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Probable and Potential Pathological Gambling

Probable and Potential Pathological Gambling in Methadone Maintenance Treatment (MMT) patients - a cross-sectional study Dr. Miriam & Sheldon G. Adelson Clinic for Drug Abuse Treatment & Research Tel-Aviv Sourasky Medical Center & Tel-Aviv University Sackler Faculty of Medicine

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Probable and Potential Pathological Gambling

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  1. Probable and Potential Pathological Gambling in Methadone Maintenance Treatment (MMT) patients - a cross-sectional study Dr. Miriam & Sheldon G. Adelson Clinic for Drug Abuse Treatment & Research Tel-Aviv Sourasky Medical Center & Tel-Aviv University Sackler Faculty of Medicine Einat Peles, Shaul Schreiber, Miriam Adelson

  2. Impulse-Control Disorders • Pathological Gambling (PG) • Kleptomenia • Pyromania • Trichotillomania • Impulse-control disorder not otherwise specified

  3. Pathological Gambling DSM-IV-TR • Persistent and recurrent maladaptive gambling behavior that disrupts personal, family, or vocational pursuits

  4. DSM-IV-TR קיום 5≥ מהקריטריונים בשנה Substance Dependence Pathological Gambling קיום 3≥ מהקריטריונים בשנה

  5. Mechanism ? (treatment) Mood stabilizer (Litium) Opioid antagonist (naltrexone) Serotonin reuptake inhibitor SSRI (paroxetine) Dopamine reuptake inhibitor (bupropion)

  6. Prevalence- Pathological Gambling • General population: 0.2% (Norway), 2.1% (Australia), 3% (USA) Israel? • Drug abusers 5-39% Israel? • MMT clinics:7% - 52.7% • Israel?

  7. Opiate agonist - long acting (Heroin short acting) T 1/224-36 hrs(Heroin 4hrs) Oral (Heroin injected) No euphoria (Heroin cause) No tolerance in steady dose (Heroin cause) Normalize the HPA (hypothalamic-pituitary-adrenal) axis (Disturbed even after Heroin abstinence ) Methadone

  8. Impact of Short-Acting Heroin versus Long-Acting Methadone Administrated on a Chronic Basis in Humans – 1964 Study "High" Functional State(Heroin) "Straight" "Sick" AM PM AM PM AM Days "High" Functional State(Methadone) "Straight" "Sick" AM PM AM H PM AM Days Dole, Nyswander and Kreek, 1966

  9. MMT Main Goal:Stop Opiate Secondary Goals: Cocaine, Benzodiazepines, Amphetamines, THC, Alcohol Infectious disease Health status Crime, Antisocial behavior (Family, Society) Work Patient retention in treatment

  10. Aims:To find prevalence and characterize pathological gambling in Methadone Maintenance Treatment (MMT) patients.

  11. Methods Study Population (N=300) • Former Heroin addicts patients (DSM-IV) • Adults (18+ years) • Patients admitted to the Adelson MMT clinic in Tel-Aviv medical center, Israel, since July 1993. Study group (n=101) • 101 non-selective group • Studied between July 2003 - July 2004

  12. Methods Study Population (N=300) • Former Heroin addicts patients (DSM-IV) • Adults (18+ years) • Patients admitted to the Adelson MMT clinic in Tel-Aviv medical center, Israel, since July 1993. Study group (n=154) • Non-selective random sample • Studied between June - October 2006

  13. South Oaks Gambling Screen (SOGS) (Lesieur and Blume, 1987). • 20-item questions instrument Potential (problem gambler) = score 3-4 Probable PG = score ≥ 5.

  14. Results

  15. Group Characteristics (N=154) • Age MMT onset 37.9±9y • Age 43.4±9y • Male 64.9%Female 35.5%. • Opiate abuse before MMT 15.4±8.3y • Duration in MMT 5.5±4y • Any Axis I psychiatric disorder 48.4%

  16. Lifetime Potential and Probable Pathological Gamblers (N=154) n=9 n=36 Probable Potential

  17. Lifetime Potential and Probable Pathological Gamblers (N=154) PG (n=45)

  18. Type of gambling by PG and non PG <5% - bet on animals, sports, play game of skill for money

  19. Perceived pathological gambling

  20. Perceived pathological gambling

  21. PG by gender Male (N=100) Female (N=54) 14.8% 37% * Fisher's Exact Test, p=0.005

  22. Differences between PG groups

  23. Differences by gender

  24. Logistic Regression for PG (yes/no)

  25. Yale-Brown Obsessive Compulsive Scale 10-item scale, ranged: 0 none -4 extreme symptoms (total range, 0 to 40) Clinical OCD defined if scored were ≥16 Moderate to Extreme OCD.

  26. Clinical Obsessive Compulsive Disease (OCD) (N=154) OCD 43%

  27. OCD by gender Male (N=100) Female (N=54) 35% 57.4% * Fisher's Exact Test, p=0.01

  28. OCD by PG No PG (N=109) PG (N=45) 39.4% 51.1% Fisher's Exact Test, p=0.2

  29. Proportion of Clinical OCD by genderand PG N=8 * N=37 * N=46 N=63 Fisher’s Exact Test *p≤0.05

  30. Logistic Regression for PG (yes/no)

  31. When PG started? Before ? After Together? with Opiate abuse (N=45) 21.3±5.2 After Together Before opiates 21.7±7.9 24.4% 16.6±6.2

  32. When PG stopped? Before /after opiate start? (N=45) Continued After opiate Before opiate 40.1±12 16±5.9

  33. When PG stopped? Before MMT ? During MMT? (N=45) During 43.1±10.9 Continue Before MMT 51.4±10.7 24.4% 30±10.7

  34. Summary Adequate diagnosis and interventional treatment should be considered due to the expected high rate (23%) of pathological gambling among MMT patients. Male gender, current OCD, and older age on admission to MMT are at greatest risk of lifetime pathological gambling.

  35. Treatment? Mood stabilizer (Litium) Opioid antagonist (naltrexone) Serotonin reuptake inhibitor (paroxetine) Dopamine reuptake inhibitor (bupropion)

  36. PG by gambling legality Tel Aviv (N=178) Las Vegas (N=113) 19.5% 27% Fisher's Exact Test, p=0.05

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