Don’t Bet On It – Preventing Teen Gambling

1. Don’t Bet On It – Preventing Teen Gambling Cele Fichter DeSando, MPM Addiction Medicine Services, WPIC, UPMC

2. Today’s Training Teen Gambling: A Growing Epidemic

3. Today’s Training • Explore adolescent problem gambling progression and risk and protective factors • Define problem and pathological gambling including DSM-V stages and criteria. • Identify the prevalence and relationship of problem gambling to alcohol, tobacco and other substance use as well as psychiatric disorders. • Provide a survey review of research-based screening/interview tools and resources for treatment. • Provide research-based prevention and intervention school and student assistance program strategies to prevent and delay adolescent problem gambling.  

4. What is Gambling? Gambling is an activity in which something of value is risked on the outcome of an event when the probability of winning and losing is less than certain. (Korn and Shaffer 1999).

5. What is Pathological (Disordered) Gambling? • Disordered gambling is classified as persistent and recurrent maladaptive gambling behavior that disrupts personal, family, or vocational pursuits and is not better accounted for by a manic episode. Source: American Psychiatric Association (APA), Diagnostic and Statistical Manual, Revision IV – Text Revision (DSM-IV-TR), (APA, 2000). • Previously categorized as an impulse control disorder but recently moved to addiction-related disorders in DSM-V

6. In DSM-V – Gambling is listed as addiction related disorder instead of old classification of impulse control disorder. The rationale for this change is that the growing body of scientific literature, especially on the brain’s reward center, has revealed commonalities between pathological gambling and substance-use disorders. Loss of control Preoccupation, urges, pathological “wanting”, cravings, associated “highs” Negative impact on major areas of life Major impacts on mood. Judgment and insight Tolerance/ Withdrawal Hereditary nature Similar treatment success-12 step and cognitive behavioral therapy Similarities to Addictions

7. Gambling as Pervasive RecreationIncreasing Opportunities • Gambling in many different forms has long been a part of the history of the world • 48 states have some form of legalized recreational gambling in the form of Bingo, Lottery, Race Track, Slots, Poker, Table Games, Sports Betting* • New Frontier -Online Gambling is widespread, yet unregulated, technically restricted and under contention in the US – Regulations change rapidly – Nevada and New Jersey recently passed legislation to allow online, while in-state, is PA next? *Exception of Utah and Hawaii

8. Who Gambles? • 85% of U.S. adults have gambled at least once in their lifetimes (60% -80% in any given year ) • 3-5% have a gambling disorder. (The National Council on Problem Gambling, 2010). • The majority of the population can gamble without negative consequences

9. Betting on a Sure ThingWho has a Problem? • 1% + are estimated to be pathological gamblers (PG) • 2-3% are considered problem or subclinical gamblers • Disordered Gambling is a term used to describe the full range of gambling problems.

10. Upping the Ante:Teens and Gambling • 2.8-8% of Adolescents and college students exhibit problem and pathological gambling (NORC,1999) • Student athletes particularly vulnerable • Affects all races – differences are found in the types of games played, belief about money, finances and self worth, • Disproportionate number of smokers, substances abusers, mentally ill and poor are problem gamblers

12. Adolescents 5-6% meet criteria 8-8% at risk for developing Elderly Harder to recoup financial losses Military – All branches run oversees slots for recreation and to make money for social events Casino Workers Chicken or the egg? Incarcerated #1 pastime is gambling Substance Use Disorders 6-10x risk for PG Lower SES Problems develop sooner Vulnerable Populations

13. 60-90% have gambled Similar, internationally Strong pop culture influences No monitoring system Societal, parental acceptance How much do adolescents gamble?

14. Win money Social activity Excitement Competition Fantasy Family members Reasons for gambling

15. Characteristics of Low Risk Gambling • Low risk gamblers know that over time nearly everyone loses. The benefit is in the social and entertainment activity not an expectation of financial gain. • Low risk gambling has limits on frequency and duration. • Low risk gambling has predetermined, acceptable limits for losses as in the acceptable and affordable cost of an entertainment activity. • Does PA have a gambling problem?

