Gambling in an AOD Context

Dr. Jane Oakes

DANA 2018 Australasian Conference

I would like to acknowledge the traditional

owners of the land we meet on and pay respect

to Elders past and present and any Aboriginal

people present today

Session Objectives

• Overview of gambling and problem gambling

• The identification of problem gambling

• Implication of AOD and gambling

• Practical ways to support people with problem gambling

behaviors

• Help referral options

Beating the odds: How Carolyn Hirsh overcame her pokies addiction

As a psychologist and a state MP, Carolyn Hirsh warned of the addictive nature of poker machines –then herself fell under their powerful spell

https://www.smh.com.au/lifestyle/beating-the-odds-how-carolyn-hirsh-overcame-her-pokies-addiction-20151001-gjzbfp.html

Gaming machines takeover peoples’ minds

Larry PA

“The damn machines take your mind over, your body and soul over, and that’s probably the reason why people commit suicide, because it just takes control. But it’s – what would you call it, it’s being delirious.”

Background

Gambling

To stake or risk money or anything of value on the

outcome of something involving chance

Australian Gambling

• Gambling participation 63.9%

• Total gambling expenditure AUD$23.648 billion

• Land-based gambling expenditure declining

• Interactive gambling growing

• Approx AUD$1.1 billion per year gambled on regulated sites

(Dowling et al., 2015; Roy Morgan Research 2012)

Types of gambling

Type Risk of harm

EGMs High

Racing High

Casino - Black Jack, Poker, Roulette Moderate

Sports bet Moderate

Lotteries Low

Cultural – Mahjong, Bingo, Two up Low

Rowe, C., White, M., Long, C., Roche, A., Orr, K. (2015)

EGMS - Most addictive

• accessibility & advertising

• lights, colors, noises, alcohol

• game variety and bonuses

• frequent wins -intermittent rewards

• illusion of skill – near misses

• capacity for uninterrupted rapid play

• use of bill acceptors / easy access to funds

Finlay, Marmurek, Kanetkar, & Londerville, 2010; Reith, 2006 Dowling et al., 2005

Abbott, 2006; Dowling, Smith, & Thomas, 2005; Gainsbury, Russell, Hing, et al.,

2014a; Wardle, Moody, Spence, et al., 2011

Problem gambling

“Problem gambling is characterised by difficulties in limiting

money and/or time spent on gambling which leads to adverse

consequences for the gambler, others or for the community”

Neal, Delfabbro and O’Neal (2005)

Australian

• Problem gambling 0.4%

• Moderate-risk gambling 1.9%

• Low-risk gambling 3.0%

Dowling et al., (2015)

Victoria

• Problem Gambling O.8 %

• 12% total population experiencing harms

(Hare et al 2015)

Gambling Prevalence

Vulnerable Populations

• young males

• people with debt

• low socio-economic status

• mental health issues

• indigenous

• poor physical health

• Alcohol problems

Thomas & Jackson,(2008). Delfabbro, (2002). Delfabbro, (2007).

• financial

• relationship

• emotional or psychological distress

• decrements to health

• cultural

• reduced performance at work or study

• criminal activity

Legacy harms - occur later in life, or transferred between generations - parental poverty impacts on children over lifespanBrowne, M, Langham, E, Rawat, V, Greer, N, Li, E, Rose, J, Rockloff, M, Donaldson, P, Thorne, H, Goodwin, B, Bryden, G & Best, T (2016)

Gambling Harms

Gambling -shame & stigma

• more publicly stigmatised than alcoholism, obesity,

schizophrenia, depression- but not drug addiction

• gamblers fault - lack of self-control

Therefore:

• significant shame, self-stigma, disappointment in self,

embarrassed, weak

• secrecy main coping mechanism - self-help most common

• relapse worsens self-stigma and shameHing, N., Russell, A., Nuske, E., Gainsbury, S. (2015)

• The gambling behavior is not better explained by a manic

episode

• Persistent /recurrent problematic gambling behavior – clinically

significant impairment / distress, as indicated by the individual

exhibiting 4+ of following in a 12-month period:

DSM-5 Diagnostic Criteria: Gambling Disorder

• Needs to gamble with increasing amounts of money

• Restless or irritable when attempting to cut down or stop gambling.

