April 2016

Getting Real about Gambling Disorder and Speeding again

savvy

I recently received this message from a long-time Tips and Topics reader: 

“Hi Dr. Mee-Lee: 

I’ve enjoyed Tips and Topics for a number of years and sometimes use excerpts from it as teaching and supervision tools for our students. I was also present for your keynote address to the National Conference on Problem Gambling (NCPG) last year and appreciated your thoughts about removing Substance Use Disorders and Gambling Disorder from their separate silos to help addictions clinicians and programs develop stronger competencies in both areas.

I do have a suggestion for Tips and Topics. Most of the insights in your newsletter relate well to the challenges counselors face working with problem gamblers and their family members, yet almost invariably when Tips and Topics refers to addictions, only Substance Use Disorders (SUDs) are mentioned. I’m wondering if, in the spirit of your keynote address to the NCPG conference, Gambling Disorder can be included, where appropriate. It could help raise the consciousness about this among your readers.Thanks for taking the time to read and consider this. — Rick Berman LPC, CADCIII, CGACII, Director, Problem Gambling Services, Lewis & Clark Graduate School of Education and Counseling

I can’t always respond to all suggestions readers make, but in this one, Rick has a point. I’ve talked before about addiction being more than just substance-related. Moreover, in The ASAM Criteria (2013) on pages 357-366 we even have a whole chapter on Gambling Disorder. Yet I have written or spoken of gambling hardly at all in Tips and Topics. 

So this month’s edition fixes that problem a bit. I will share excerpts of my presentation on July 10, 2015 at the 29th National Conference on Problem Gambling in Baltimore, Maryland: “Getting Real about Gambling Disorder: How The ASAM Criteria Can Help“. 

TIP 1

Why Consider Gambling Disorder? 

American Society of Addiction Medicine (ASAM) Definition of Addiction 

* The Definition of Addiction adopted by the ASAM Board of Directors in April 2011 states that persons with addiction can be seen as “pathologically pursuing reward and/or relief by substance use and other behaviors.” One of those “behaviors” is gambling.

* This definition does not state that Alcohol Addiction, Opioid Addiction, Nicotine Addiction and Gambling Addiction are separate conditions. It states that addiction can be involved with various substances and behaviors. (Nicotine addiction is the other neglected addiction).

* People with addiction manifest a pathological pursuit of reward or relief, and have a “disease of brain reward, motivation, memory and related circuitry” which is “characterized by inability to consistently abstain, impairment in behavioral control, craving, diminished recognition of significant problems with one’s behaviors and interpersonal relationships, and a dysfunctional emotional response.”   

Statistics on Gambling Disorder 

* Gambling Disorder is widespread and often co-exists with substance-related disorders as well as other mental disorders. Various estimates indicate that 1-2% of U.S. adults and 2-4% of U.S. adolescents are diagnosable with Gambling Disorder. (The ASAM Criteria, 2013)

* Lifetime prevalence is about 0.4%-1% – females about 0.2%; males about 0.6%; African Americans about 0.9%; whites about 0.4%; Hispanics about 0.3% (DSM-5, page 587, 2013)

* “Up to half of individuals in treatment for gambling disorder have suicidal ideation, and about 17% have attempted suicide.” (DSM-5, page 587, 2013)

* For 6-9 million Americans, gambling is a damaging behavior that can harm relationships, family life, and careers. (SAMHSA – http://blog.samhsa.gov/?s=Gambling+Disorder#.VYXAHGCnRfQ) 

TIP 2

Getting Real about Health Coverage for Gambling Disorder (The ASAM Criteria 2013, page 358)

* In contrast with substance use disorders, it is currently uncommon for commercial or governmental health plans to offer payment for treatment in residential or inpatient levels of care unless there are co-occurring medical or psychiatric problems, which would, in and of themselves, justify reimbursement for such placements.

