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TRANSCRIPT
Christopher Welsh, MD Associate Professor
University of Maryland School of Medicine Medical Director
Maryland Center of Excellence on Problem Gambling
Tuesday, April 14th, 2020 12:00 PM – 1:00 PM EST
The Intersection of Problematic Gambling and Opioid Use Disorder
2
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3
Disclosures
• I do not have a financial relationship with a commercial entity producing, marketing, re-selling or
distributing health-care related products or services consumed by, used on, patients.
Affordable Care Act
21st Century Cures Act
-State Targeted Response to the Opioid Crisis Grants
-Tribal Opioid Response Grants
-Targeted Capacity Expansion: Medication Assisted Treatment
-State Targeted Response- Technical Assistance
Carefirst, Aetna, Kaiser, etc. grants
The content of this activity may include discussion of off label or investigative drug uses.
The faculty is aware that is their responsibility to disclose this information.
4
Educational Objectives
At the conclusion of this activity participants should be able to:
• Recognize four (4) brief screening tools for problematic
gambling that can be used by providers of treatment for opioid
use disorder.
• Understand medications that may be used to help treat
gambling disorder.
• Provide at least three (3) ways in which problematic gambling
might effect a patient’s treatment/recovery from opioid use
disorder.
5 5
What Is Gambling?
•Webster says:
•“to stake or risk money or anything of value on
the outcome of something involving chance.”
•“any matter or thing involving risk.”
6
Types Of Gambling
Games Of Skill • Cards
• Pool
Lottery • Mega Millions/Powerball
• Instant Scratch Tickets
• Daily Numbers
• Lotto
Sports • Horse Racing At Tracks
• Off Track Betting
• Office Pools
• Super Bowl, March Madness, etc.
7
Types Of Gambling
•Games Of Chance • Slot Machines
• Roulette
• BINGO
• Dice
• Raffles
•Stock Market
8
Gambling: Some Numbers
• About 75-86% of all adults in the US gamble at one time or another.
• 48 states have legalized gambling
•Except Hawaii and Utah. • Gambling goes on in Hawaii and Utah via the stock market,
internet gambling, cruise ship casinos, illegal gambling such as sports betting.
• 43 states have lotteries
• 6 states have river boat gambling
• 28 states (plus 2 territories) have casino gambling
• 30 states have casinos on Native American land
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Terminology
•Problem
•Compulsive
•At risk
•Pathological
•Gambling vs Gaming
10
Problem Gambling in the U.S.
• Numbers vary depending on type of study
• Adults
•0.4 to 3%- Pathological
•1.6-3.8% - at risk or problematic
• Adolescents
•1-7%- Pathological
•5-10%- at risk or problematic
• College
•3-11%-Pathological
•5-15%- at risk or problematic
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Problem Gambling: High Risk Groups
• Growing numbers of gambling problems among:
•Adolescents
•Older Adults
•Women
•People of Color
•Lower Income populations
•Less educated populations (high school or less)
12
Gambling Types
• Action Gambling • Primarily at games of perceived “skill”
• Believe they can “beat the house” or other individuals by developing a system
• Preferred Games
• Poker
• Dice
• Cards
• Horse/Dog Racing
• Sports Betting
•Escape Gambling • Primarily as a way to escape “stress”
• often in a hypnotic state while gambling
• Does not gamble to beat the house or others
• Preferred Games
• Bingo
• Slot Machines
• Video Poker
• Lottery
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13
Psychiatric Co-Morbidity
• High correlation with mood and anxiety disorders
•One study found 76% of pathological gamblers
had a major depressive disorder with recurrent
episodes in 28%
• Suicide risk is high (17-24%)
14 14
Associated Medical Findings
• 2-6% of primary care patients meet the criteria of problem or pathological gamblers
• increased incidence of • insomnia
• irritable bowel syndrome
• peptic ulcer disease
• hypertension
• headaches/migraines
15
History of the DSM
• DSM I (1952) • Disordered gambling not mentioned
• Substance related disorders placed in “Personality Disorders- Sociopathic PD.”
