The Intersection of Problematic Gambling and Opioid Use Disorder

Christopher Welsh, MD Associate Professor University of Maryland School of Medicine Medical Director Maryland Center of Excellence on Problem Gambling

Tuesday, April 14th, 2020 12:00 PM – 1:00 PM EST Webinar Housekeeping

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2 Disclosures

• I do not have a financial relationship with a commercial entity producing, marketing, re-selling or distributing health-care related products or services consumed by, used on, patients.

Affordable Care Act

21st Century Cures Act

-State Targeted Response to the Opioid Crisis Grants

-Tribal Opioid Response Grants

-Targeted Capacity Expansion: Medication Assisted Treatment

-State Targeted Response- Technical Assistance

Carefirst, Aetna, Kaiser, etc. grants

The content of this activity may include discussion of off label or investigative drug uses. The faculty is aware that is their responsibility to disclose this information.

3 Educational Objectives

At the conclusion of this activity participants should be able to:

• Recognize four (4) brief screening tools for problematic gambling that can be used by providers of treatment for opioid use disorder.

• Understand medications that may be used to help treat gambling disorder.

• Provide at least three (3) ways in which problematic gambling might effect a patient’s treatment/recovery from opioid use disorder.

4 What Is Gambling?

•Webster says: •“to stake or risk money or anything of value on the outcome of something involving chance.” •“any matter or thing involving risk.”

5 5 Types Of Gambling

Games Of Skill • Cards • Pool Lottery • Mega Millions/Powerball • Instant Scratch Tickets • Daily Numbers • Lotto Sports • Horse Racing At Tracks • Off Track Betting • Office Pools • Super Bowl, March Madness, etc.

6 Types Of Gambling

•Games Of Chance • Slot Machines • Roulette • BINGO • Dice • Raffles •Stock Market

7 Gambling: Some Numbers

• About 75-86% of all adults in the US gamble at one time or another. • 48 states have legalized gambling •Except Hawaii and Utah. • Gambling goes on in Hawaii and Utah via the stock market, internet gambling, cruise ship casinos, illegal gambling such as sports betting. • 43 states have lotteries • 6 states have river boat gambling • 28 states (plus 2 territories) have casino gambling • 30 states have casinos on Native American land 8 Terminology

•Problem •Compulsive •At risk •Pathological •Gambling vs Gaming

9 Problem Gambling in the U.S.

• Numbers vary depending on type of study • Adults •0.4 to 3%- Pathological •1.6-3.8% - at risk or problematic • Adolescents •1-7%- Pathological •5-10%- at risk or problematic • College •3-11%-Pathological •5-15%- at risk or problematic 10 Problem Gambling: High Risk Groups

• Growing numbers of gambling problems among: •Adolescents •Older Adults •Women •People of Color •Lower Income populations •Less educated populations (high school or less)

11 Gambling Types

• Action Gambling •Escape Gambling • Primarily at games of • Primarily as a way to escape perceived “skill” “stress” • Believe they can “beat the • often in a hypnotic state house” or other individuals while gambling by developing a system • Does not gamble to beat the • Preferred Games house or others • Poker • Preferred Games • Dice • Bingo • Cards • Slot Machines • Horse/Dog Racing • Video Poker • Sports Betting • Lottery

12 Psychiatric Co-Morbidity

13 • High correlation with mood and anxiety disorders •One study found 76% of pathological gamblers had a major depressive disorder with recurrent episodes in 28%

• Suicide risk is high (17-24%)

13 Associated Medical Findings

• 2-6% of primary care patients meet the criteria of problem or pathological gamblers • increased incidence of • insomnia • irritable bowel syndrome • peptic ulcer disease • hypertension • headaches/migraines

14 14 History of the DSM

• DSM I (1952) • Disordered gambling not mentioned • Substance related disorders placed in “Personality Disorders- Sociopathic PD.”

