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Addiction

Addiction. Centre. PROGRAM. Network. Addressing Comorbidities* in the Treatment of Gambling Problems Nady el-Guebaly, MD Professor & Head, Division of Substance Abuse, University of Calgary Medical Director, Addictions Program, Calgary Health Region.

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Addiction

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  1. Addiction Centre PROGRAM Network Addressing Comorbidities* in the Treatment of Gambling ProblemsNady el-Guebaly, MDProfessor & Head, Division of Substance Abuse, University of CalgaryMedical Director, Addictions Program, Calgary Health Region * “Two or more concurrent, independent disorders in single individual interacting in the clinical picture”

  2. Community Prevalence: Problem vs Non-Gambler OR ECA (2) NESARC (3) CCHS (4) N=36984 1 problem = 161 N=42898 Gamblers 14934; incl 29 PG DSM III PG .42; N=195 Problem = 1513 Comorbidities with (1): OR Lifetime OR OR Substance Use Disorders: Alc 3.3 73% 6.0 2.9 Nicotine 2.1 60% 6.7 Illicit 1.3 38% 4.4 Mood Disorders: 3.3 50% 4.4 1.8 (Mood & Anx) Bipolar 3.4 --- 2.3 (5) Suicidality 1.6 --- Anxiety Disorders, spec Phobias (not OCD) 2.3 41% 3.9 Somatoform Disorders 3.0 --- Schizophrenia (severe & persistent MI) 3.5 --- Both 5.2 ADHD? --- 20% trt Antisocial Personality (1ery & 2 ary) 6.1 61% PD 6.0 (obsC, par) >F • 1. Crockford, el-Guebaly. Can Psych 1998;43:43-50. • 2. Cunningham-Williams, et al. Am J Public Health 1998;88:1093-1096; St. Louis DSM III DIS • Petry et al. J Clin Psychiatry 2005; 66:564-573; Nat Epid S Alc & Related Conditions; DSM IV AUDADIS; lifetime • el-Guebaly N et al J Gambling Stud 2006; 22: 275-287; CPGI, 12 m prev • McIntyre et al. J Affective Dis 2007 [In Press]

  3. Correlation with Smoking & Alcohol –Can Community Health Survey (CCHS) 2003 – Stats Can Signif .000 = *** - Other drugs including marijuana NS

  4. RISK OF GAMBLING CPGI 8-16 Thinking about the past 12 months (scale 1-4): • Have you bet more than you could really afford to lose? • Have you needed to gamble larger amounts to get same excitement? • Have you gone back another day to try & win back the money you lost? • Have you borrowed money or sold anything to get money to gamble? • Have you felt that you might have a problem with gambling? • Have people criticized your betting or told you that you had a problem? • Have you felt guilty about the way you gamble? • Has your gambling caused you any health problems (stress & anxiety)? • Has your gambling caused any financial problems?

  5. Correlation with Personality Assessment Inventory (PAI) – Morey, 1991 Signif .000 = *** - Composite Intern Diagn Interview (CICD-SF/DSM IV) = NS

  6. Correlation for SF-8 Health Survey (Ware et al, 2001) Signif .000 = ***

  7. Correlation with Childhood Trauma Questionnaire (CTQ) – Bernstein & Fink, 1998 ALSO: Vietnam Vets Twins Registry – Health Related QOL: gambling, SUD & MH> Physical PG & Depression (Potenza et al): Overlap Genetics> Environment Shared stress response, impulse control? µ alleles & naltrexone? Sig .000 = ***

  8. Case “A” (1) • 42 y/o, married female; postal clerk 8 y; 2 daughters: 20 y & 14 y • “Job was stressful”; ending a 4 yr educational leave; • Quite involved in her union • PRESENTING COMPLAINT: GAMBLING (last 3 yrs): - progressive increase in VLT use - currently gambles ~ once/week, 8-10 hours/session, spending 3-600$ each time - last month, stole husband’s bank card: worried! - reported being given the “run-around” when seeking help & no follow-up