• DSM II (1968) • Disordered gambling not mentioned
• Substance related disorders placed in “Personality Disorders and Certain Other Non-Psychotic Mental Disorders”
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History of the DSM
• DSM III (1980)
• 1st time “Pathological Gambling” included (312.31)
• Placed in “Disorders of Impulse Control- Not Elsewhere Classified”
• With Kleptomania, Pyromania, Intermittent Explosive Disorder,
Isolated Explosive Disorder
• Failure to resist impulse/ rising tension before act/ pleasure or
release during act/ may be guilt after act
• No formal testing of diagnostic criteria
• Based on limited clinical experience
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DSM-III Diagnostic Criteria
A. The individual is chronically & progressively unable to resist impulses to
gamble.
B. Gambling compromises, disrupts or damages family, personal & vocational
pursuits, as indicated by at least 3 of the following:
• arrest for forgery, fraud, embezzlement or income tax evasion due to
attempts to obtain money for gambling
• default on debts or other financial responsibilities
• disrupted family or spouse relationships due to gambling
• borrowing of money from illegal sources (loan sharks)
• inability to account for loss of money or to produce evidence of winning
money if this is claimed
• loss of work due to absenteeism in order to pursue gambling activity
• necessity for another person to provide money to relieve a desperate
financial situation
C. The gambling is not due to ASPD
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DSM-III Associated Features
• “These individuals most often are over confident, somewhat abrasive,
very energetic and “big spenders”; but there are times when they show
obvious signs of personal stress, anxiety and depression.”
• Differential Diagnosis
• Social Gambling
• Manic or hypomanic episode
• Antisocial Personality Disorder
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History of the DSM
• DSM III-R (1987)
• “Pathological Gambling” basically, changed from focus
on fraud and money to adapting substance dependence
criteria to gambling
• Remained 312.31
• Remained in “Impulse Control Disorder NEC”
• Dropped Isolated Explosive Disorder and added
Trichotillomania
• Increased to 9 criteria (needed
4 for diagnosis)
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DSM-III-R Diagnostic Criteria
Maladaptive gambling behavior, as indicated by at least four of the following:
• frequent preoccupation with gambling or with obtaining money to gamble
• frequent gambling of larger amounts of money or over a longer period than intended
• a need to increase the size or frequency of bets to achieve the desired excitement
• restlessness or irritability if unable to gamble
• repeated loss of money by gambling and returning another day to win back losses ("chasing")
• repeated efforts to reduce or stop gambling
• frequent gambling when expected to meet social or occupational obligations
• sacrifice of some important social, occupational, or recreational activity in order to gamble
• continuation of gambling despite inability to pay mounting debts, or despite other significant social, occupational, or legal problems the person knows to be exacerbated by gambling
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DSM-III-R Associated Features
“Generally, people with Pathological Gambling have the
attitude that money causes and is also the solution to all
their problems. As the gambling increases, the person is
usually forced to lie in order to obtain money and to
continue gambling. There is no serious attempt to budget or
save money. When borrowings resources are strained,
antisocial behavior in order to obtain money is likely. People
with this disorder are often overconfident, very energetic,
easily bored, and “big spenders”; but there are times when
they show obvious signs of personal stress, anxiety, and
depression.”
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History of the DSM
• DSM IV (1994)
• Remained “Pathological Gambling”
·Remained 312.31
• Remained in “Impulse-Control Disorders NEC”
• Based on empirical trials of multiple items
• New set of 10 criterion (needed 5 for diagnosis)
• Added criterion to address lying, commission of illegal
acts & escaping from problems or dysphoric mood
• Differential Diagnosis
• Added “Professional Gambling”
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DSM-IV Diagnostic Criteria
A. Persistent and recurrent maladaptive gambling behavior as indicated by 5 (or more) of the following: • 1. is preoccupied with gambling (e.g., reliving past gambling experiences, handicapping or
planning the next venture, or thinking of ways to get money with which to gamble)
• 2. needs to gamble with increasing amounts of money in order to achieve the desired excitement
• 3. has repeated unsuccessful efforts to control, cut back or stop gambling
• 4. is restless or irritable when attempting to cut down or stop
• 5. gambles as a way of escaping from problems or relieving dysphoric mood (e.g. feelings of helplessness, guilt, anxiety, depression)
• 6. after losing money gambling, often returns another day in order to get even (“chasing” one's losses)