• Made repeated unsuccessful efforts to control, cut back, or stop gambling.

• Preoccupied with gambling

• Gambles when feeling distressed

• After losing money gambling, often returns another day to get even (“chasing”)

• Lies to conceal extent of gambling involvement

• Jeopardized or lost significant relationship, job, educational or career opportunity

because of gambling

• Relies on others to provide money to relieve desperate financial situations caused by

gambling

DSM-5 Diagnostic Criteria: Gambling Disorder

The Problem Gambling Severity Index (PGSI)

Maximum=27

PGSI Score

Non-problem gambler

(0)

Low risk gambler

(1-2)

Moderate risk gambler

(3-7)

Problem gambler (8+)

1• Have you bet more than you could really afford to lose?

2• Have you needed to gamble with large amounts of money to get the same feeling of

excitement?

3• When you did gamble, did you go back another day to try to win back the money you lost?

4• Have you borrowed money or sold anything to get money to gamble?

5• Have you felt that you might have a problem with gambling?

6• Has gambling cause you any health problems, including stress or anxiety?

7• Have people criticized your betting or told you that you have a gambling problem, regardless

of whether or not you thought it was true?

8• Has your gambling caused any financial problems for you or your household?

9• Have you felt guilty about the way you gamble or what happens when you gamble?

Early Detection

If your client is presenting with symptoms of depression and anxiety, addictions or family, social and financial problems, asking the following two questions can help in determining whether gambling may be a problem.

Screens need to be short and effective

Have you ever had an issue with your gambling?

Or

Has anyone in your family ever had an issue with gambling?

If the client answers yes undertake an assessment or refer for a more thorough assessment

(Thomas et al., 2008)

Problem Gambling and Mental Health Problems

Prevalence of mental health in Problem gamblers (PGs)

Systematic review & meta-analysis - PGs in general population • 57% substance use disorder

• 38% mood disorder (any)

• 37% anxiety disorder (any) (Lorains et al,. 2011)

Systematic review & meta-analysis - Treatment seeking studies• 75% of treatment seeking gamblers report co-morbid DSM Axis I disorders

• 23% co-morbid mood disorder

• 18% alcohol use disorder

• 7% substance (non-alcohol) use disorder

• 48% have a personality disorder (Dowling et al., 2015)

PG prevalence - Victorian community-based mentalhealth services N = 837

• Gambling participation rate 41.6%

• Participants with current drug use disorder diagnosis - more-than-fourfold increase in risk of problem gambling

• Low-risk gamblers (highest proportion) identified as hazardous drinkers

Manning, V., Dowling, N. A., Lee, S., Rodda, S., Garfield, J. B. B., Volberg, R., ... & Lubman, D. I. (2017)

One in Two

• One in two mental health patients who gamble experience gambling related harm

• 6 % mental health patients have problem gambling

AOD and problem gambling

4 times more likely to have problems with alcohol

30-46% report drug use disorders

More than 25% experienced both alcohol use disorders and

severe mental health disorders

Thomas, S. A., & Jackson, A. C. (2008).

Townshend, P., Dowling, N., Rodda, S., & Legge, B. (2014).

• exacerbate gambling problems: increase amount prepared to

bet

• more disinhibited & have less cognitive control

• less likely to stop once started gambling

• ability to evaluate costs / benefits /understand games rules

compromised

• AOD – escape distress gambling losses

Ministerial Council on Drug Strategy. (2010)

French, M. T., Maclean, J. C., & Ettner, S. L. (2008)

AOD and Gambling

• Higher levels depression, anxiety, suicidal ideation, and dissociation (Delfabbro, 2007)

• Suicidal ideation and suicide attempts among individuals with pathological gambling 20% to 40% (Kausch, 2003 Blaszczynski & Farrell, 1998; DeCaria et al., 1996)

• Suffer higher rates of depression

• Suicidal thoughts 48-79% in clients with problem gambling and co-morbidity

• Suicide attempts 12-20 % (Rugle, 2000)

Depression / Suicide

Rates of suicidal ideation(thoughts and plan) but not lifetime attempts were significantly higher among gambling than substance use patients