• DSM II (1968) • Disordered gambling not mentioned • Substance related disorders placed in “Personality Disorders and Certain Other Non-Psychotic Mental Disorders”

History of the DSM

• DSM III (1980) • 1st time “Pathological Gambling” included (312.31) • Placed in “Disorders of Impulse Control- Not Elsewhere Classified” • With Kleptomania, Pyromania, Intermittent Explosive Disorder, Isolated Explosive Disorder • Failure to resist impulse/ rising tension before act/ pleasure or release during act/ may be guilt after act • No formal testing of diagnostic criteria • Based on limited clinical experience

16 DSM-III Diagnostic Criteria

A. The individual is chronically & progressively unable to resist impulses to gamble. B. Gambling compromises, disrupts or damages family, personal & vocational pursuits, as indicated by at least 3 of the following: • arrest for forgery, fraud, embezzlement or income tax evasion due to attempts to obtain money for gambling • default on debts or other financial responsibilities • disrupted family or spouse relationships due to gambling • borrowing of money from illegal sources (loan sharks) • inability to account for loss of money or to produce evidence of winning money if this is claimed • loss of work due to absenteeism in order to pursue gambling activity • necessity for another person to provide money to relieve a desperate financial situation 17 C. The gambling is not due to ASPD DSM-III Associated Features

• “These individuals most often are over confident, somewhat abrasive, very energetic and “big spenders”; but there are times when they show obvious signs of personal stress, anxiety and depression.”

• Differential Diagnosis • Social Gambling • Manic or hypomanic episode • Antisocial Personality Disorder

18 History of the DSM

• DSM III-R (1987) • “Pathological Gambling” basically, changed from focus on fraud and money to adapting substance dependence criteria to gambling • Remained 312.31 • Remained in “Impulse Control Disorder NEC” • Dropped Isolated Explosive Disorder and added Trichotillomania • Increased to 9 criteria (needed 4 for diagnosis)

19 DSM-III-R Diagnostic Criteria

Maladaptive gambling behavior, as indicated by at least four of the following: • frequent preoccupation with gambling or with obtaining money to gamble • frequent gambling of larger amounts of money or over a longer period than intended • a need to increase the size or frequency of bets to achieve the desired excitement • restlessness or irritability if unable to gamble • repeated loss of money by gambling and returning another day to win back losses ("chasing") • repeated efforts to reduce or stop gambling • frequent gambling when expected to meet social or occupational obligations • sacrifice of some important social, occupational, or recreational activity in order to gamble • continuation of gambling despite inability to pay mounting debts, or despite other significant social, occupational, or legal problems the person knows to be exacerbated by gambling 20

DSM-III-R Associated Features

“Generally, people with Pathological Gambling have the attitude that money causes and is also the solution to all their problems. As the gambling increases, the person is usually forced to lie in order to obtain money and to continue gambling. There is no serious attempt to budget or save money. When borrowings resources are strained, antisocial behavior in order to obtain money is likely. People with this disorder are often overconfident, very energetic, easily bored, and “big spenders”; but there are times when they show obvious signs of personal stress, anxiety, and depression.”

21 History of the DSM

• DSM IV (1994) • Remained “Pathological Gambling” ·Remained 312.31 • Remained in “Impulse-Control Disorders NEC” • Based on empirical trials of multiple items • New set of 10 criterion (needed 5 for diagnosis) • Added criterion to address lying, commission of illegal acts & escaping from problems or dysphoric mood • Differential Diagnosis

• Added “Professional Gambling” 22

DSM-IV Diagnostic Criteria

A. Persistent and recurrent maladaptive gambling behavior as indicated by 5 (or more) of the following: • 1. is preoccupied with gambling (e.g., reliving past gambling experiences, handicapping or planning the next venture, or thinking of ways to get money with which to gamble) • 2. needs to gamble with increasing amounts of money in order to achieve the desired excitement • 3. has repeated unsuccessful efforts to control, cut back or stop gambling • 4. is restless or irritable when attempting to cut down or stop • 5. gambles as a way of escaping from problems or relieving dysphoric mood (e.g. feelings of helplessness, guilt, anxiety, depression) • 6. after losing money gambling, often returns another day in order to get even (“chasing” one's losses) • 7. lies to family members, therapist, or others to conceal the extent of involvement with gambling • has committed illegal acts such as forgery, fraud, theft, or embezzlement to finance gambling • has jeopardized or lost a significant relationship, job, educational, career opportunity because of gambling • relies on others to provide money to relieve a desperate financial situation caused by gambling B. Not better accounted for by a Manic Episode 23