• 7. lies to family members, therapist, or others to conceal the extent of involvement with gambling
• has committed illegal acts such as forgery, fraud, theft, or embezzlement to finance gambling
• has jeopardized or lost a significant relationship, job, educational, career opportunity because of gambling
• relies on others to provide money to relieve a desperate financial situation caused by gambling
B. Not better accounted for by a Manic Episode
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Differences Between DSM-IV & 5
• Renamed: Gambling Disorder
• Maintained 312.31 (will become F63.0 with ICD-10)
• Reclassified: into “Substance Related & Addictive Disorders”
(renamed from “Substance-Related Disorders”)
• Reduced to 9 criterion
• Elimination of “illegal acts” criterion (as with SUDs)
• Was least endorsed; almost always captured by others
• Diagnostic cut-off lowered: 5 to 4 (different than SUDs)
• Addition of time frame:
• Symptoms must be present
• within a 12-month period (as with SUDs)
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Differences Between DSM-IV & 5
• Addition of Course Specifiers (different than SUDs):
• Episodic- sxs subsiding for at least several months
• Persistent- continuous sxs for multiple years
• Addition of Remission Specifiers (similar to SUDs):
• Early- no criteria for >3 but <12 months
• Sustained- no criteria for > 12 months
• Addition of Severity Specifiers (different than SUDs):
• Mild- 4-5 criteria
• Moderate- 6-7 criteria
• Severe-8-9 criteria
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DSM-5 Diagnostic Criteria
A. Persistent and recurrent problematic gambling behavior leading to clinically significant impairment or distress, as indicated by the individual exhibiting 4 (or more) of the following in a 12-month period:
Needs to gamble with increasing amounts of money in order to achieve the desired excitement
Is restless or irritable when attempting to cut down or stop
Has made repeated unsuccessful efforts to control, cut back or stop gambling
Is often preoccupied with gambling (e.g., having persistent thoughts of reliving past gambling experiences, handicapping or planning the next venture, or thinking of ways to get money with which to gamble)
4
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DSM-5 Diagnostic Criteria (continued)
.Often gambles when feeling distressed (e.g. helpless, guilty,
anxious, depressed)
After losing money gambling, often returns another day in order
to get even (“chasing” one’s losses)
Lies to conceal the extent of involvement with gambling
Has jeopardized or lost a significant relationship, job, or
educational or career opportunity because of gambling
Relies on others to provide money to relieve a desperate financial
situation caused by gambling
B. Not better explained (changed from “accounted for”) by a
Manic Episode
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Gambling Disorder Need 4 out of 9
Substance Use Disorder Need 2 out of 11
1. Tolerance
2. Withdrawal
3. Control
4. Preoccupation
5. Escape
6. Chasing
7. Lying
8. Impact on social function
9. Bailouts
1. Using more or longer than intend
2. Control
3. Time spent in obtaining substance
4. Craving or strong desire (does not
count in establishing remission)
5. Failure to meet role obligations
6. Continued use despite social or
interpersonal problems
7. Important activities given up or
reduced
8. Recurrent use in physically
hazardous situations
9. Continued use despite physical
and psychological consequences
10.Tolerance
11.Withdrawal (not for all substances)
Comparison of GD to SUDs
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Other Non-substance “Addictions”
• Internet Gaming- in Section III (“Conditions for Further Study”)
•Sex- dropped from Section III in final version
•Eating- can be included in Feeding & Eating Disorders
•Collecting- Hoarding Disorder added
•Shopping- not included
•Exercise- not included
• Internet – not included
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DSM-5 Internet Gaming Disorder
Persistent and recurrent use of the Internet to engage in games, often with other players, leading to clinically significant impairment or distress as indicated by 5(or more) of the following in a 12-month period:
1. Preoccupation with Internet gaming (IG).
2. Withdrawal sxs when internet gaming is taken away.
3. Tolerance- the need to spend increasing amounts of time engaged in IG.
4. Unsuccessful attempts to control participation in IG.
5. Loss of interest in previous hobbies & entertainment as a result of IG.
6. Continued excessive use of Internet games despite knowledge of psychosocial problems.
7. Has deceived family members, therapists, or others regarding the amount of Internet gaming.
8. Use of internet games to escape or relieve a negative mood.
9. Has jeopardized or lost a significant relationship, job, or educational or career opportunity because of participation in Internet games.
*Does not include internet use for work, gambling, social media, sexual purposes.
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“Unique” Characteristics Of Pathological Gambling?