16. Gambling Ambivalence Love the Money – Hate the Problems

17. Societal Approval and Fallacy

18. Gambling and SpendingHow much is too much? • 2002 U.S. legal gaming revenue was $68.7 billion. • In 1999 the National Gambling Impact Study Commission estimated the annual cost to society of problem gambling was $5 billion. • It is estimated that in 1997 Americans collectively wagered more than $1/2 trillion (National Research Council, 1999) • Consumers spend more on legal gaming in the U.S. than most other forms of entertainment combined (1998 Gross Annual Wager Report, 1999) • Sports betting -38 billion legally wagered-380 billion illegal

19. $600 billion wagered annually Revenue Comparisons (2005) Gambling (Legal) $83 Billion per year DVDs: $22 Billion per year Cigarettes: $19 Billion per year NIH Annual Budget: $30 Billion per year (American Gaming Association, CDC, Hollywood Reporter) “Gambling Nation”

20. Pennsylvania Monthly Casino Gambling – Table games

21. Pennsylvania Casino Gambling Slot Machines

22. PA Casino Amounts Wagered – Gambler’s Fallacy • Table Games • 2010-11 - $507,711,162 • 2011-12 - $663,854,672 • 2012-13 - $ 713,107,163 Slots 2006-07 - $ 5,055,282,636 2007-08 - $17,288,615,432 2008/09 - $22,509,815,164 2009/10 - $29,308.239,022 2010/2011 - $29,759,096,846 2011-12 - $ 31,164,547,147 2012-13 - $30,819,486,036

23. Of the 23 states with casinosName the top three states for gambling revenue • Nevada 10.860 billion • Pennsylvania 3.158 billion • New Jersey 3.051 billion

24. Gambling Ambivalence and DistortionIt’s all about the Marketing Your chances of being murdered 1 in 18,000 Your chances of winning Mega Millions Lottery 1 in 135,145,920

25. What are the odds you’ll become a problem gambler? • Pathological gambling is hypothesized to be caused by a complex interplay involving neurobiological, genetic, psychological and social risk factors. (Shaffer et al. 2004c) • There is evidence of associations between pathological gambling and a variety of neurotransmitters (e.g. noradrenaline, serotonin, glutamate, dopamine and endorphins); (Potenza 2008).

27. The Brain and Addiction

28. Dopamine and Nicotine Dopamine is a brain chemical involved in many different functions including movement, motivation, reward and addiction. Altering dopamine levels alters the normal communication between neurons

29. Gambling as a Brain Disease

30. Potenza’s Imaging Studies (PG vs Normals) Decreased activity in: Left ventromedial PFC (Decision-making) Orbitofrontal cortex (processing of rewards, dealing with uncertainty, inhibiting responses) Anterior Cingulate (Decision-making) Ventral striatum (NA, Limbic system) Neurobiology of PG(Neuroanatomy)

31. Are brains of problem gamblers different? • Pathological Gamblers exhibit lower activity in prefrontal cortex compared to Non-PGs • In performing neuro-cognitive tests, PGs showed similar dysfunctions in prefrontal cortex as Methamphetamine addicts Potenza et al., 2003

32. This Is Your Brain on Gambling fMRI of subject anticipating a monetary win in simulated game fMRI of subject anticipating a small amount of cocaine Breiter et al., 2001

33. No toxicology test to diagnosis it; easier to hide Behaviors are not due to drug effects (thus, makes it more open to shame/guilt) Directly associated with financial gains and losses – accolades and blame for same behavior Greater uncertainty of outcome (i.e. anything can happen) Ego related symptoms- gambling can boost ego or cause discord with self image More Socially acceptable Differences from Addictions

34. Similarities / Difference • Immediate gratification • Addictive: preoccupation, inability to stop, tolerance & withdrawal, progressive • Cravings & urges • Denial is common • Accompanying depression / anxiety • Blackouts / brownouts • Disassociation • Mechanism for escape • Dysfunctions in the family often present • Gambling more hidden • Impossible to overdose on gambling • No ingestion of chemicals • Labile financial situation • More unpredictable outcome • Generally not perceived as a disease • Fewer resources for gamblers • Faster progression

35. DSM-V Workgroup on Gambling Disorder • Gambling Disorder can be episodic or chronic, and the course of the disorder can vary by type of gambling as well as life circumstances (Hodgins and el Guebaly, 2004; Slutske, 2006). For example, an individual who wagers problematically only on football games may have Gambling Disorder during football season and not wager at all, or not wager problematically, throughout the remainder of the year. Gambling Disorder may also occur at one or more points in an individual’s life but be absent during other periods. Alternately, some individuals experience chronic Gambling Disorder throughout all or most of their lives.