* Most insurance companies that do not categorically exclude coverage for the treatment of gambling disorder have had benefits for the treatment of gambling disorders. But those benefits do not include payment for residential or inpatient treatment unless there is another, primary diagnosis such as major depressive disorder. It is the major depressive disorder which generates the reimbursement, not the gambling disorder. A state or local drug and alcohol authority could elect (and some do) to pay for the treatment of gambling disorder, regardless of level of care.

* Even partial hospitalization or intensive outpatient treatment programs for gambling disorder have historically been considered a “non-covered benefit”; patients needed to meet criteria for a substance use disorder or a separate mental disorder in order for payment to be authorized when the treatment focus would otherwise be the person’s pathological gambling.  

* “Across all states, there was a lack of uniformity regarding what types of problem gambling services were funded. Some states funded a comprehensive array of services ranging from prevention through multiple levels of treatment, while other states provided only one service (e.g., a problem gambling helpline or a prevention program).”

* “Among state agencies this variability in services provided was often rooted in the legislation that originally established the problem gambling program. Some states had legislation that restricted the use of funding to specific service areas. Another driving factor for which services were funded was linked to budget pragmatics, such as having insufficient funds to expand the range of services offered.” (2013 NATIONAL SURVEY OF PROBLEM GAMBLING SERVICES, March 2014) 

TIP 3

Getting Real about Staff Credentials and Competence for Gambling Disorder (The ASAM Criteria 2013, page 358)

* Staff providing treatment to patients with gambling disorder should have a state-sponsored or -approved Gambling Counselor Certification.

* Not all states have such credentialing – some states accept a national credential such as the National Certified Gambling Counselor (NCGC), provided by the National Council on Problem Gambling.

* State certification or licensure as an Alcohol and Drug, Chemical Dependency, or Substance Abuse Counselor should not be considered a substitute for or equivalent to a Gambling Counselor Certification.

* In the future, the evolution of professional training and professional certification, possibly being influenced by the 2011 ASAM Definition of Addiction, may mean that all addiction counselors will receive sufficient training in addiction associated with gambling, and thus separate certification will not be necessary. But at this time, there are relatively few well-trained and certified Gambling Treatment counselors. 

TIP 4

Getting Real about Filling Gaps for Gambling Disorder 

2013 NATIONAL SURVEY OF PROBLEM GAMBLING SERVICES: Survey participants were asked to identify one item as their state’s “greatest obstacle in meeting service needs to address problem gambling.” 

* “Inadequate funding” was most frequently identified as the largest gap.

* The second most commonly endorsed service gap was a lack of public awareness about problem gambling.

* Problem gambling treatment availability.

* Need to increase the number of treatment providers.

* Improve research.

* Increase the number of prevention providers.

* Improve information management services.

* Increase the size of administrative staff.

References

American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Arlington, VA, American Psychiatric Association, 2013. 

2013 NATIONAL SURVEY OF PROBLEM GAMBLING SERVICESPrepared by Problem Gambling Solutions, Inc. for Association of Problem Gambling Service Administrators (APGSA) and the National Council on Problem Gambling (NCPG). March 2014 

Mee-Lee D, Shulman GD, Fishman MJ, and Gastfriend DR, Miller MM eds. (2013). The ASAM Criteria: Treatment Criteria for Addictive, Substance-Related, and Co-Occurring Conditions. Third Edition. Carson City, NV: The Change Companies.For more information on the new edition: www.ASAMcriteria.org 

“The Definition of Addiction” Adopted April 12, 2011.http://www.asam.org/quality-practice/definition-of-addiction

skills

Note the following about gambling:

  • Gambling problems are assessed under ASAM Dimension 3, Emotional, Behavioral or Cognitive Conditions and Complications.
  • Gambling commonly co-occurs with substance use disorders (SUD).
  • Either gambling or substance use may act as a trigger for relapse to the other disorder.
  • Screening for gambling problems should be a routine part of SUD assessment.