Differences Between DSM-IV & 5

• Renamed: Gambling Disorder • Maintained 312.31 (will become F63.0 with ICD-10) • Reclassified: into “Substance Related & Addictive Disorders” (renamed from “Substance-Related Disorders”) • Reduced to 9 criterion • Elimination of “illegal acts” criterion (as with SUDs) • Was least endorsed; almost always captured by others • Diagnostic cut-off lowered: 5 to 4 (different than SUDs) • Addition of time frame: • Symptoms must be present • within a 12-month period (as with SUDs)

24 Differences Between DSM-IV & 5

• Addition of Course Specifiers (different than SUDs): • Episodic- sxs subsiding for at least several months • Persistent- continuous sxs for multiple years • Addition of Remission Specifiers (similar to SUDs): • Early- no criteria for >3 but <12 months • Sustained- no criteria for > 12 months • Addition of Severity Specifiers (different than SUDs): • Mild- 4-5 criteria • Moderate- 6-7 criteria • Severe-8-9 criteria

25 DSM-5 Diagnostic Criteria

A. Persistent and recurrent problematic gambling behavior leading to clinically significant impairment or distress, as indicated by the individual exhibiting 4 (or more) of the following in a 12-month period: Needs to gamble with increasing amounts of money in order to achieve the desired excitement Is restless or irritable when attempting to cut down or stop Has made repeated unsuccessful efforts to control, cut back or stop gambling Is often preoccupied with gambling (e.g., having persistent thoughts of reliving past gambling experiences, handicapping or planning the next venture, or thinking of ways to get money with which to gamble)

26 4 DSM-5 Diagnostic Criteria (continued)

.Often gambles when feeling distressed (e.g. helpless, guilty, anxious, depressed) After losing money gambling, often returns another day in order to get even (“chasing” one’s losses) Lies to conceal the extent of involvement with gambling Has jeopardized or lost a significant relationship, job, or educational or career opportunity because of gambling Relies on others to provide money to relieve a desperate financial situation caused by gambling

B. Not better explained (changed from “accounted for”) by a Manic Episode 27 Comparison of GD to SUDs

Gambling Disorder Substance Use Disorder Need 4 out of 9 Need 2 out of 11 1. Tolerance 1. Using more or longer than intend 2. Withdrawal 2. Control 3. Control 3. Time spent in obtaining substance 4. Preoccupation 4. Craving or strong desire (does not count in establishing remission) 5. Escape 5. Failure to meet role obligations 6. Chasing 6. Continued use despite social or 7. Lying interpersonal problems 8. Impact on social function 7. Important activities given up or 9. Bailouts reduced 8. Recurrent use in physically hazardous situations 9. Continued use despite physical and psychological consequences 10.Tolerance 11.Withdrawal (not for all substances)

28 Other Non-substance “Addictions”

•Internet Gaming- in Section III (“Conditions for Further Study”) •Sex- dropped from Section III in final version •Eating- can be included in Feeding & Eating Disorders •Collecting- Hoarding Disorder added •Shopping- not included •Exercise- not included •Internet – not included

29 DSM-5 Internet Gaming Disorder

Persistent and recurrent use of the Internet to engage in games, often with other players, leading to clinically significant impairment or distress as indicated by 5(or more) of the following in a 12-month period: 1. Preoccupation with Internet gaming (IG). 2. Withdrawal sxs when internet gaming is taken away. 3. Tolerance- the need to spend increasing amounts of time engaged in IG. 4. Unsuccessful attempts to control participation in IG. 5. Loss of interest in previous hobbies & entertainment as a result of IG. 6. Continued excessive use of Internet games despite knowledge of psychosocial problems. 7. Has deceived family members, therapists, or others regarding the amount of Internet gaming. 8. Use of internet games to escape or relieve a negative mood. 9. Has jeopardized or lost a significant relationship, job, or educational or career opportunity because of participation in Internet games. *Does not include internet use for work, gambling, social media, sexual purposes. 30 “Unique” Characteristics Of Pathological Gambling?

