Oregon Problem Gambling Helpline
Primary Care Providers
Jeffrey Marotta, Ph.D.
If you treat adult patients, you’ve provided care to someone who has a gambling disorder – whether you knew it or not. Although 1 in 10 primary care patients may have a gambling problem,1 you won’t find patients volunteering information about their gambling behavior. Instead, they present with secondary symptoms such as depression, anxiety, sleep disturbances, headaches, or other somatic symptoms associated with stress.
Although most health care providers are aware of problem gambling, studies find that very few ask their patients about problem gambling.2,3 Data from multiple sources suggests that problem gambling poses a threat to public health. Increased awareness and early intervention are the keys to reducing the personal, family, and social costs of problem gambling.
Physicians can play an integral role in this process by recognizing early signs of problems, motivating patients to seek help, and readily providing useful referral resources such as the number to the Oregon Problem Gambling Helpline (call 1-877-MYLIMIT or log onto 1877mylimit.org). We are fortunate in Oregon to be home of an award winning problem gambling treatment system. In Oregon, treatment directed at problem gambling, for both gamblers and family members, is fully subsidized by revenues generated by the Oregon Lottery.
How big is the problem?
Persons seeking medical care generally have higher psychiatric co-morbidity rates than the general population. This is true for chemical dependency and for problem gambling. Studies conducted in Oregon found past-year prevalence rates in adults of 1% for pathological gambling and an additional 1.7% for problem gambling.4 However, the prevalence of problem gambling among persons entering a primary care setting appears to be closer to 10% (6.2% for pathological gambling and 4.2% for problem gambling).1 The incidence rate of problem gambling is expected to grow as gambling becomes more culturally accepted and legalized gambling opportunities expand.5
How is problem gambling associated with patient health?
Problem gambling affects not only the gamblers and their family finances, but also their mental and physical well-being. Similar to other addictive behaviors, gambling is often considered a precipitating factor in a variety of health problems. Several studies have documented the relationship between problem gambling and specific health issues found in general medical care.6 The three broad categories of co-occurring conditions include mental health problems, chemical dependency problems, and stress related problems. Problem gamblers have been identified as being at increased risk of dysthymia, major depression, anti-social personality disorder, phobias, and chemical dependency. Studies identify problem gamblers as being at increased risk for cardiac arrest due to sustained stress and hypertension. Additionally, problem gamblers present with higher rates of stress-related physical problems , including migraine headache, tension headache, irritable bowel syndrome, peptic ulcer, GERD, insomnia, sexual dysfunction, myalgias, and neurotic dermatitis.
What is problem gambling?
Gambling is a widespread activity, with 86% of the general adult population having some gambling activity over a lifetime. 5 While the majority of people gamble, a small minority has a gambling problem. Pathological gambling (Table 1) represents the most severe pattern of excessive or destructive gambling behavior and is the only gambling related disorder for which there are formal diagnostic criteria. Problem gambling is a term that has different meaning depending on the context. Used colloquially, problem gambling describes any form of gambling that results in functional consequences. In the scientific literature, problem gambling refers to less-severe forms of dysfunctional gambling as differentiated from pathological gambling. This article uses the former meaning of the term except were noted otherwise.
Although pathological gambling had originally been conceptualized as a chronic and progressive disorder, new evidence suggests there are multiple courses the disorder can follow.7 Sometimes the gambling problem is transient; sometimes it plateaus and maintains for years; and sometimes it follows a progressive course. Regardless of the course, it is common for a problem gambler to experience mental and physical health problems.
Problem gambling treatment
Research concerning the treatment of problem gambling is early in its development, but has benefited from the body of evidence on other addictive and impulse disorders. Multiple pharmacological approaches to reduce problem gambling behaviors or craving have been evaluated in small pilot studies, including lithium carbonate, carbamazepine, clomipramine, naltrexone, and fluvoxamine. Use of serotonin re-uptake inhibitors seems to be promising but multisite, double-blind studies are not yet published. Consequently, there are no FDA approved medications for problem gambling yet. Gambler’s Anonymous (GA) is a self-help fellowship based on 12-step principles, similar in approach to other addictive disorders. Drop-out rates are very high among GA utilizers. Regular GA participation can be greatly facilitated by directive and supportive physicians or other health care providers. A number of psychosocial approaches have been used to treat gambling disorders: behavioral, cognitive-behavioral, psychodynamic, and addiction based. While no best practice exists, most problem gambling treatment programs employ cognitive-behavioral and addiction based change techniques. As with other psychiatric disorders, a combination of treatment methods is often most useful, such as GA with professional psychosocial treatment. Co-morbid chemical dependency, affective, or anxiety disorders need to be treated and stabilized by health care professionals in conjunction with specialized behavioral treatment for the gambling disorder.