Manning et al, 2015, Psychiatry Research

Risk Assesment

“oh my God, you really, really did lose that amount of money”

“I got a bank statement which showed me what I’d earned and what I still

had in the account and it was like ‘oh my God, I can’t possibly have earned

that amount of money and spent that amount of money’ and I did ……. control

was gone and I didn’t realise it was gone until I had that bank

statement sitting in front of me going ‘oh my God, you really, really

did lose that amount of money”

Colleen

Family violence andgambling-related harm

Family violence three times more likely to occur in families

where gambling is a problem

(Dowling, Ewin, Youssef, Thomas & Jackson In preparation)

Differences Domain Alcohol Gambling

Reason for continued use Avoid withdrawal symptoms Desire to win back losses

Signs dependence Physiological signs eg smell No physical - secretive

Overdose/Excessive use Biological consequences Lose +++ money quickly

Service recognition Screened Unrecognised /unscreened

Help seeking Rates vary Low rates

Speed of harm Can take time for problems to

develop

Incur harms quickly

Rowe, C., White, M., Long, C., Roche, A., Orr, K. (2015). Slots and Shots: A Gambling Resource for AOD Workers. Odyssey House Victoria, Melbourne, Victoria.

Dopamine and Gambling

• The behavioural, cognitive, and neurobiological profiles resemble those whom

have addiction to alcohol and/or substances, particularly stimulants

• Secretion of dopamine in the ventral striatum is a function of gambling severity

and excitement level

(van Holst et al., 2018)

• The neurotransmission of dopamine in the mesolimbic prefrontal cortex has been

implicated in gambling, which reinforces the conditioned relationship between

gambling and reward

(van Holst, van den Brink, Veltman, & Goudriaan, 2010)

Harm Reduction

Relapse Study (Battersby et al 2010)

Significant predictors of problem gambling and relapse

Relapse and continuing to gamble:

Gambling urge

Gambling related cognitions

Urges Powerful and overwhelming

(Blaszczyncki et al, 1986, Freidenberg et al, 2002 & Kushner et al, 2007)

External Triggers:

Classical Conditioning

Operant Conditioning –

reward learning

Tension relief

Money – winning

Free drinks and food

Gambling

Uncontrollable urge

(Battersby et al., 2008)

Gambling reduces the urge temporarily and reinforces the gambling behaviour

0

2

4

6

8

0 4 8 11.5 15 18.5

Urge

Time

Allowing the urge to peak and subsidethe strength of the trigger is weakened

0

2

4

6

8

0 6.8 7.35 4.5 2 0

Urge

TimeTrigger

0

2

4

6

8

0.00 6.80 7.35 4.50 2.00 0.00

Urge

Time

Each time the urge passes and the person resists gambling the power of the urge reduces and subsides with repeated practice

Faulty Cognitions –Cognitive Therapy

PGs believe they can predict or control the outcome of a bet

• These types of thoughts may include

• Thinking the odds are in your favour

• Playing on certain machines increases your odds

Changing the thoughts

• What evidence do I have for this thought?

Harm Reduction

Distress

level

Time with clinician

10

9

8

7

6

5

4

3

2

1

0

Workable Zone

Increased distress

Continued gambling

Self-harm

Severity of situation

minimised

Perceived permission to

continue gambling

Extreme distress

Relaxation

Managing Distress (Oakes et al 2016)

Money Management

GHO – information • Financial counselling

• Weekly budget - a running tally of true wins and loses

• Have wages electronically paid into a bank account

• Unlink accounts, lower withdrawal limits 2 signatures

• Cancel the redraw facility on the home loan

• Keep money in a place that is difficult to access

• Visa Gift card

Harm Reduction

• Negative affect / Risk Assessment

• Management of gambling urge

• Support Important - professional / personal

• Money / debts - financial assistance can be a problem

• Examination of permission giving cognition's

• GHO – information

Gambling Help Online

Gambling help Online provides free:

• 24 hour live counselling

• 24 hour email- based counselling

• Online peer support community

• Self Help Tools and Modules

• Range of web based self-help information and referral and support materials

• Blogs

• SMS support

• Face book site

Contact Details

Dr Jane Oakes

M: 0432 224 939