• The behavior is harder to define • It is a more “hidden” addiction • less physical consequences of use • no real equivalent of overdose

• It is even less perceived of as a disorder than substance use disorders • There is no good objective test for “use” • The problem is more often perceived of as the solution

31 Problem Gambling Screens & Assessment Instruments

32 • South Oaks Gambling Screen (SOGS) • National Opinion Research Center DSM Screen for Problem Gambling (NODS) • G.A.’s Twenty Questions • “Lie-Bet” 2 Question Brief Screen • CLiP • PERC • Brief Biosocial Gambling Screen • SOGS-R A- Adolescent Screen

32 South Oaks Gambling Screen (SOGS)

• Valid And Reliable Instrument • May Be Self Administered • Most Widely Used Screen • Available in 25 languages • Has been revised for use among adolescents • (SOGS-RA)

Asks about • Types of gambling • Amount of money spent • Family History • 11 “consequence” questions

33 NODS-SA

2. Have there ever been periods when you needed to gamble with increasing amounts of money or with larger bets than before in order to get the same feeling of excitement?

3. Have you ever felt restless or irritable when trying to stop, cut down, or control your gambling?

4. Have you tried and not succeeded in stopping, cutting down, or controlling your gambling three or more times in your life?

5. Have you ever gambled to escape from personal problems, or to relieve uncomfortable feelings such as guilt, anxiety, helplessness, or depression? 34

NODS-SA

6. Has there ever been a period when, if you lost money gambling one day, you would often return another day to get even?

7. Have you lied to family members, friends, or others about how much you gamble, and/or about how much money you lost on gambling, on at least three occasions?

8. Have you ever written a bad check or taken money that didn’t belong to you from family members, friends, or anyone else in order to pay for your gambling?

9. Has your gambling ever caused serious or repeated problems in your relationships with any of your family members or friends? Or, has your gambling ever caused you problems at work or at school?

10. Have you ever needed to ask family members, friends, a lending institution, or anyone else to loan you money or otherwise bail you out of a desperate money situation that was largely caused by your gambling? 35 NODS-CLiP

36 NODS- PERC

1. Have there ever been periods lasting 2 weeks or longer when you spent a lot of time thinking about your gambling experiences, planning out future gambling ventures or bets, or thinking about ways of getting money to gamble with? 2. Have you ever written a bad check or taken money that didn’t belong to you from family members, friends, or anyone else in order to pay for your gambling? 3. Have you ever needed to ask family members, friends, a lending institution, or anyone else to loan you money or otherwise bail you out of a desperate money situation that was largely caused by your gambling? 4. Has your gambling ever caused serious or repeated problems in your relationships with any of your family members or friends?

37 LIE-BET

1. Have you ever lied to people important to you about how much you gambled?

2. Have you ever felt the need to bet more and more money?

If the answer is “yes” to either or both, further assessment is needed.

38 Brief Biosocial Gambling Screen

39 Gambling Disorder Screening

Patient may not acknowledge in first interview either because they simply don’t categorize these issues as problematic or because of shame and the desire to avoid talking about these issues

Individuals coming into treatment for a substance use or mental health disorder may have any or all of the following attitudes toward their gambling: • Never thought of it as a problem or potential problem • Believe it is a solution to their problems (emotional and or financial) • Realize it may be a problem, but don’t want to think about giving up “all their fun.” • Feel overwhelmed by dealing with just one problem, don’t want to have to think about any others. 40

Gambling Disorder & SUD

• 7% - 40% of those in SUD treatment have co-morbid GUD • Past year SUD severity related to greater gambling problems •Those with Gambling Disorder in SUD have significantly worse: •Physical Health •Mental Health •Treatment Adherence Increased Heroin/Cocaine Use

Gambling Disorder & OUD

•Various studies show higher than most other SUDs •Even higher rates in patients on methadone through OTP •Some studies 45-55% with some level of problematic gambling •See more lottery tickets, slot machines, cards for money

42 DSM-5 Gambling Disorder (Univ. of Md. OTP)

No Gambling Gambling Disorder Disorder Characteristics n = 99 n = 85 Age (M ± (SD)) 48.2 (9.2) 46.8 (8.0) Gender – Male 54.5% 52.9% Married or Living with a partner 26.3% 20.0% Race – Black or African American 71.7% 70.6% Complete HS and/or some college 51.5% 61.2% Employed full or part-time 13.1% 10.6% Income < $20,000 last year (n = 182) 85.6% 91.8%