  9. “A” (2) SUBSTANCES - age 18-24, 26 oz liquor every W/E, many blackouts; currently drinking once/week, 4 drinks/sitting - one joint of cannabis/day, “most difficult to give up” - 1/2 pack cigs/day - experimented with solvents, LSD & cocaine - FH +ve: mother & 5 out of 7 siblings from 4 fathers have alcohol problems

  10. “A” (3) DEPRESSION/DYSTHYMIA - emotional abuse from parents & siblings, no sexual abuse - episodes of depression throughout her life, particularly severe 1 yr ago - occasional suicide ideation & one serious attempt - Paroxetine 20 mgm/day

  11. “A” (4) CHRONIC PAIN - chronic cervical disc degeneration from “repetitive movement at work” - history of TM Jaw pain & fainting spells for 6 years - Medications: Tylenol #3, 3 times/day Elavil, 150 mgm hs, for sleep & pain Physical comorbidities? • Stress related disorders, • Medication side-effects • CHR 1000/3 hospital-wide consults: 12 Prob G, all MH • Survey of 51 New Zealand urban & rural practices (N=2536): no relation with physical inactivity or weight concerns

  12. “A” (5) PERSONALITY - 5 y ago, 6 m psychological FU for Union “bullying” - Charge of mischievous conduct; running key down co-workers’ cars with whom she had difficulty - Postal service may release her; on probation for abusing educational leave. She plans legal action. COURSE: motivated to seek help for GAMBLING! - Residential program entered but on relapse wished to deal with “one addiction at a time” - Repeated complaints up “the managerial chain” about “personality conflicts” with therapist!

  13. The Role of Gambling? PRESENTING COMPLAINT: GAMBLING (last 3 years) BUT • Substances • Depression/Dysthymia • Chronic Pain • Personality • Treatment Course WHERE TO START? • Rules of engagement “common ground” • Find out sources of strength & your true friends “co-therapists”: sig other; daughters? • Address the behaviors! • No RCTs! the closest : - Hollander et al ’02: lithium & bipolar spectrum gamblers - Grant & Potenza ’06: Escitalopram “open label” anxiety & gamblers (N=13 - 12 w)

  14. (2) SUBSTANCE DEPENDENCE (1) PATHOLOGICAL GAMBLING Persistent & recurrent maladaptive gambling 5+ (if not mania) Maladaptive pattern of substance use 3+ within 12 months: 1. Tolerance 2. Withdrawal 3. Unsuccessful efforts to cut/control 4. A great deal of time spent to obtain substance 5. Substance taken in larger amounts or over a longer period than intended 6. Important social, occupation or recreation given up or reduced 7. Use is continued despite physical or psychological problems 1. Increasing amounts of money for excitement 2. Restless or irritable when cutting down/ stop 3. Unsuccessful efforts to control, stop… 4. Preoccupied with gambling 5. Escaping from problems or dysphoria 6. Lies to family members, therapist, or others 7. Illegal acts to finance gambling 8. Jeopardized or lost significant opportunities 9. “Chasing” one’s losses 10. Relies on others for money COMORBID IMPACT: - Rosenthal & Lesieur DSM “plot” addiction-impulsivity-compulsivity Loss of control? Is persistence of erroneous cognition = physiological craving? - See-Saw association - Anti-craving meds: Naltr/Nalmefine - Range of Support: OP  residential; Twelve Steps

  15. (3) MOOD DISORDERS • Sadness  MAJOR DEPRESSIVE EPISODE > 2 wks A. Depressed Mood + B. 4 for either: - change in weight, sleep … - feelings of worthlessness or guilt, - difficulty thinking or concentrating - recurrent thoughts of death/suicide + plan • DYSTHYMIC DISORDER > 2 yrs More days than not, chronic, less severe depressive symptoms • COMORBID IMPACT:Role of SSRI’s; ineffectual with substance CBT – gambling + depression? Suicide assessment

  16. MANIC/BIPOLAR EPISODES Mood Stabilizers: Lithium; Anticonvulsants Group Support, ie, Integrated Group Therapy (Weiss) Interpers & Social Rhythm Therapy (Frank)? ANXIETY DISORDERSFear & Tension reduction  “lost in machine” Bi-directional and complex, i.e., social phobia preceding & GAD following alcohol! SCHIZOPHRENIA Withdrawal  AISH & Internet Lower “cumulative” threshold of care! Concurrent approach Review diagnoses after behavior ends!

