1. Co-Morbid Alcohol Use and Alcohol Use Disorders within Pathological Gamblers Jeremiah Weinstock, PhD Saint Louis University

2. Presentation Overview 1.Alcohol use and gambling 2.Alcohol use disorders (AUD) and pathological gambling (PG) 3.Alcohol use during treatment 4.Implications

3. Drinking & Gambling Some clients will report that they currently: 1.Drink and gamble at the same time. 2.Do both, but never at the same time. Meanwhile, others report only a history of alcohol problems.

4. Drinking & Gambling Many gambling environments serve free or reduced cost alcoholic beverages. Why? 1.Alcohol impairs our ability make good decisions. 2.Alcohol weakens our ability to recognize the importance/salience of gambling losses. 3.Individuals frequently wager more than they intend while intoxicated. Cronce &Corbin, 2010; Giacoppassi et al., 1998; Nelson et al., 2011

5. Pathological Gamblers Who Drink Epidemiological studies find: – Gamblers who drink 3 or more per occasion were more likely to be problem gamblers – If both disorders are present, severity of both disorders are closely linked. – Drinking predicts long-term gambling problems in problem and pathological gamblers. Abbott et al., 2004; Blankenship et al., 2007; French et al., 2008;

6. How Much Do They Overlap? Epidemiological studies estimate: – 28% of pathological gamblers have comorbid alcohol use disorder. – Lifetime rates are even higher (~50%). Which came first? PG 1 st Alcohol 1 st Same Time Alcohol Abuse 18.7%70.9%10.4% Alcohol Dependence 44.3%55.7%0.0% Lorains et al., 2011; Kessler et al., (2008)

7. Prevalence in Treatment Centers Comorbidity is rule rather than the exception: – Alcohol use disorders range from 33% to 64% of treatment seekers. – Depends upon the setting. Addiction clinics higher prevalence. Outpatient clinics slightly lower. Ibanez et al., 2001; Black & Moyer, 1998; Kausch, 2003

8. Why Do They Overlap? Genetics? – Genetic factors account for ~50% - 60% of alcohol use disorders. – Genetic factors account for ~50% - 60% of pathological gambling. – Overlap of genetic factors between the two disorders is about 12% - 20%. – Most overlap revolves around impulsivity and poor decision making. Shah et al., 2005; Sherrer et al., 2005

9. Addictive Personality? Slutske et al., 2005

10. Implications for Treatment Comorbid AUD & PG – A blessing and a curse: – One study found current AUD at treatment entry predicted gambling abstinence at 3 month follow-up. Why? – History of AUD is associated with lower rates of initial abstinence after treatment. – History of AUD is associated with higher rates of relapse after achieving 6 months of abstinence (37% vs. 17%). Hodgins et al., 2005, 2010

11. Symptom Substitution? If a client stops drinking will his or her gambling get worse? If a client stops gambling, will his or her drinking get worse? Empirical question!

12. Drinking During Treatment? We examined this very question in a large pathological gambling treatment seeking sample (N = 293). Drinking assessed via the Timeline Followback. Slightly more than half (56%) report drinking any alcohol in the 3 months prior to and six months after starting gambling treatment. Rash, Weinstock, & Petry, 2011

13. At-Risk Drinking Almost half of the drinkers (47%) were classified as “At-Risk Drinkers.” At-Risk Drinkers: – MEN: > 14 drinks/week or > 4 drinks/episode – WOMEN: > 7 drinks/week or > 3 drinks/episode At-Risk Drinkers were more likely to be: – Male, younger, greater PG severity, and drink 25% of pre-treatment days with an mean of 5.0 drinks.

14. Pre-Treatment Weekly Drinking Pre-treatment weeks -------------------------->

15. During Treatment, Weekly Drinking Treatment Week -------------------------------------------------->

16. Post-Treatment Drinking Post-Treatment Follow-Up ------------>

17. All Together

18. Other Important Findings At-Risk Drinkers: – Had lower rates of PG treatment adherence Reductions in drinking occurred as individuals entered treatment. – Possibly part of a broader health behavior change.

19. Implications Many gamblers seeking treatment will come in with either: – A history of alcohol problems – Currently at-risk drinking Conceptualize it as an opportunity! – History = experience making significant change – Current drinking = chance to make global health changes

20. THANK YOU! jweinsto@slu.edu