1. Gambling: The silent addiction
Oct. 10, 2013
Jennifer Clegg, MSW, LSW, NCGC-II/BACC, OCPS-II
Gambling Program Specialist
Recovery Resources
3950 Chester Ave
Cleveland, OH

3. What is Gambling?
Gambling is risking something of value on an event that is determined mostly by chance.
A person is gambling if:
he or she puts up something of value, such as money or property
the outcome has an element of chance beyond the person’s control
once the bet is made, it’s not reversible

4. Types of Gambling Activities
Lottery, scratch, pull-tabs and raffle tickets
Bingo
Sports betting
Slot machines
Card and table games
Horse betting
Internet gambling
Stock market speculation
Betting on other games
Other?

5. Problem or Not? Telling the Difference
PROBLEM GAMBLING
SOCIAL GAMBLING
Frequent, or spends more time gambling.
Occasional gambler.
Plays with $ that is needed or borrowed.
Sticks to limits of money to play with.
Expects to win; keeps playing to win back losses.
Hopes to win but
expects to lose.
Can take it or
leave it.
Is revolved around gambling.

6. Problem Gambling Definition
Gambling is a problem when it disrupts or damages your:
mental or physical health
work, school or other activities
relationships
finances
reputation

7. 1.5 % Pathological Gamblers 4% Problem Gamblers
United States Estimates
1.5 % Pathological Gamblers
4% Problem Gamblers
Problem and pathological gambling rates in adolescents at least 2-3 times those of adults

8. 2012 Ohio Survey

9. Estimated Percent and Number of Persons for At-Risk and Problem Gambling in Ohio
The prevalence of at risk and problem gambling in Ohio is 2.8%, which equates to an estimated 246,561 individuals in the target population of 8,805,761.*
*(18 years and older)
No Problem
Low
Risk
Moderate Risk
Problem
Don’t Gamble
Gamble
43.3%
53.8%
2.2%
0.3%
3,812,895
4,737,499
193,727
26,417
Of the 8.8 million Ohioans aged 18 and older, an estimated 3.8 million (43.3%) do not gamble. Of the Ohioans who do gamble, an estimated 4.7 million (53.8%) do not experience any risk factors.
Prevention activities may be beneficial if directed at the 220,144 (2.5%) persons who are estimated to be at-risk for problem gambling, while treatment services and/or self-help programs such as Gamblers Anonymous should be directed at the 0.3% who are estimated to have a gambling problem that meets DSM-IV diagnostic criteria.
Approximately 10% of those who need treatment will seek treatment (Cunningham, 2005), suggesting that approximately 2,640 individuals may seek treatment or seek out self-help such as Gamblers Anonymous.

10. Map of Cuyahoga Cluster Area

11. Estimated Percent and Number of Persons for At-Risk and Problem Gambling – Cuyahoga County Cluster
The prevalence of at risk and problem gambling is % which equates to an estimated 145,143 individuals in the target population of 1,251,231.*
*(18 years and older)
No Problem
Low
Risk
Moderate Risk
Problem
Don’t Gamble
Gamble
28.8%
59.6%
9.5%
2.0%
0.1%
360,355
745,734
118,867
25,025
1,251
Of the 1.25 million Ohioans aged 18 and older in the Cuyahoga area, an estimated 360,355 (28.8%) do not gamble. Of the Ohioans in this cluster who do gamble, an estimated 745,734 (59.6%) do not experience any risk factors.
Prevention activities may be beneficial if directed at the 143,892 (11.5%) persons who are estimated to be at-risk for problem gambling, while treatment services and/or self-help programs such as gamblers anonymous should be directed at the 0.1% who are estimated to have a gambling problem that meets DSM-IV diagnostic criteria.
Approximately 10% of those who need treatment will seek treatment (Cunningham, 2005), suggesting that approximately 125 individuals may seek treatment.