  17. (4) CHRONIC PAIN & DISABILITY TREATMENT PHASES • Assessment • Education & CBT group – 10 wkly Sessions • Claresholm Residential Program for Taper & Rehab 3 – 24 wks • Follow-up support groups

  18. (5) AXIS II - PERSONALITY DISORDER CLUSTERS A. Paranoid* B.ANTISOCIAL: impulsivity + disregard rights C. Avoidant Schizoid Borderline: impulsivity + affect instability Dependent Schizotypa Histrionic Obsessive-Compulsive* Narcissistic* (N Petry P109) > 33% NOS COMORBID IMPACT: Idiopathic or Symptomatic? Continuum with Normalcy  Stigma Therapy subject to: Crisis/Consequences Introspection potential

  19. Case management SPECIFIC OBJECTIVES + Level I (Pre-Contemplation) < 6 individual Build motivation for change Level II (Pre-Contemplation) Group (2/wk for 3 wks) Engagement & assessment; Assess group treatment suitability Move patient into action ( Level IV) Reduce psychiatric/Add symptoms Engage supports (e.g., AA). Level III (Contemplation) (3 days/wk) Level IV (Action & Maintenance) (5 days/wk) Prevent relapse  Confidence;  Psychiatric/SA symptoms Open: harm reduction & support Couple: prevent relapse,  communication Chr pain: reduce med reliance,  non-drug coping GAMBLING: CBT & PREVENT RELAPSE (8 sessions) Speciality groups Inpt for Crisis stabilization only ADDICTION CENTRE ADULT OUTPATIENT SEQUENTIAL/CONCURRENT FLEXIBILITY = RETENTION!

  20. What about Mrs. “A”? July Assessment; Family? enabling or detached Sept-OctSecond residential program During childhood was the family social worker H sold marihuana; she gambled his money! Strengths: a leader in groups; attended GA; spiritual life Oct-Dec On discharge: no shows, no GA; using alcohol & marihuana Anxious about return to work; enquired about ADHD? Requested sole focus on “gambling” which was refused Angry phone call to managers in Nov about “personality conflict” & need to switch therapist DecDischarge back to GP with information – latter acknowledged PD PROGNOSIS “It’s a long life!” – she is a bright, resourceful lady Loss of job/income may be the crisis required Couple therapy? Or separation? Anger management Crisis management until meaningful involvement

  21. A. GENO-PHENOTYPES? Serotonin – impulse control Endorphin – urges, cravings Dopamine – reward, re-enforcement Norepinephrine – arousal, excitement B. SEVERITY LEVELS Social Abuse & Dependence LI, LII, L III Non-problem  Problem  Pathological C. ONSET (Early  Late), Childhood stability & Psychopathology Blaszczynski’s Pathways D. CORMORBIDITIES % range SUD incl nicotine 20 – 70 Mood 30 – 75 Anx/PTSD 20 – 40 Impulse control 20 (sex, spending) Antisocial 20-40 PG: TYPOLOGY OF BEHAVIORAL DRIVERS? COMPULSIVE Body dysmorphia Anorexia Tourette Path Gambling Sexual compulsions Impulsive PD IMPULSIVE “Repetitive behavior with inhibition defect, ADDICTION: Behavior with tolerance, withdrawal i.e., from hyper-vigilance & rituals to risk seeking & loss of control causing harm “cravers”

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