TIP 1
Getting Real about Screening and Assessment for Gambling Disorder
(The ASAM Criteria 2013, page 361)

The purpose of screening is to conduct a preliminary inquiry to rule an individual “in” or “out.” If “ruled in,” the next step is to perform a comprehensive diagnostic assessment using the DSM-5 criteria for Gambling Disorder.

Once a Gambling Disorder diagnosis is established, the next question – answerable by use of The ASAM Criteria – is: What is the severity of the disorder? Severity of illness guides the clinician to an intensity of service recommendation for the patient.

  • There are over 27 instruments for identifying disordered gambling, though there is debate about them and what they measure.
  • An appropriate instrument should be able to screen for gambling disorders in both the general population and a population of persons who have a substance use disorder.

Two screening tools are recommended.

A. The first is the two-item “Lie/Bet Screen.”

  • Advantage is that it is only two questions, and is more likely to be used in community and clinical settings where clinicians feel overwhelmed with current assessment responsibilities and other paperwork.

The “Lie/Bet” two item questionnaire are:
1) Have you ever had to lie to people important to you about how much you gambled?

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

B. The second and better-known and researched screening instrument is the South Oaks Gambling Screen (SOGS), a 16-item scorable questionnaire, which is in the public domain and can be found on the Internet.

TIP 2
Compare and Contrast ASAM Multidimensional Assessment for Substance Use Disorders versus Gambling Disorder.
ASAM Multidimensional Assessment (The ASAM Criteria 2013, page 362-363)

Here are examples of questions that would be asked in a multidimensional assessment of individuals with substance use disorders; and questions as they would apply to individuals with gambling disorders. The italics identify the differences. There are such common characteristics between assessment of both disorders, with the least overlap being in Dimension 1: Acute Intoxication and/or Withdrawal Potential. The assessment questions of the other dimensions are generally a very close match.

ASAM Criteria Dimension 1: Acute Intoxication and/or Withdrawal Potential
Sample Questions:

  1. Substance Use Disorder:
    Are there current signs of withdrawal?
  1. Gambling Disorder:
    Are there current signs of withdrawal (restlessness or irritability when attempting to cut down or stop gambling)?

2. Substance Use Disorder:
Does the patient have supports to assist in ambulatory withdrawal management if medically safe?

2. GamblingDisorder:
Does the patient have supports in the community to enable him/her to safely tolerate the restlessness or irritability when attempting to cut down or stop gambling?

3. Substance Use Disorder:
Has the patient been using multiple substances in the same drug class?

3. Gambling Disorder:
What forms of gambling has the individual engaged in? Has the patient also been using psychoactive substances to the point where alcohol or other drug withdrawal management is necessary?

ASAM Criteria Dimension 2: Biomedical Conditions and Complications
 Sample Questions:

  1. Substance Use Disorder:
    Are there current physical illnesses, other than withdrawal, that need to be addressed or which complicate treatment?
  1. Gambling Disorder:
    Are there current physical illnesses, other than withdrawal, that need to be addressed or which complicate treatment? Does the individual manifest any acute conditions associated with prolonged periods of gambling (e.g., urinary tract infection)?

2. Substance Use Disorder:
Are there chronic illnesses, which might be exacerbated by withdrawal (e.g., diabetes, hypertension)?

2. Gambling Disorder:
Are there chronic medical conditions such as hypertension, peptic ulcer disease, or migraines that might be exacerbated by either cessation or continuation of the gambling behavior?

ASAM Criteria Dimension 3: Emotional, Behavioral or Cognitive Conditions and Complications
 Sample Questions:

  1. Substance Use Disorder:
    Do any emotional/behavioral problems appear to be an expected part of addiction illness, or do they appear to be separate?
  1. Gambling Disorder:
    Do any emotional/behavioral problems appear to be an expected part of the gambling disorder, or do they appear to be separate?

ASAM Criteria Dimension 4: Readiness To Change
 Sample Questions:

  1. Substance Use Disorder:
    If willing to accept treatment, how strongly does the patient disagree with others’ perception that s/he has an addiction problem?
  1. Gambling Disorder:
    If willing to accept treatment, how strongly does the patient disagree with others’ perception that s/he has a gambling problem?