12. Map of Lucas County Cluster Area

13. Estimated Percent and Number of Persons for At-Risk and Problem Gambling – Lucas County Cluster
The prevalence of at risk and problem gambling is % which equates to an estimated 62,652 individuals in the target population of 423,316.*
*(18 years and older)
No Problem
Low
Risk
Moderate Risk
Problem
Don’t Gamble
Gamble
30.7%
54.5%
11.9%
2.7%
0.2%
129,958
230,707
50,375
11,430
847
Of the 423,316 Ohioans aged 18 and older in the Lucas County Cluster, an estimated 129,958 (30.7%) do not gamble. Of the Ohioans in the cluster who do gamble, an estimated 230,707 (54.5%) do not experience any risk factors.
Prevention activities may be beneficial if directed at the 61,805 (14.6%) persons who are estimated to be at-risk for problem gambling, while treatment services and/or self-help programs such as gamblers anonymous should be directed at the 0.2% who are estimated to have a gambling problem that meets DSM-IV diagnostic criteria.
Approximately 10% of those who need treatment will seek treatment (Cunningham, 2005), suggesting that approximately 84 individuals may seek treatment.

14. Map of Franklin County Cluster Area

15. Estimated Percent and Number of Persons for At-Risk and Problem Gambling – Franklin County Cluster
The prevalence of at risk and problem gambling is % which equates to an estimated 153,815 individuals in the target population of 1,083,205.*
*(18 years and older)
No Problem
Low
Risk
Moderate Risk
Problem
Don’t Gamble
Gamble
37.6%
48.2%
9.2%
4.8%
0.2%
407,285
522,105
99,655
51,994
2,166
Of the 1,083,205 Ohioans aged 18 and older in the Franklin Cluster, an estimated 407,285 (37.6%) do not gamble. Of the Ohioans in this cluster who do gamble, an estimated 522,105 (48.2%) do not experience any risk factors.
Prevention activities may be beneficial if directed at the 151,649 (14.0%) persons who are estimated to be at-risk for problem gambling, while treatment services and/or self-help programs such as gamblers anonymous should be directed at the 0.2% who are estimated to have a gambling problem that meets DSM-IV diagnostic criteria.
Approximately 10% of those who need treatment will seek treatment (Cunningham, 2005), suggesting that approximately 216 individuals may seek treatment.

16. Map of Hamilton County Cluster Area

17. Estimated Percent and Number of Persons for At-Risk and Problem Gambling – Hamilton County Cluster
The prevalence of at risk and problem gambling is % which equates to an estimated 108,453 individuals in the target population of 853,962.*
*(18 years and older)
No Problem
Low
Risk
Moderate Risk
Problem
Don’t Gamble
Gamble
31.6%
55.7%
7.8%
3.5%
1.4%
269,852
475,657
66,609
29,889
11,955
Of the 853,962 Ohioans aged 18 and older in the Hamilton County Cluster, an estimated 269,852 (31.6%) do not gamble. Of the Ohioans in this cluster who do gamble, an estimated 475,657 (55.7%) do not experience any risk factors.
Prevention activities may be beneficial if directed at the 96,498 (11.3%) persons who are estimated to be at-risk for problem gambling, while treatment services and/or self-help programs such as gamblers anonymous should be directed at the 1.4% who are estimated to have a gambling problem that meets DSM-IV diagnostic criteria.
Approximately 10% of those who need treatment will seek treatment (Cunningham, 2005), suggesting that approximately 1,195 individuals may seek treatment.