• The behavior is harder to define
• It is a more “hidden” addiction
• less physical consequences of use
• no real equivalent of overdose
• It is even less perceived of as a disorder than substance use disorders
• There is no good objective test for “use”
• The problem is more often perceived of as the solution
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Problem Gambling Screens
& Assessment Instruments
• South Oaks Gambling Screen (SOGS)
• National Opinion Research Center DSM Screen for
Problem Gambling (NODS)
• G.A.’s Twenty Questions
• “Lie-Bet” 2 Question Brief Screen
• CLiP
• PERC
• Brief Biosocial Gambling Screen
• SOGS-R A- Adolescent Screen
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South Oaks Gambling Screen (SOGS)
• Valid And Reliable Instrument
• May Be Self Administered
• Most Widely Used Screen
• Available in 25 languages
• Has been revised for use among adolescents
• (SOGS-RA)
Asks about
• Types of gambling
• Amount of money spent
• Family History
• 11 “consequence” questions
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NODS-SA
1. Have there ever been periods lasting 2 weeks or longer when you spent a
lot of time thinking about your gambling experiences, planning out future
gambling ventures or bets, or thinking about ways of getting money to
gamble with?
2. Have there ever been periods when you needed to gamble with increasing
amounts of money or with larger bets than before in order to get the same
feeling of excitement?
3. Have you ever felt restless or irritable when trying to stop, cut down, or
control your gambling?
4. Have you tried and not succeeded in stopping, cutting down, or controlling
your gambling three or more times in your life?
5. Have you ever gambled to escape from personal problems, or to relieve
uncomfortable feelings such as guilt, anxiety, helplessness, or depression?
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NODS-SA
6. Has there ever been a period when, if you lost money gambling one day, you
would often return another day to get even?
7. Have you lied to family members, friends, or others about how much you
gamble, and/or about how much money you lost on gambling, on at least three
occasions?
8. Have you ever written a bad check or taken money that didn’t belong to you
from family members, friends, or anyone else in order to pay for your gambling?
9. Has your gambling ever caused serious or repeated problems in your
relationships with any of your family members or friends? Or, has your gambling
ever caused you problems at work or at school?
10. Have you ever needed to ask family members, friends, a lending institution, or
anyone else to loan you money or otherwise bail you out of a desperate money
situation that was largely caused by your gambling?
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NODS-CLiP
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1. Have there ever been periods lasting 2 weeks or longer when you spent
a lot of time thinking about your gambling experiences, planning out
future gambling ventures or bets, or thinking about ways of getting
money to gamble with?
2. Have you ever written a bad check or taken money that didn’t belong to
you from family members, friends, or anyone else in order to pay for
your gambling?
3. Have you ever needed to ask family members, friends, a lending
institution, or anyone else to loan you money or otherwise bail you out
of a desperate money situation that was largely caused by your
gambling?
4. Has your gambling ever caused serious or repeated problems in your
relationships with any of your family members or friends?
NODS- PERC
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LIE-BET
1. Have you ever lied to people important to
you about how much you gambled?
2. Have you ever felt the need to bet more and
more money?
If the answer is “yes” to either or both, further assessment is needed.
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Brief Biosocial Gambling Screen
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Gambling Disorder Screening
Patient may not acknowledge in first interview either because they simply don’t categorize these issues as problematic or because of shame and the desire to avoid talking about these issues
Individuals coming into treatment for a substance use or mental health disorder may have any or all of the following attitudes toward their gambling:
• Never thought of it as a problem or potential problem
• Believe it is a solution to their problems (emotional and or financial)
• Realize it may be a problem, but don’t want to think about giving up “all their fun.”
• Feel overwhelmed by dealing with just one problem, don’t want to have to think about any others.
