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Pathological Gambling and Alcohol Use Disorder

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Pathological Gambling and Alcohol Use Disorder Pathological Gambling and Alcohol Use Disorder Jon E. Grant, M.D., Matt G. Kushner, Ph.D., and Suck Won Kim, M.D. Problematic gambling is more common among people with alcohol use disorders (AUDs) (i.e., either alcohol abuse or dependence) compared with those without AUDs. This association holds true for people in the general population and is even more pronounced among people receiving treatment. No broadly accepted explanation for the link between problematic gambling and AUD currently exists. The available literature suggests that common factors may increase the risk for both conditions. For example, a defect of functioning in a particular brain system may underlie both conditions. This hypothesis should be further developed using brain imaging and psychopharmacological studies. Effective treatment and prevention will require additional research into relevant associations on both the event level (e.g., the effects of drinking on gambling behavior and vice versa) and the syndrome level (e.g., the relative onset and course of each condition among those who have either one or both disorders). A prudent interpretation of the available data suggests careful screening and treatment when necessary for problematic gambling among people with alcohol abuse and for alcohol abuse among people with gambling problems. KEY WORDS: pathological gambling; AODD (alcohol and other drug dependence); comorbidity; etiology; diagnostic criteria; disinhibition; impulsive behavior; ventral tegmental area; encephalopathy; naltrexone; genetic linkage; causal path analysis; treatment outcome athological gambling (PG) is both community and clinical samples. problem compared with PG. Rather, characterized by a persistent mal­ The article then reviews the processes this term is used to distinguish between Padaptive pattern of gambling and mechanisms that might account problem gambling formally shown to behavior. PG was first formally included for the frequent co-occurrence of these meet the DSM criteria (PG) and all in the Diagnostic and Statistical Manual disorders. Finally, it examines what the other cases of problematic gambling of Mental Disorders, Third Edition (DSM– co-occurrence of these disorders implies behavior (disordered gambling behavior). III) in 1980 (American Psychiatric for treatment and highlights promising Association [APA] 1980). Currently, areas for future research. PG is classified under the category Many terms have been used to describe JON E. GRANT, M.D., is a psychiatry resi­ “disorders of impulse control not else- people with problematic gambling dent, MATT G. KUSHNER, PH.D. is an where classified” (APA Committee on behavior (see Cunningham-Williams associate professor, and SUCK WON KIM, Nomenclature and Statistics 2000). and Cottler 2001). In this article, PG M.D., is an associate professor, all in the This article explores the association refers to pathological gambling as diag­ Department of Psychiatry, University of between pathological gambling and nosed using DSM diagnostic criteria. Minnesota Medical School, Minneapolis, alcohol use disorders (AUDs) (i.e., the The term “disordered gambling behavior” Minnesota. general name for either alcohol abuse is used to refer to problematic gambling or alcohol dependence). It first examines behavior that is not defined by DSM This research was supported, in part, by the separate and overlapping preva­ diagnostic criteria. Note, however, that a grant from the National Institute on lences of PG and AUD as estimated by this term is not used as a means of Alcohol Abuse and Alcoholism (AA–12426) epidemiological surveys conducted in identifying a less serious gambling awarded to the second author. Vol. 26, No. 2, 2002 143 Epidemiology findings from the National Comorbidity with disordered gambling behavior also Survey (NCS) (Kessler et al. 1994), the report a lifetime history of AUD estimated lifetime prevalence is 14.2 (Cunningham-Williams et al. 1998), Pathological Gambling percent for alcohol dependence and 9.4 a rate that greatly exceeds general preva­ percent for alcohol abuse, based on cri­ lence estimates for AUD (see above). In During the 1990s, changes in State and teria in the DSM–III–R (APA 1987). fact, these studies reported that as gam­ local legislation encouraged the expan­ The National Longitudinal Alcohol bling severity increased, so did the risk sion of all types of wagering (e.g., casino Epidemiologic Survey (NLAES) found for AUD, even when sociodemographic gambling, lotteries, Internet gambling). that over the 12 months preceding the variables were controlled. Similarly, As an apparent consequence, gambling survey, 4.4 percent of adults age 18 or Feigelman and colleagues (1998) found and gambling-related problems are on older met the criteria for alcohol depen­ that 26 percent of U.S. community-based the rise in the United States and Canada. dence and 3.0 percent met the criteria respondents with disordered gambling A recent meta-analysis of 120 published for alcohol abuse (Grant et al. 1994). behavior reported