43 DSM-5 Gambling Disorder (Univ of Md OTP)

120

100 46.2% met DSM-5 80 criteria for 60 Gambling Disorder

0 Non-Disordered Disordered Gambler Mild Gambler Moderate Gambler Severe Gambler Gambler (<4) (≥4) (4-5) (6-7) (8-9)

44 DSM-5 Gambling Disorder (Univ of Md OTP)

120

100 75.2% identified as Moderate or 80 Severe Gambler

0 Non-Disordered Disordered Gambler Mild Gambler Moderate Gambler Severe Gambler Gambler (<4) (≥4) (4-5) (6-7) (8-9)

45 Most Common Type of Gambling

Lottery Tickets 81.1%

Scratch Offs 71.8%

Games of Skill 40.5%

Casino 9.2%

46 No Gambling Gambling Disorder Disorder Variables n = 99 n = 85 Purchased lottery tickets Not at alla 30.3% 5.9% Less than 10 times in total 12.1% 2.4% At least once a month 8.1% 1.2% At least once a week 49.5% 90.6%

a Note. denotes significance at p < 47 0.05 No Gambling Gambling Disorder Disorder Variables n = 99 n = 85 Purchased lottery tickets Not at alla 30.3% 5.9% Less than 10 times in total 12.1% 2.4% At least once a month 8.1% 1.2% At least once a week 49.5% 90.6% Monthly spent ($) (M±(SD))a 72.3 (159.1) 302.5 (469.2)

a Note. denotes significance at p < 48 0.05 No Gambling Gambling Disorder Disorder Variables n = 99 n = 85 Purchased instant win tickets Not at alla 37.4% 14.3% Less than 10 times in total 11.1% 1.2% At least once a month 17.2% 13.1% At least once a week 34.3% 71.4%

a Note. denotes significance at p < 49 0.05 No Gambling Gambling Disorder Disorder Variables n = 99 n = 85 Purchased instant win tickets Not at all a 37.4% 14.3% Less than 10 times in total 11.1% 1.2% At least once a month 17.2% 13.1% At least once a week 34.3% 71.4% Monthly spent a 37.9 (76.5) 233.9 (418.5)

a Note. denotes significance at p < 50 0.05 No Gambling Gambling Disorder Disorder Variables n = 99 n = 85 Played casino table games Yes – play at any location 1.0% (n = 1) 18.8% (n = 16) Not at all at a casino 0.0% 12.5% Less than 10 times in total at a 100.0% 25.0% casino At least once a month at a casino 0.0% 25.0% At least once a week at a casino 0.0% 37.5% Monthly spent 0.0% 63.4 (190.2) (casino, bar or online)b

51 Neuroimaging

• Ventromedial prefrontal cortex (vmPFC) •implicated in decision-making circuitry in risk-reward assessment •decreased activation in vmPFC in PG subjects during gambling cues • Also decreased activity in the basal ganglia and thalamus

52 Gambling Disorder & Opioid System

• The mu-opioid system: •Underlies urge regulation through the processing of reward, pleasure, and pain •Contributes to learning & determination of salience •Primarily via modulation of dopamine neurons in mesolimbic pathway through GABA interneurons. • The kappa-opioid system: •Involved with negative reinforcement

53 54 Treatment

• Psychotherapy • Pharmacotherapy • Mutual help

55 Psychotherapy

• Few well-controlled studies • Best evidence for CBT and Motivational Interviewing

56 Gamblers Anonymous

•Founded In 1957 By Jim W. •Open And Closed Meetings • Not Many Open Meetings Secondary To Legal Concerns •Pressure Relief Group • Not Found In AA • Gambler And Spouse Meet With NA members • Bring In Income And Debt Information • The Group Works Out A Budget To Repay Those Owed Money •12 Steps • Similar To AA

57 Pharmacotherapy

Various Medications Studied: • SSRIs • Nefazodone • Buproprion • Atypical antipsychotics • Mood stabilizers/Anticonvulsants • Memantine • Opioid antagonists

None FDA approved

58 Pharmacotherapy

59 Naltrexone •mu, kappa & delta antagonist •Inhibits mu opioid receptor input to the VTA •Ultimately causes decreased DA release •Appears to alter hedonic response Lowering pleasure associated w use/gambling •Multiple open label studies/case reports •5 Double-blind placebo controlled trials Modest effect on gambling behavior •No studies with Vivitrol 59