41
Gambling Disorder & SUD
• 7% - 40% of those in SUD treatment have co-morbid
GUD
• Past year SUD severity related to greater gambling
problems
•Those with Gambling Disorder in SUD have
significantly worse:
•Physical Health
•Mental Health
•Treatment Adherence Increased Heroin/Cocaine Use
42
•Various studies show higher than most other
SUDs
•Even higher rates in patients on methadone
through OTP
•Some studies 45-55% with some level of
problematic gambling
•See more lottery tickets, slot machines, cards for
money
Gambling Disorder & OUD
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Characteristics
No Gambling
Disorder
n = 99
Gambling
Disorder
n = 85
Age (M ± (SD)) 48.2 (9.2) 46.8 (8.0)
Gender – Male 54.5% 52.9%
Married or Living with a partner 26.3% 20.0%
Race – Black or African American 71.7% 70.6%
Complete HS and/or some college 51.5% 61.2%
Employed full or part-time 13.1% 10.6%
Income < $20,000 last year (n = 182) 85.6% 91.8%
DSM-5 Gambling Disorder (Univ. of Md. OTP)
44
DSM-5 Gambling Disorder
(Univ of Md OTP)
0
20
40
60
80
100
120
Non-Disordered
Gambler (<4)Disordered Gambler
(≥4)
Mild Gambler
(4-5)
Moderate Gambler
(6-7)
Severe Gambler
(8-9)
46.2% met DSM-5
criteria for
Gambling Disorder
45
DSM-5 Gambling Disorder
(Univ of Md OTP)
0
20
40
60
80
100
120
Non-Disordered
Gambler (<4)Disordered Gambler
(≥4)
Mild Gambler
(4-5)
Moderate Gambler
(6-7)
Severe Gambler
(8-9)
75.2% identified as
Moderate or
Severe Gambler
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Most Common Type of Gambling
Lottery Tickets 81.1%
Scratch Offs 71.8%
Games of Skill 40.5%
Casino 9.2%
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Variables
No Gambling
Disorder
n = 99
Gambling
Disorder
n = 85
Purchased lottery tickets
Not at alla 30.3% 5.9%
Less than 10 times in total 12.1% 2.4%
At least once a month 8.1% 1.2%
At least once a week 49.5% 90.6%
Note. a denotes significance at p <
0.05
48
Variables
No Gambling
Disorder
n = 99
Gambling
Disorder
n = 85
Purchased lottery tickets
Not at alla 30.3% 5.9%
Less than 10 times in total 12.1% 2.4%
At least once a month 8.1% 1.2%
At least once a week 49.5% 90.6%
Monthly spent ($) (M±(SD))a 72.3 (159.1) 302.5
(469.2)
Note. a denotes significance at p <
0.05
49
Variables
No Gambling
Disorder
n = 99
Gambling
Disorder
n = 85
Purchased instant win tickets
Not at alla 37.4% 14.3%
Less than 10 times in total 11.1% 1.2%
At least once a month 17.2% 13.1%
At least once a week 34.3% 71.4%
Note. a denotes significance at p <
0.05
50
Variables
No Gambling
Disorder
n = 99
Gambling
Disorder
n = 85
Purchased instant win tickets
Not at all a 37.4% 14.3%
Less than 10 times in total 11.1% 1.2%
At least once a month 17.2% 13.1%
At least once a week 34.3% 71.4%
Monthly spent a 37.9 (76.5) 233.9
(418.5)
Note. a denotes significance at p <
0.05
51
Variables
No Gambling
Disorder
n = 99
Gambling
Disorder
n = 85
Played casino table games
Yes – play at any location 1.0% (n = 1) 18.8% (n =
16)
Not at all at a casino 0.0% 12.5%
Less than 10 times in total at a
casino
100.0% 25.0%
At least once a month at a casino 0.0% 25.0%
At least once a week at a casino 0.0% 37.5%
Monthly spent
(casino, bar or online)b
0.0% 63.4 (190.2)
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Neuroimaging
• Ventromedial prefrontal cortex (vmPFC)
• implicated in decision-making circuitry in risk-reward assessment
•decreased activation in vmPFC in PG subjects during gambling cues
• Also decreased activity in the basal ganglia and thalamus
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Gambling Disorder &
Opioid System
• The mu-opioid system:
•Underlies urge regulation through the processing of
reward, pleasure, and pain
•Contributes to learning & determination of salience
•Primarily via modulation of dopamine neurons in
mesolimbic pathway through GABA interneurons.
• The kappa-opioid system:
• Involved with negative reinforcement
54
55
Treatment
• Psychotherapy
• Pharmacotherapy
• Mutual help
56
Psychotherapy
• Few well-controlled studies
• Best evidence for CBT and Motivational Interviewing
57
Gamblers Anonymous
•Founded In 1957 By Jim W.