To screen or not to screen
Screening for gambling-related history and symptoms is justified because of the prevalence and potential severity of problem gambling, the potential to improve patient outcomes, and the low costs and low risk associated with asking about problem gambling. Simple asking and advising have been proven to be effective interventions in the allied field of alcohol abuse. 8 Early intervention of problem gambling through screening and motivating help-seeking may reduce the harm of problem gambling on individuals and their families.
Problem gambling screening procedures
Surveys have found that health care providers see problem gambling as a medical issue and that they have a mandate to intervene when such issues arise. 3 The trick is catching the gambling problem. If patients present with symptoms that could be related to sustained stress, when you assess for behavioral conditions, include questions on gambling. If gambling is a frequent activity, then consider utilizing a simple screening tool - the Lie-Bet Questionnaire.9 This questionnaire is valid and reliable for ruling out pathological gambling behaviors.
The Lie-Bet questions
1) Have you ever felt the need to bet more and more money?
2) Have you ever had to lie to people important to you about how much you gambled?
If a patient answers yes to one or both of the questions on the Lie-Bet questionnaire, further assessment is indicated. Either make an assessment, based on the clinical interview, using the DSM-IV criteria provided in Table 1 or provide self assessments such as the SOGS or NODS. Patients suspected of manifesting a gambling problem should be encouraged to seek specialized treatment and provided with a referral for such services.
Resources for clinicians
Oregon operates a 24-hour confidential problem gambling helpline 1-877-MYLIMIT. Operators are certified problem gambling counselors and can assist callers with general information about problem gambling, crisis-intervention, motivational interviewing, and referrals to state-funded gambling treatment providers in their area. There is also an online version of the Helpline which offers help via chat/email/IM and can be accessed at 1877mylimit.org. Oregon has 25 outpatient PG treatment centers, two short-term residential treatment programs, one longer-term residential program and a structured self-change program that utilizes workbooks and telephone counseling. Over 2,000 individuals are treated each year in Oregon’s system of state-funded problem gambling treatment centers. About 75% of the problem gamblers who enroll in Oregon’s treatment programs report significantly reduced or no gambling at 90-days post-discharge. 10 In Oregon, problem gambling treatment is free, confidential, and effective. What a wonderful resource to have at your disposal. Let’s use it!
Free clinician brochure download: egov.oregon.gov/DHS/addiction/gambling.shtml click on Resources
REFERENCES
1 Pasternak IV, A.V. & Fleming, M.F. (1999). Prevalence of gambling disorders in a primary care setting. Archives of Family Medicine, 8, 515-520.
2 Christensen, M.H., Patsdaughter, C.A., & Babington, L.M. (2001). Health care providers’ experiences with problem gamblers. Journal of Gambling Studies, 17 (1), 71-79.
3 Sullivan, S., Arroll, B., Coster, G., Abbott, M., & Adams, P. (2000). Problem gamblers: Do GP’s want to intervene? New Zealand Medical Journal, 113(1111), 204-207.
4 Volberg, R. (2001, February). Changes in gambling and problem gambling in Oregon: Results from a replication study, 1997 to 2000. Salem, OR: Oregon Gambling Addiction Treatment Foundation.
5 National Opinion Research Center (NORC). (1999). Gambling impact and behavior study, report to the national gambling impact study commission. Chicago, IL: Author.
6 Potenza, M.N., Fiellin, D.A., Heninger, G.R., Rounsaville, B.J., & Mazure, C.M. (2002). Gambling: An addictive behavior with health and primary care implications. Journal of General Internal Medicine, 17, 721-732.
7 Abbott, M, Williams, M., Volberg, R. (1999). Seven years on: A follow-up study of frequent and problem gamblers living in the community. Wellington: Department of Internal Affairs.
8 WHO Brief Intervention Study Group. (1996). A cross-national trial of brief interventions with heavy drinkers. AM J Public Health, 86, 948-955.
9 Johnson, E.E., Hamer, R., Nora, R.M., Tan, B., Eistenstein, N., & Englehart, C. (1988). The lie/bet questionnaire for screening pathological gamblers. Psychological Reports, 80, 83-88.
10 Moore, T. (2003). Oregon gambling treatment programs evaluation update 2002. Salem, OR: Department of Human Services, Office of Mental Health and Addiction Services.