treatment principles:
According to Dr Levy, more than 20 sites in the United States are conducting clinical trials on nalmephine hydrochloride, an opioid antagonist, to treat pathological gamblers. Other medications, such as naltrexone hydrochloride and acamprosate calcium, may also be helpful, he said, although at this point the evidence is only anecdotal. The US Food and Drug Administration has not approved any medications for pathological gambling, and the most successful treatment modality is cognitive behavioral therapy.
Dr Levy outlined the phases of compulsive gambling and recovery:
●___ winning—The patient is only gambling occasionally and is winning more than losing. This is when the patient experiences that first “big win.”
●___ losing—The patient is preoccupied with gambling and can’t stop. The patient starts borrowing money, losing time at work, and covering up his or her gambling behavior.
●___ desperation—There is a marked increase in the amount of money and time spent on gambling. The patient becomes increasingly alienated from family and friends, may commit illegal acts to finance gambling, and needs to get “bailed out” of financial straits. Panic and remorse set in.
●___ hopelessness—The patient may have an emotional breakdown, get divorced or lose his or her job. He or she may even get arrested. This is when many pathological gamblers turn to alcohol and contemplate or attempt suicide. This phase can also be a turning point for the patient.
●___ critical—The patient decides to stop gambling and expresses an honest desire
for help. He or she becomes hopeful about the future.
●___ rebuilding—The patient develops goals, begins to stick to a budget, re-establishes relationships with family and friends, and feels self-respect again.
●___ growth—The patient’s preoccupation with gambling decreases, and he or she begins to face problems head-on. This is when the patient begins to have insight into himself or herself and is ready to start a new life.
But pathological gamblers can’t recover alone, Dr Levy emphasized. Physicians must stay involved and treat patients’ comorbid conditions, such as depression and alcoholism, to help reduce the risk of suicide. Enlisting family members to encourage follow-through with treatment recommendations is critical, he added.
“We physicians have to enlist gamblers’ families to help with treatments,” Dr Levy said. “There is a high risk of suicide for substance abusers and pathological gamblers, and we have to be there to help prevent that from happening.”