36. DSM-V Criteria • A.     Persistent and recurrent problematic gambling behavior as indicated by four (or more) of the following in a 12-month period:            1.needs to gamble with increasing amounts of money in order to achieve the desired excitement            2. is restless or irritable when attempting to cut down or stop gambling            3. has repeated unsuccessful efforts to control, cut back, or stop gambling            4. is often preoccupied with gambling (e.g., persistent thoughts of reliving past gambling experiences, handicapping or planning the next venture, or thinking of ways to get money with which to gamble)

37. DSM-V Criteria 5.   gambles often when feeling distressed (e.g., helpless, guilty, anxious, depressed)  6. after losing money gambling, often returns another day to get even (“chasing” one’s losses)  7.  lies to conceal the extent of involvement with gambling 8.  has jeopardized or lost a significant relationship, job, or educational or career opportunity because of gambling  9.  relies on others to provide money to relieve desperate financial situations caused by gambling B.     The gambling behavior is not better accounted for by a Manic Episode.

38. What are problem gamblers looking for? With all of the negative consequences why continue to gamble? • Action – Looking for excitement “rush” • Escape – Looking for relief from painful emotions or stress Lesieur and Rosenthal (1991).

39. Many adolescents think they can become professional

40. Action Gamblers • Gambles for excitement , competition • More likely to engage in “skilled” forms of gaming. (sports betting, poker, etc). • More likely to have early onset of gambling • Longer progression from regular to out of control (addicted) gambling • More likely to be male • More likely to present narcissistic or antisocial traits

41. Bragging Denial Fallacy of Skill

42. Allure Appeals to Action and Escape Gamblers

43. Escape Gamblers • Gambles for relief, escape from stress or negative affect • More likely to engage in passive, luck forms of gambling (Lottery, slots, bingo) • Shorter progression from regular gambling to out of control behavior • More likely to be female • More likely to be have experienced chronic depresssion

44. Escape - Gambling looks like fun – and it is!

45. Problem Gambling Progression: When it stops being fun • Winning Phase- gamblers experience a big win or series of wins resulting in unreasonable optimism or belief in their ability to win. • Losing Phase-gamblers begin bragging and thinking about past wins, secretly gambling and begin to chase their losses. • Desperation Phase- gambling increases in time, frequency and amount. Remorse, alienation and problems increase. • Hopeless Phase – Gambler no longer believes there is help or hope. Lesieur and Custer (1984).

46. Upping the ante: What’s the Problem with Problem Gambling? Several studies have documented the relationship between problem gambling and specific health issues. • Mental Health – Gamblers are at increased risk for major depression, anti-social personality disorder, phobias and other mental conditions. Problem gamblers were also identified as being at increased risk for alcohol, nicotine, and other drug abuse. Potenza, (2008).

47. Double or Nothing • Individuals with mental and/or substance use disorders are 17 times more likely to develop pathological gambling • Pathological Gamblers are 5.5 more likely to have to have had a substance use disorder (Kessler et al. 2008) • 75% of pathological gamblers have had an alcohol disorder; 38% have had a drug use disorder; 60% have had nicotine dependency (Petry et al. 2005). • Recreational Gamblers smoke at same rate as general population, 60-80% of pathological gamblers smoke.

48. The Hidden Vigorish Genetic and Familial Factors • Research consistently shows higher rates of pathological gambling in teens whose parents gamble too much (Gupta & Derevensky, 1997; Jacobs, 2000; Wallisch & Liu, 1996) • Children of problem gamblers have been shown to have higher levels of use for tobacco, alcohol, drug use, and overeating than do their classroom peers (Gupta & Derevensky, 1997)

49. The Hidden Vigorish Co-occurring disorders • In treatment-seeking pathological gamblers, 32-76% of patients evidenced other mental health problems, with anxiety, depression, and suicide being most common. • Problem gamblers are 4 times more likely to have major depression than non-problem gamblers • Suicide attempt rates are 17% -24% for problem gamblers (US DHHS,SAMSHA, 2005)

50. The Hidden Vigorish • Gambling problems may be major impediments to recovery and contributors to relapse in mental health and substance abuse disorders.