Co-occurring substance use and problem gambling: Implications for clinicians
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This document discusses co-occurring substance use and problem gambling. It finds that there is significant evidence that substance use and gambling problems often occur together. Studies have found that 63% of people seeking help for problem gambling also have substance abuse issues, and about 10-20% of people in substance abuse treatment also have gambling problems. Treating both issues concurrently seems to be most effective in preventing relapse. The document is based on interviews with 20 clinicians, and it calls for developing clinical guidelines, training for staff, and further research on best practices for treating co-occurring substance use and gambling disorders.
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Co-occurring substance use and problem gambling: Implications for clinicians
- 1. Co-occurring substance use and problem gambling: Implications for clinicians Louise King BA, MSW
- 2. A Clinician Perspective • Curiosity • Pat, not his real name • Ice and the pokies • Help - there are no clinical guidelines here!
- 3. Evidence of Co-occurrence • Evidence for co-occurrence of AOD and gambling in many studies • 63% of problem gamblers seeking treatment have co-occurring AOD issues (Black & Moyer, 1998) • 1 in 10 substance users seeking treatment report co-occurring problem gambling (Cunningham- Williams et al, 2000; Toneatto & Brennan, 2002) • One study reported up to 21% of treatment seeking AOD clients had problem gambling (Mathias et al, 2009)
- 4. What else the literature tells us… • Alcohol, cannabis and methamphetamines • Substance use precedes gambling • Increased risk of suicide, incarceration, mental & physical health problems (Bruner et al 2010) • Harms of AOD/Gambling – individual & community • Screening • Concurrent treatment helps prevent relapse
- 5. Methodology • Exploratory, practice based research • Literature Review, Policy Review & Qualitative study • 20 clinician interviews
- 6. Key Questions • Are gambling issues raised as part of normal, everyday practice a in typical AOD service? • How do AOD clinicians assist clients who disclose gambling issues? • What extent of knowledge do AOD clinicians have about gambling issues and the best practice treatment for clients?
- 7. Themes • Co-occurrence of AOD and gambling • Interventions • Barriers to treatment • Future directions for practice
- 8. Summary of findings • AOD clinicians do perceive problem gambling as an issue for some clients • Literature indicates co-occurrence of AOD and gambling (& mental health) • Screening for both issues and concurrent treatment is appropriate. • Training staff and development of relationships between AOD & gambling services.
- 9. The Future • Development of Clinical Guidelines • Training • Future research opportunities
- 10. Acknowledgments University of Melbourne Dr David Rose Dr Winsome Roberts ReGen All my colleagues and clients Donna Ribton-Turner Trevor King Malcolm Doreian
- 11. Questions….
Editor's Notes
- Hi, I’m Louise King, a social worker and I work at UnitingCare ReGen, an AOD service in an inner Melbourne. I work as an adult AOD counsellor and as an intake and assessment clinician. I’m presenting the research I did for my Master of Social Work at the University of Melbourne on AOD clinicians’ perceptions and practice with clients who disclose co-occurring problem gambling.
- We are all here because we are curious. It’s curiosity that drives research. And my curiosity was raised by one of my clients, Pat, who attended counselling seeking assistance for his Ice use. Pat also disclosed he had a gambling problem – pokies - that he believed was linked to his Ice use. At this point I knew nothing about gambling. Pat taught me about the impacts of having a gambling addiction, the relationship between Ice and gambling (from his perspective), and the negative impacts of a co-occurring disorder across life domains. Through Pat I learnt that the casino is full of Ice users and dealers and that ceasing substance use did not necessarily mean the gambling ceases. I had no idea how to assist Pat with his gambling. Hence the curiosity that led me to my research.