18. Gambling and Incarceration
43.7 % of Pathological Gamblers have committed crimes (Blaszynski, McConaghy, Francova, 1989)
Various reports indicate % of incarcerated offenders meet criteria for problem or pathological gambling (Zorland, Mooss, Perkins, 2008)
In a sample of 101 people with gambling problems 18

19. Gambling and Arrest Rates
Pathological gambler
Problem Gambler
Low Risk Gambler
No Gambling
Arrest rates
32%
10%
4.5%
# of times arrested
3.3
1.6
2.1
1.7
Imprisoned
23%
13% 6%
National Gambling Impact Study, NORC 1999
In a sample of 114 people with gambling problems
VA medical Center 19

20. Impact Each compulsive gambler costs society $13,000.00 each year.
In Ohio: more than $2.2 billion each year.
One estimate: $289 in social costs for every $46 economic benefit
It is estimated that each problem gambler will directly impact the lives of a minimum of 7 other people – mostly family.

21. Gambling Consequences
Debt
$38,000 to $113,000
Illegal Activities
60% estimated to commit illegal acts

22. Crimes Embezzlement Forgery Identity Theft Fraud Robbery Drug Dealing
Assault

23. Comparison of CD and Gambling Tolerance
Chemical Dependency
Tolerance, as defined by either of the following:
a need for markedly increased amounts of the substance to achieve intoxication or desired effect
markedly diminished effect with continued use of the same amount of substance.
Pathological Gambling
needs to gamble with increasing amount of money in order to achieve the desired excitement.

24. Comparison of CD and Gambling Withdrawal
Chemical Dependency
withdrawal, as manifested by either of the following:
the characteristic withdrawal syndrome for the substance
the same (or closely related) substance is taken to relieve or avoid withdrawal symptoms.
Pathological Gambling
is restless or irritable when attempting to cut down or stop gambling

25. Comparison of CD and Gambling Loss of control
Chemical Dependency
the substance is often taken in larger amounts or over a longer period than was intended
there is a persistent desire or unsuccessful efforts to cut down or control substance use.
Pathological Gambling:
repeated unsuccessful effort to control, cut back, or stop gambling.

26. Comparison of CD and Gambling Preoccupation
Chemical Dependency
A great deal of time is spent in activities necessary to obtain the substance, use the substance, or recover from its effects.
Pathological Gambling
is preoccupied with gambling …

27. Comparison of CD and Gambling Consequences
Chemical Dependency
important social, occupational, or recreational activities are given up or reduced because of substance use.
the substance is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been causes or exacerbated by the substance…
Pathological Gambling:
lies to family member, therapist, or others to conceal …gambling
has committed illegal act …to finance gambling.
has jeopardized or lost a significant relationship, job or educational or a career opportunity because of gambling

28. Comparison of CD and Gambling
Similarities
Preoccupation
Lack of control
Ambivalence (rather than denial or resistance)
Substance use
Depression
Escape
Family dysfunction
Intolerance
Chasing
Need immediate gratification
Shame
Co morbidity

29. Comparison of CD and Gambling
Differences
Not easily detected
Fantasy/Dream Life
Not self limiting, can’t pass out or overdose
Job, family, functional
Suicidality
Hopelessness
Financial (extreme debt)
Family impact (finances)
Social perception of gambling
Few resources
Solitary

30. Pathological Gambling DSM IV
A. Persistent and recurrent maladaptive gambling behavior as indicated by five (or more) of the following:
Preoccupation
Gamble more money in order for desired excitement
Unsuccessful at control, cut back, or stopping gambling
Restless or irritable when cut down or stop
Escaping problems / relieving a dysphoric mood
Chasing
Lies
Illegal acts to finance gambling
Risked or lost a significant relationship, job, or school
Bailouts to relieve a desperate financial situation
B. The gambling behavior is not better accounted for by a Manic Episode.