ASAM Criteria Dimension 5: Relapse, Continued Use or Continued Problem Potential
 Sample Questions:

  1. Substance Use Disorder:
    How aware is the patient of relapse triggers, ways to cope with cravings, and skills to control impulses to use?
  1. Gambling Disorder:
    How aware is the patient of relapse triggers, ways to cope with cravings, and skills to control impulses to gamble?o accept treatment, how strongly does the patient disagree with others’ perception that s/he has a gambling problem?

ASAM Criteria Dimension 6: Recovery Environment
 Sample Questions:

  1. Substance Use Disorder:
    All Recovery Environment questions similar between SUD and gambling disorder. An additional question listed for Gambling Disorder
  1. Gambling Disorder:
    Are the patient’s financial circumstances due to the gambling or associated legal problems an obstacle to receiving or distraction from treatment, or a threat to personal safety (e.g., loan sharks)?

soul

What do January 2006, May 2010, October 2011 and April 2016 all have in common? Before you feel bad these might be some historical events you should know about, let me hasten to say that these dates only matter to ME.

You might be thinking: So why are you talking to me about dates that only matter to you? Because, there but for the grace of God go you. Actually, as I think about it, it has nothing to do with the “grace of God”. It has all to do with inattention, lack of commitment and risky behavior.

I did it AGAIN! I landed a speeding ticket this week, driving in Maine after a full day of training in Portland, Maine. If you’ve been a Tips and Topics reader for some years, you may remember the speeding topic has come up before in SOUL. Here are the links if you want to feel superior to me:

January, 2006
May, 2010
October 2011

I don’t have a speeding addiction. That’s not “denial”; it is just a fact that by comparing my speeding with the “Lie/Bet” two item questionnaire for gambling disorder, I am zero-zero. I understand that’s a screening tool for gambling addiction not speeding, but it is comparable, trust me. I compared my speeding with the diagnostic criteria for gambling disorder and I didn’t come close to the required threshold for addiction. As well, I don’t want to trivialize the devastating disease and real tragedy of substance-related and gambling addiction by throwing around the word “addiction” and my speeding.

This is not to say, however, that I can sound like a person not yet in recovery from addiction. Here are reasons I am not addicted to speeding:

  1. Three of the four times I received a speeding ticket, I was driving a rental car. In my familiar car at home, I can feel when I’m speeding. (Oh, so they don’t have speedometers in rental cars that you can look at and monitor your speed?!)
  2. In the 2010 incident I was driving a brand new Prius, not yet used to the feel of speeding like in my old familiar car. (Oh, so again, the Prius didn’t have a speedometer to look at and monitor your speed?!)
  3. I thought I was following the flow of the traffic, so I bet I wasn’t the only one speeding. Why didn’t they catch them? It was probably racial or professional profiling, picking on Australian-born Chinese psychiatrists. (Yeah, right.)
  4. This latest speeding ticket was only for 79 mph in a 70 mph zone. Well actually the police officer took pity on me. Since it was decades since I have had a violation in Maine, he reduced my “speed” from the 83 mph to 79 (and saved me some dollars.) (79 mph and certainly 83 mph are both breaking the law and are both speeding – 70 mph is 70 mph, not 79 mph or 83.)
  5. The police are just trying to raise revenue by ticketing good citizens like me. They should be out there stopping real criminals like burglars and murderers. (So your illegal behavior is not as bad as those crimes, so you should get a break?!)

I surrender. My inattention, lack of commitment to not speeding, and risky behavior got me the ticket. I’m telling you now in hopes that my fine, my bank account and my public confession will change my speeding ways.

sharing solutions

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This 48-page facilitator guide provides quick and easy to use reference for facilitation; offers core activities and alternative strategies; highlights key journaling activities with mini-pages.Here it is: https://www.changecompanies.net/products/?id=SBF
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