•Open And Closed Meetings • Not Many Open Meetings Secondary To Legal Concerns
•Pressure Relief Group • Not Found In AA
• Gambler And Spouse Meet With NA members
• Bring In Income And Debt Information • The Group Works Out A Budget To Repay Those Owed Money
•12 Steps • Similar To AA
58
Pharmacotherapy
Various Medications Studied:
• SSRIs
• Nefazodone
• Buproprion
• Atypical antipsychotics
• Mood stabilizers/Anticonvulsants
• Memantine
• Opioid antagonists
None FDA approved
59
59
Pharmacotherapy
Naltrexone •mu, kappa & delta antagonist
• Inhibits mu opioid receptor input to the VTA
•Ultimately causes decreased DA release
•Appears to alter hedonic response Lowering pleasure associated w use/gambling
•Multiple open label studies/case reports
•5 Double-blind placebo controlled trials Modest effect on gambling behavior
•No studies with Vivitrol
60
60
Pharmacotherapy
Nalmefene •Structurally similar to naltrexone
•mu & delta antagonist; kappa partial agonist
•Less hepatotoxicity than w naltrexone
•Used for Alcohol Use Disorder in Europe
•Injectable form FDA approved in U.S. in 1995 for opioid overdose (manufacture discontinued)
•2 Double-blind placebo controlled trials • Modest effect on gambling behavior
61
Why address gambling problems in SUD and MH programs
• Individuals with substance use & mental health disorders are at higher risk for having a gambling problem
•Gambling (even at moderate levels) may have an adverse impact on treatment outcome
•Unaddressed gambling and gambling problems are likely to add to treatment costs and service utilization
62
Why address gambling problems in SUD and MH programs
• Gambling may become a sequential addiction for individuals recovering from an SUD
• Gambling can be a relapse risk factor
• Gambling and problem gambling may exacerbate psychiatric symptoms
• Relationship violence and child abuse are related to problem gambling and severely aggravated if substance use is involved.
63
64
Gambling & Recovery
Even though individuals in recovery from substance use and mental health disorders are at higher risk for gambling problems, this does not mean that gambling always has a negative impact on someone’s recovery
It is our job to help our patients be aware of and evaluate the risks as well as benefits that gambling can bring to their recovery, and to assist them in making the best informed decisions regarding the role of gambling in their lives and recoveries.
65
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Special Case
• Pramipexole (Mirapex)
• Dopamine agonist
• Used to treat Parkinson’s Disease & RLS
• Some patients have developed gambling problems
•very small number (9 out of 529)
•not sure of the etiology
66
Funding
Affordable Care Act
21st Century Cures Act
-State Targeted Response to the Opioid Crisis Grants
-Tribal Opioid Response Grants
-Targeted Capacity Expansion: Medication Assisted
Treatment
-State Targeted Response- Technical Assistance
Carefirst, Aetna, Kaiser, etc. grants
67
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PCSS Mentoring Program
PCSS Mentor Program is designed to offer general information to clinicians
about evidence-based clinical practices in prescribing medications for
opioid use disorder.
PCSS Mentors are a national network of providers with expertise in
addictions, pain, evidence-based treatment including medications for
addiction treatment.
• 3-tiered approach allows every mentor/mentee relationship to be unique
and catered to the specific needs of the mentee.
• No cost.
For more information visit:
https://pcssNOW.org/mentoring/
71
PCSS Discussion Forum
Have a clinical question?
http://pcss.invisionzone.com/register
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PCSS is a collaborative effort led by the American Academy of Addiction
Psychiatry (AAAP) in partnership with:
Addiction Technology Transfer Center American Society of Addiction Medicine
American Academy of Family Physicians American Society for Pain Management Nursing
American Academy of Pain Medicine Association for Multidisciplinary Education and
Research in Substance use and Addiction
American Academy of Pediatrics Council on Social Work Education
American Pharmacists Association International Nurses Society on Addictions
American College of Emergency Physicians National Association for Community Health Centers
American Dental Association National Association of Social Workers
American Medical Association National Council for Behavioral Health
American Osteopathic Academy of Addiction
Medicine The National Judicial College
American Psychiatric Association Physician Assistant Education Association
American Psychiatric Nurses Association Society for Academic Emergency Medicine
73
Session Evaluation and Certificate
• Instructions will be provided in an email sent to participants an hour
after the live session
• Certificates are available to those who complete an evaluation
• Recordings of today’s webinar can be accessed at:
www.pcssNOW.org and education.psychiatry.org
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Educate. Train. Mentor
www.pcssNOW.org
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Funding for this initiative was made possible (in part) by grant no. 1H79TI081968 from SAMHSA. The views expressed in written conference materials or
publications and by speakers and moderators do not necessarily reflect the official policies of the Department of Health and Human Services; nor does
mention of trade names, commercial practices, or organizations imply endorsement by the U.S. Government.