31. Pathological Gambling DSM V Proposed changes
New Name:
Disordered Gambling
New Classification:
Addiction and Related Disorders
Disordered Gambling the only behavioral addiction
Addiction and related disorders will replace substance related disorders

32. Pathological Gambling DSM V Proposed changes
Why change?
Reward center research
Similarities to Substance Use Disorders
Cravings
Highs
Hereditary nature
Similar treatment
12 step
CBT MI

33. Pathological Gambling DSM V Proposed changes
“Is preoccupied with gambling” most useful criteria with lowest levels of gambling severity
“Illegal acts” is most helpful only for highest levels of gambling severity
Result…consider dropping the Illegal Act criteria
Strong and Kahler, 2007
Those who commit illegal acts as a result of their gambling already reach the threshold of five or more symptoms and therefore this symptom does not improve the precision of the diagnostic code for identifying most individuals with PG

34. Signs that May Point to a Gambling Problem
Criminal activity
Theft/Robbery
Embezzlement
Drug dealing
Shoplifting
FAMILY
COMMUNITY
Work
Secrecy/withdrawal
Unexplained debts/cash
Missing money
Increased anxiety
Substance use
Tardiness
Missing work
Stealing
Mood swings

35. Warning Signs Loss of control over gambling behaviors
Spending more money than intended
Playing for longer periods than intended
Playing more often than intended
Wanting to gamble when one knows
they should be doing other things
Not being able to stop thinking
about gambling

36. Being preoccupied with gambling
Frequently talking about gambling
Often thinking of the next
gambling venture
Lying about one’s gambling
Borrowing and stealing
money from friends, family
members and others in order to keep gambling.

37. Screening Tools SOGS-R (South Oaks Gambling Screen-Revised)
The following can be found at:
SOGS-R (South Oaks Gambling Screen-Revised)
NODS (National Opinion Research Center DSM Screen for Gambling Problems)
NODs CLiP
GA 20 Questions
The following can be found at:
SOGS-RA (South Oaks Gambling Screen-Revised Adolescent)

38. Additional Screening Tools
The following can be found at: .pdf?ga=t
BBGS – Bio-Social Gambling Screen
The following can be found at: als/Pages/IGS.aspx
IGS- Inventory of Gambling Situations

39. Brain Activity to losses/gains
The blue areas at the left are those that become activated as we make decisions that will likely cause us to lose money. The orange and red at the right show the activation that occurs in the brain when we believe the odds are in our favor to win money 39

40. Gambling Activity
Identification of risk adverse..at the track and further
WIN
Ventral striatum becomes activated, flooded with dopamine (sex, drugs, pleasure)
Once activated want more..and more and more
LOSS
The same area of the brain become less active
Risk aversion
Should I take this new job, should I invest in the company, should I invest in this stock. 40

41. For Pathological Gamblers in that gambling activity
The Ventral Striatum remains unreactive EVEN DURING WINNING STREAKS
Decreased response to the “high”
Decreased activation in the ventrolateral prefrontal cortex
Keep gambling despite negative impact
Keep gambling to increase to normal levels of dopamine
Seen in SUD
Clark et al 2009
ventrolateral prefrontal cortex (the mom of the brain) that keeps people from acting impulsively 41

42. Pathological Gambling addiction
The brain is hijacked….
When triggered with a gambling cue the area of the brain responsible for impulse control is off
Potenza et al 2003
In men with PG, gambling cue presentation elicits gambling urges and leads to a temporally dynamic pattern of brain activity changes in frontal, paralimbic, and limbic brain structures. When viewing gambling cues, PG subjects demonstrate relatively decreased activity in brain regions implicated in impulse regulation compared with controls 42

43. Gambling Court
It is a therapeutic, intervention and rehabilitative approach — within the criminal justice system and under judicial supervision — for defendants who commit non-violent crimes because of gambling addiction.

44. Gambling Court Started by Judge Mark Farrell in New York State in 2001
350 people screened for gambling addiction
100 deemed appropriate for diversion
27 have graduated from treatment programs
Only 3 have returned to the legal system, with non-gambling offenses
The cost of gambling court treatment is only one sixth the amount of money it costs to keep someone in jail.