Pharmacotherapy

60 Nalmefene •Structurally similar to naltrexone •mu & delta antagonist; kappa partial agonist •Less hepatotoxicity than w naltrexone •Used for Alcohol Use Disorder in Europe •Injectable form FDA approved in U.S. in 1995 for opioid overdose (manufacture discontinued) •2 Double-blind placebo controlled trials • Modest effect on gambling behavior 60

Why address gambling problems in SUD and MH programs

•Individuals with substance use & mental health disorders are at higher risk for having a gambling problem •Gambling (even at moderate levels) may have an adverse impact on treatment outcome •Unaddressed gambling and gambling problems are likely to add to treatment costs and service utilization

61 Why address gambling problems in SUD and MH programs

• Gambling may become a sequential addiction for individuals recovering from an SUD

• Gambling can be a relapse risk factor

• Gambling and problem gambling may exacerbate psychiatric symptoms

• Relationship violence and child abuse are related to problem gambling and severely aggravated if substance use is involved.

62 63 Gambling & Recovery

 Even though individuals in recovery from substance use and mental health disorders are at higher risk for gambling problems, this does not mean that gambling always has a negative impact on someone’s recovery

 It is our job to help our patients be aware of and evaluate the risks as well as benefits that gambling can bring to their recovery, and to assist them in making the best informed decisions regarding the role of gambling in their lives and recoveries.

64 Special Case

65 • Pramipexole (Mirapex) • Dopamine agonist • Used to treat Parkinson’s Disease & RLS • Some patients have developed gambling problems •very small number (9 out of 529) •not sure of the etiology

65 Funding

Affordable Care Act

21st Century Cures Act

-State Targeted Response to the Opioid Crisis Grants

-Tribal Opioid Response Grants

-Targeted Capacity Expansion: Medication Assisted Treatment

-State Targeted Response- Technical Assistance

Carefirst, Aetna, Kaiser, etc. grants 66

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Victorri-Vigneau C, Spiers A, Caillet P, et al. Opioid Antagonists for Pharmacological Treatment of Gambling Disorder: Are they Relevant?. Curr Neuropharmacol. 2018;16(10):1418– 1432. doi:10.2174/1570159X15666170718144058

Weinstock, J., Blanco, C., & Petry, N. M. (2006). Health correlates of pathological gambling in a methadone maintenance clinic. Experimental and Clinical Psychopharmacology, 14(1), 87–93.

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69 PCSS Mentoring Program

. PCSS Mentor Program is designed to offer general information to clinicians about evidence-based clinical practices in prescribing medications for opioid use disorder.

. PCSS Mentors are a national network of providers with expertise in addictions, pain, evidence-based treatment including medications for addiction treatment.

• 3-tiered approach allows every mentor/mentee relationship to be unique and catered to the specific needs of the mentee.

• No cost.

For more information visit: https://pcssNOW.org/mentoring/

70 PCSS Discussion Forum

Have a clinical question?

http://pcss.invisionzone.com/register

71 PCSS is a collaborative effort led by the American Academy of Addiction Psychiatry (AAAP) in partnership with:

Addiction Technology Transfer Center American Society of Addiction Medicine American Academy of Family Physicians American Society for Pain Management Nursing Association for Multidisciplinary Education and American Academy of Pain Medicine Research in Substance use and Addiction American Academy of Pediatrics Council on Social Work Education American Pharmacists Association International Nurses Society on Addictions American College of Emergency Physicians National Association for Community Health Centers American Dental Association National Association of Social Workers American Medical Association National Council for Behavioral Health American Osteopathic Academy of Addiction The National Judicial College Medicine American Psychiatric Association Physician Assistant Education Association American Psychiatric Nurses Association Society for Academic Emergency Medicine

72 Session Evaluation and Certificate

• Instructions will be provided in an email sent to participants an hour after the live session • Certificates are available to those who complete an evaluation • Recordings of today’s webinar can be accessed at: www.pcssNOW.org and education.psychiatry.org

73 Educate. Train. Mentor

@PCSSProjects www.pcssNOW.org www.facebook.com/pcssprojects/ [email protected]

Funding for this initiative was made possible (in part) by grant no. 1H79TI081968 from SAMHSA. The views expressed in written conference materials or publications and by speakers and moderators do not necessarily reflect the official policies of the Department of Health and Human Services; nor 74does mention of trade names, commercial practices, or organizations imply endorsement by the U.S. Government.