Symptoms or Root Cause
How Problem Gambling Affects Health
In medical school, we were all taught the importance of a good and complete history. We learned how to do a thorough review of systems and ask about things such as shortness of breath, chest pain, palpitations, bowel habits, dizziness, depression, and use of alcohol or other drugs to name only a few. But when we use only our usual battery of questions, we will never detect a problem that can have devastating physical, emotional and financial effects on a person and his or her family: gambling disorder.
Every March, Ohio recognizes Problem Gambling Awareness Month and uses this as a time to better acquaint healthcare professionals and other community members with problem gambling and its adverse impacts. While gambling is harmless fun for most people, some individuals experience life problems due to their gambling: either “problem gambling” or “gambling disorder.” Problem gambling, which affects 1 in 10 Ohioans, refers to the urge to gamble despite harmful negative consequences or a desire to stop. Gambling disorder, affecting 1 in 100 Ohioans is more severe and has specific diagnostic criteria as outlined in DSM-5 (Table 1).
The percentages of individuals with problem gambling or a gambling disorder are even higher in patients presenting for medical care. Most physicians will see one or more patients with a gambling disorder each week. While it is unlikely that a patient will present to a primary care physician with a complaint directly related to gambling, individuals with problem gambling may demonstrate co-morbid medical conditions such as cardiac disease, liver disease, substance use disorders, depression, anxiety, peptic ulcer disease, hypertension, nicotine dependence, weight swings, insomnia and many others.
Gambling as little as five times a year is associated with higher medical utilization rates and increased healthcare costs. Injuries and emergency department visits are also associated with gambling problems. Additionally, suicidal ideation and attempts are significantly overrepresented among individuals with gambling problems, with 38% of people with Gambling Disorder having suicidal ideation and 32% attempting suicide.
Gambling Disorder can affect people of any demographic group, but factors have been identified which increase risk.
Pathophysiology of Gambling Disorder
Gambling disorder is a true “biopsychosocial” condition, with biological, psychological and social factors influencing its development and manifestations The biological component is evident by genetic studies that demonstrate a higher concordance in monozygotic than dizygotic twins. Neurobiological studies have identified both dopaminergic and serotonergic
dysfunction in problem gamblers. Although much work still needs to be done in this area, these identified factors enhance our evolving ability to prevent gambling disorders in the general population and high-risk groups, as well as treat the disorder when it becomes symptomatic.
Identifying Problem Gambling or a Gambling Disorder
Problems related to gambling can have as profound an effect on a person’s health as a substance use disorder. Having the ability to identify and respond to such individuals should be in the skillset of all physicians and many of these skills translate readily from existing ones to identify and respond to substance use disorders.
The formal way to diagnose a gambling disorder is using the DSM-5 criteria in Table 1; however, it is rarely practical for physicians to go through this entire process in the face of everyday practice demands. A more realistic approach involves knowing the basic signs and symptoms (Table 3), and using a brief, but simple, screening to identify those who may be experiencing a gambling problem.
Screening for a Gambling Addiction
Most physicians are familiar with “SBIRT” (Screening, brief intervention and referral to treatment), an evidence-based process to identify and respond to individuals with high-risk alcohol consumption. “GBIRT” is a similar process for gambling-related problems—an easily administered tool to start patients with gambling addiction on the path to recovery. Considered a promising practice at this point, GBIRT presents a framework familiar to physicians. As with all interactions with patients, this screening approach should be compassionate and not judgmental in any way. Patients with positive screens should have brief intervention from the physician, with referral for more extensive evaluation and treatment.
As with most addictions, the treatment of gambling disorder requires a comprehensive approach that goes beyond the constraints of most primary care practices. In Ohio, we are fortunate to have a large network of professionals who are trained and credentialed to address gambling problems, and treatment is offered at no charge to most individuals. The treatment is based on modern psychotherapies such as cognitive-behavioral treatment and/or 12-step groups such as gamblers’ anonymous (GA) supports.
Physicians should be attentive to potential medical causes of gambling problems, particularly medication side-effects. Most of the medications associated with new-onset gambling problems activate dopamine in some manner, and include aripiprazole, levodopa, pramipexole and ropinirole. Medical conditions such as frontotemporal dementia have also been linked
to gambling problems.
Many individuals with gambling addiction will have co-morbid psychiatric diagnoses, in which case the patient should receive appropriate medication and psychotherapy based upon a thorough assessment. For the treatment of gambling addiction without co-morbid psychiatric conditions, serotonin reuptake inhibitors and the opioid antagonist naltrexone have been investigated and demonstrate some promise; however, these studies are limited due to small sample size and study design and pharmacological treatment alone should never be considered adequate to address a gambling addiction. There is no pharmacological treatment for gambling addiction that is FDA approved.
For most people, gambling is a leisure pursuit and harmless fun. Unfortunately, some individuals are predisposed to develop either problem gambling or gambling disorder, which can adversely affect them and their families, leading to financial, social and medical problems which can shorten their lives. It is incumbent on all of us as physicians to be able to identify individuals with a gambling disorder to help lead them down a path of recovery.
By: Mark Hurst, MD,
Ohio Department of Mental Health and Addiction Services