45. Gambling Court http://gamblingcourt.org/videoFarrell.php

46. RULES OF RESPONSIBLE GAMBLING
TREAT THE MONEY YOU LOSE AS THE COST OF YOUR ENTERTAINMENT: Treat any winnings as a bonus.
PLAN AHEAD: SET A DOLLAR LIMIT AND STICK TO IT. Decide before you go not only what you can "afford" to lose, but how much you want to spend. Do not change your mind at the casino after losing.
SET A TIME LIMIT AND STICK TO IT: Decide how much of your time you want to allow for gambling - leave when you reach the time limit whether you are winning or losing.
BE PREPARED TO LOSE: The odds are that you will lose. Accept loss as part of the game.
MAKE IT A PRIVATE RULE NOT TO GAMBLE ON CREDIT: Do not borrow to gamble.
CREATE BALANCE IN YOUR LIFE: Gambling should not interfere with or substitute for friends, family, work or other worthwhile activities
AVOID "CHASING" LOST MONEY. After you've reached your designated dollar limit, DON'T continue to play in order to try to win back the money. Stop gambling and go see a show, or go home.
DON’T GAMBLE AS A WAY TO COPE WITH EMOTIONAL OR PHYSICAL PAIN. Instead, talk to a friend, a family member or a professional counselor.
BECOME EDUCATED ABOUT THE WARNING SIGNS OF COMPULSIVE GAMBLING

47. Abstinence is recommended when:
you are experiencing significant financial problems;
you continue to see gambling as a solution to financial problems;
you gamble to escape and/or cope with negative situations and moods;
your gambling is related to an impulse disorder;
you have been mandated to by the legal system;
you have already made unsuccessful attempts to reduce your gambling; or
your relationships or employment may be at risk if you continue to gamble.
Although it is still their choice..we still have to mention best scenario as it relates to the research..always do with respectfully asking for permission 47

48. Treatment Recovery Resources Gambling Service Assessment
Individual Counseling
Group Therapy
Family Therapy
Prevention Education Services

49. Treatment Recovery Resources Services Assessment
Substance abuse treatment
Case management
Mental health services
Education and prevention services
Adolescent treatment services

50. Please visit our website at
What can you do?
For more information about our services at Recovery Resources, please call,
Please visit our website at

51. For more information about the gambling services at Recovery Resources, visit our website at

52. 1-800-589-9966 Ohio Hotline Cleveland Toledo Youngtown Columbus Athens
Cincinnati

53. Resources www.facetheodds.org – Recovery Resources Gambling website
– Recovery Resources website
– Gambling Court in New York State
– National Council on Problem Gambling
– Problem Gambling Network of Ohio
- GA meetings
– National Problem Gambling Awareness Week
– Ohio Department of Alcohol and Drug Addiction Services

54. Athens
Health Recovery Services 244 West State St. Athens, Ohio Toll Free: Phone: Fax:
Cincinnati
Central Community Health Board Drug Services Program Vernon Place Cincinnati, OH
Cleveland
Recovery Resources
Jennifer Clegg, MSW, LSW, NCGCI Detroit Ave. Suite 200
Lakewood, OH   44107
ext. 4215
Cleveland
Cleveland V.A. Hospital Wade Park
Heather A. Chapman, Ph.D., NCGC II East Blvd., 3rd Floor, Room # 3A165 Cleveland, OH (440) x 6962
Columbus
MARYHAVEN MAIN CAMPUS 1791 Alum Creek Drive Columbus, Ohio Phone (614)
Toledo
Substance Abuse Services 832 Adams Street Toledo, OH
Youngstown
Meridian Services
Lynn Burkey NCGCI 527 North Meridian Road Youngstown, OH

55. Resources www.facetheodds.org – Recovery Resources Gambling website
– Recovery Resources website
– Gambling Court in New York State
– National Council on Problem Gambling
- GA meetings
– National Problem Gambling Awareness Week
– Ohio Department of Alcohol and Drug Addiction Services
– Ohio for Responsible Gambling