having experienced studies estimated that 1.6 percent of In sum, between 7 percent and 14 per- AUD or some other substance use disor­ adults in the United States and Canada cent of adults in the United States der at some point during their lifetime. meet the DSM criteria for pathological experience an AUD at some point in These survey findings, considered gambling at some point in their lives their lives. against findings from the ECA survey (Shaffer et al. 1999). Among people The NCS found that the median age showing that approximately 14 percent younger than 18 years of age, the cur- of onset was 19 years for alcohol abuse of U.S. adults experience AUD (above), rent prevalence of PG is estimated to and 18 years for alcohol dependence indicate that, in the general population, be 3.9 percent, with past-year rates for (Kessler et al. 1997). The NLAES found the risk for AUD is two to four times adults and adolescents estimated at 1.1 that the risk for developing an AUD higher for people with PG compared percent and 5.8 percent, respectively was substantially increased among those with those without PG. However, a (Shaffer and Hall 1996). who started drinking before age 17 more recent study found a substantially Slightly lower prevalence rates of (24.5 percent lifetime prevalence) com­ greater association between AUD and PG were found by a national study pared with those who started drinking PG (Welte et al. 2001). This study conducted by the National Opinion at age 21 or 22 (10 percent lifetime reported an odds ratio for current alcohol Research Center (NORC). This study prevalence) or at age 25 years or older dependence with current PG of 23.1 found the lifetime prevalence of adult (less than 4 percent lifetime prevalence) (Welte et al. 2001). That is, the odds of pathological gambling to be 0.9 per- (Grant and Dawson 1997). In fact, the having a current alcohol dependence cent, with past-year rates of 0.6 percent prevalence of alcohol abuse detected in diagnosis were 23 times greater among (NORC 1999). that study declined with each increas­ those in the survey who had a PG diag­ Although studies using historical ing year of age of onset of drinking. nosis than for those with no PG diag­ review (i.e., retrospective methodologies) nosis. It should be noted that this study have tended to point to a young age of Comorbid AUD and PG focused on having a current (vs. lifetime) onset of PG (Cunningham-Williams diagnosis and on alcohol dependence, and Cottler 2001), more definitive Given the relative frequency of both rather than abuse. Similar to the study studies that follow participants over PG and AUD, these conditions would reported by Cunningham-Williams time (i.e., prospective studies) to deter- be expected to co-occur in some cases and colleagues (1998), Welte and col­ mine the natural course of PG have yet by chance alone. However, there is evi­ leagues (2001) also found that the to be conducted. Studies looking at dence that disordered gambling behav­ prevalence of current PG increased with cross sections of different age groups ior and AUD co-occur in U.S. and increasing alcohol consumption. Among have shown that PG prevalence rates Canadian residents at a rate exceeding those people with higher socioeconomic appear higher for adolescents and that expected by chance. As described status, alcohol dependence and PG were young adults than for middle-aged and below, studies of treatment populations even more strongly correlated (Welte et older adults (Shaffer and Hall 1996). found an increased risk of PG in alco­ al. 2001). Long-term studies are necessary, how- holism treatment patients and an ever, to clarify these findings. increased risk for AUD in PG treat­ Treatment Populations. Consistent ment patients. with observations pertaining to comor­ AUD bidities involving a variety of disorders Community Populations. A large epi­ (e.g., Kushner et al. 1990), comorbid Based on DSM–III criteria, the demiological survey in Canada esti­ PG and AUD tend to be more prevalent Epidemiologic Catchment Area (ECA) mated that the relative risk for AUD is in treatment (vs. community) samples. survey estimated that 13.8 percent of 3.8 times higher when disordered gam­ One early study suggested that 17 per- adults in the United States meet the cri­ bling behavior is present (Bland et al. cent of alcoholism treatment patients teria for AUD at some time during their 1993). A study conducted in the United reported disordered gambling behavior lives (Robins et al. 1991). According to States found that 44 percent of those (Haberman 1969). A later study of 100 144 Alcohol Research & Health Pathological Gambling and Alcohol Use Disorder inpatients with alcohol dependence to develop an AUD (e.g., Helzer et al. on comorbidity without also consider­ found that 14 percent met the criteria 1991). Because men are more likely than ing a wide range of variables that often for PG, and that an additional 14 per- women to experience both AUD and correlate strongly with race/ethnic des­ cent suffered from subclinical gambling PG, the co-occurrence of these disorders ignations (e.g., social, economic, cul­ problems (Lesieur and Heineman 1988).
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