- Beginning with the literature on AOD and gambling I found plenty of evidence for co-occurrence. Black & Moyer found that 63% of treatment seeking problem gamblers met the criteria for a co-occurring substance use disorder. 1 in 10 substance users seeking treatment report co-occurring problem gambling (Cunningham-Williams et al, 2000; Toneatto & Brennan, 2002) Another study found that the prevalence of problem gambling increased with substance use severity. One Australian study Maccallum and Blaszcynski (2002) of poker machine gamblers seeking treatment found higher rates of alcohol use disorders compared to the general population. Mathias et al (2009) found from a study of 147 substance users in AOD treatment that were screened for gambling, 21.7% were pathological gamblers. Researchers Crockford and el-Guebaly (1998) review the literature of over 60 studies into gambling and co-morbidity from 1966 to 1996 and found that “people with pathological gambling have a significantly increased prevalence of the substance use disorders and vice versa”
- Alcohol, cannabis and methamphetamines •Alcohol is the most common substance used by people with problem gambling, whereas cannabis is the most commonly used illicit substance, most likely reflecting prevalence rates in the population. Research into the link between methamphetamines and gambling concludes that people who use methamphetamines may be more vulnerable to problem gambling. They also found that methamphetamine users had higher levels of problem gambling than all other substance users combined. (Bruner et al, 2010) Substance use precedes gambling •Generally the literature reported substance use most often preceded problem gambling. Except for one study that found problem gambling preceded methamphetamine use by 4 years (Cunningham-Williams et al, 2000) Increased risks … •We know about the prevalence of co-occurring AOD and mental health, so not surprisingly problem gamblers with co-occurring substance use issues were found to co-occur with mental health disorders including anxiety, depression, bi polar disorder, impulse control disorders and increased suicidal ideation Add in higher rates of legal issues including incarceration and family problems Harms • It is estimated that 90,000 to 170,000 Australian adults experience significant harm from their gambling (Productivity Commission, 2010), and up to 5 million people – family, friends and employers - are impacted by problem gambling in Australia. We are talking significant public health issue Like gambling we all know the impact of AOD use on individuals, families and the community The literature found that co-occurring AOD and gambling increased the harms – increased spending on gambling, less resistance to gambling, and inability to stop gambling Screening •The productivity commission in 2010 estimated that only 8-17% of problem gamblers seek treatment – therefore identification at AOD services has the possibility of identifying more problem gamblers. One consistent finding from the literature reviewed was the recommendation to screen those attending AOD services for problem gambling and vice versa. Routine screening would identify co-occurring disorders for appropriate treatment, thereby lowering the burden of illness. Evidence for co-treatment •Lesieur & Blume study followed 72 patients being treated for co-occurring problem gambling and AOD & at the third follow up interview found evidence of reduced AOD use, reduced gambling and improvements in legal, family, social and psychological functioning. The literature calls for the co-treatment of both disorders because of the risk of relapse is high for the treated addiction, the risk of substitution, and overall poor treatment outcomes. Summary In summary the research discussed illustrates the link between substance use and problem gambling and the need to develop an effective response from treatment providers. Co-occurring AOD and problem gambling increases the risk of other co-occurring disorders – most notably mental health issues. And knowing that substance use probably precedes problem gambling provides the opportunity for harm reduction work with clients.
- The study comprised a literature review – of which I’ve just mentioned, a policy review – which I won’t mention here, and a qualitative study involving interviews with 20 AOD clinicians working at UnitingCare ReGen. The clinicians interviewed were a mix of direct practice clinicians and team leaders and managers. This allowed me to gain an understanding of both the experiences of clinicians in direct practice and those in leadership and management positions across the domains of perceptions, practice and knowledge of treatment and policy.
- The key questions of the study were Are gambling issues raised as part of normal, everyday practice in a typical AOD service? How do AOD clinicians assist clients who disclose gambling issues? What extent of knowledge do AOD clinicians have about gambling issues and the best practice treatment for clients?
- Four major themes emerged from the interviews with clinicians Co-occurrence of AOD and gambling In line with the literature, the interviews confirmed the co-occurrence of AOD and gambling, alcohol and methamphetamines were those substances most linked with gambling, and clinicians agreed that screening clients would be appropriate given the harms associated with the co-occurring issues. Interventions Most clinicians reported they were not confident in dealing with co-occurring problem gambling, however they were able to articulate appropriate interventions as being referral to gambling services, using motivational interviewing and stages of change and CBT to assist clients. And they reported using a harm minimisation framework. Barriers to treatment Client barriers were identified as the perception that gambling is secondary to their AOD use. Why talk about their gambling at an AOD service? Clients may be at a different stage of change for their AOD and gambling Stigma The normalisation of gambling in the community and as a peer activity The barriers identified by clinicians were lack of knowledge and confidence, lack of screening, and time constraints The main organisational barrier identified was lack of funding. Future directions for practice Training staff, finding better ways to work with complex clients, funding, and developing relationships with gambling services.
- The study found that AOD clinicians perceive problem gambling as an issue for some complex clients, including a link between methamphetamine use and problem gambling. However this is not always reliably revealed or addressed in current practise. This is also reflected in the literature that argues for screening and treatment of AOD and problem gambling at both AOD and gambling services to reduce the risk of relapse for either condition. To address this deficit, this study recommends that AOD clinicians would benefit from further training around co-occurring AOD use and problem gambling, and treatment pathways for problem gambling. Developing relationships between AOD and gambling services would facilitate exchange of knowledge and provide clear treatment pathways.
- My study uncovered that potentially significant impacts can be achieved by adopting a wider and more flexible approach to treatment of co-occurring problem gambling that can impact the recovery of this client group. At ReGen I have been developing clinical guidelines to ensure the screening and identification of problem gamblers and providing guidelines for referral pathways and providing information to clinicians and clients about the risks of co-occurring AOD and gambling. This will be extended to provide more formalised training for clinicians. One benefit of my interviews with clinicians was an increased awareness of this as an issue and has prompted them to ask clients about gambling. They have reported that a significant amount of clients are disclosing problem gambling. Almost every study concerning AOD and gambling recommended further study in this area, in particular research into methamphetamine use and gambling.
- I would like to thank my supervisor from the University of Melbourne, Dr David Rose and also Dr Winsome Roberts I would also like to express my thanks and appreciation of my colleagues and clients at ReGen, in particular I want to note the support given by Donna Ribton-Turner, Trevor King, and Malcolm Doreian