Strategies for Starting the Conversation: Developing and Implementing a Problem Gambling SBIRT Lori Rugle, PhD, ICGC-II, BACC ACKNOWLEDGEMENTS Study funded by National Center on Responsible Gambling TEAM Megan Well, BS Hana Machover, BS Rachel Arnold, BA
Wendy Potts, MA Chris Welsh, MD Lori Rugle, PhD Objectives Understand the SBIRT model Understand the rationale for a gambling SBIRT including relevant research and clinical findings Understand and be able to implement effective strategies for administering a problem gambling SBIRT ALCOHOL
AND THOSE SCREENING FOR ALCOHOL RELATED DISORDERS! https://www.cdc.gov/vitalsigns/alcohol-screening-counseling/index.html Browne & Rockloff, 2017 Problem Gambling In 2015, 10.8% of people aged 12 or older (23 million) who needed substance use disorder treatment received treatment at a specialty facility
In 2016, one quarter of one percent (.25%) of people (14,375) who needed gambling disorder treatment received treatment at a publicly funded specialty facility. Association of Problem Gambling Service Administrators, 2017 Why Bother? Per DSM5, Gambling disorder is associated with poor general health...Some specific medical diagnoses, such as tachycardia and angina are more common than in the general population. Health Problems and Medical Utilization with Gambling Disorders Gambling even 5 times a year (at risk) is associated with
adverse health consequences, increased medical utilization and health care costs. At risk gamblers more likely to be diagnosed with hypertension, receive ER treatment, experienced severe injury, be obese, have history of mood or anxiety disorder, have an alcohol use disorder and nicotine dependence. At risk group comprises 25% of the population. 7 National Epidemiologic Survey on Alcohol and Related Conditions (Morasco et al, 2006) Why Bother Although nearly half (49%) of those with lifetime pathological gambling received
treatment for mental health or substance abuse problems, none reported treatment for gambling problems Kessler et al., 2008 (National Comoribidty Survey Replication) Funded by DHMH/BHA 8 You know one if you see one --Director of Substance Abuse Treatment Program, Detroit VA PREVALENCE OF PROBLEM GAMBLING IN MEDICAL TREATMENT SETTING
1,999 6.2% 10.6% 10.7% PHYSICAL HEALTH AND GAMBLING Morasco et al. Gen Hosp Psych. 2006 Health Habits Black et al, 2013
Problem Gambling Subjects: Smoke >/= 1ppd Drink >/= 5 servings of caffeine/day Watch >/= 20 hrs TV/week More ER visits Less likely to have regular dental care More likely to postpone medical care due to financial problems Have higher Body Mass Index and be obese Have poorer self-perception of health Severity of gambling positively correlated with # of medical problems
What is SBIRT? Screening Brief Intervention Referral to Treatment Application of a simple Test to determine if a Patient is at risk for or may have a gambling disorder
Explanation of screening results, information on responsible gambling, assessment of readiness to change, advice on change Patients with positive results on a screening may be referred to resources for further assessment and/or
counseling or self-help resources It is important to remember that a positive screen does not constitute a diagnosis, even if the screen suggests a high probability of problematic gambling behavior. IOM Conceptualization and Problem Gambling Public Health Interventions Provide Screening for Problem Gambling No gambling
Social gambling At Risk Gambling Mild Problem Gambling ate Moder
Korn & Shaffer, 99 IOM Conceptualization and Problem Gambling Public Health Interventions No gambling Social gambling At Risk Gambling
Mild None For those who screen positive provide brief intervention Universal Selective Brief Problem Gambling
ate Moder Gambling Disorder Severe Specialized Treatment Indicated Prevention IOM Conceptualization and Problem Gambling Public Health Interventions
No gambling Social gambling At Risk Gambling Mild None
Brief Universal Selective Problem Gambling ate Moder Gambling Disorder
Severe Then inform of and offer referral to treatment Specialized Treatment Indicated Prevention WHAT ARE THE KEY ELEMENTS FOR A SUCCESSFUL SBIRT INTERVENTION? Screening Questionnaire Short, Reliable, Valid & Interpretable
Brief Intervention Acceptable & Implementable Referral to Treatment Specialty treatment available Defining Gambling WHAT IS 38 grams of alcohol? http://www.health.govt.nz/your-health/healthy-living/addictions/alcohol-and-drug-abuse/alcohol WHAT IS 38 grams of alcohol?
About 4 standard drinks http://www.health.govt.nz/your-health/healthy-living/addictions/alcohol-and-drug-abuse/alcohol WHAT IS STANDARD GAMBLING? FIRST DEFINE GAMBLING The following questions are about gambling. By gambling, we mean when you bet or risk money or something of value so that you can win or gain money or something else of value.
For example, buying lottery tickets or scratchoffs, gambling at a casino, playing bingo, shooting dice, betting on sports, or playing keno. Risk Levels for Gambling Disorder and Brief Interventions Risk Levels for Gambling Disorder and Brief Interventions Low Risk: An individual has answered no to all questions. Provide individuals with their score, give feedback on their risk level and give literature regarding Gambling Disorder in case their behavior worsens or they have affected family/friends with whom they want to share. Moderate Risk: An individual has responded yes to question 1, but has said no to all other questions.
Give the low risk intervention. Additionally, the clinician should discuss with the participant the continuum of gambling behaviors (e.g., recreational, at risk, problem disorder), risk factors associated with moderate and problem gambling (e.g., medical issues), and guidelines to reduce risk for gambling problems. High Risk: An individual has responded yes to question 1 and has said yes to at least one other question. Combine low and moderate risk intervention. Additionally, review risk factors for problem gambling and options for further assistance including self-help materials, referral for further evaluation and referral to Gamblers Anonymous or a recovery support specialist. 24
DETERMINE PREVALENCE OF PROBLEM GAMBLING AND PILOT USE OF BBGS Study Sample: 100 randomly selected patients in an urban clinic Gold Standard DSM 5 Diagnostic Criteria Screening Instrument BBGS PREVALENCE (>4 DSM 5 CRITERIA)
12 % DEMOGRAPHIC CHARACTERISTICS CHARACTERISTIC Age (n=99) Male HS or > Single Unemployed or disabled
SAMPLE (N=100) 53 56.0% 60.0% 63.0% 80.0% DSM5 POSITIVE DSM5 NEGATIVE FOR GAMBLING FOR GAMBLING (N=12) (N=88)
53 75.0% 33.3% 66.7% 91.7% 54 53.4% 63.6% 62.5% 78.4% HISTORY OF SUBSTANCE USE
CHARACTERISTIC SAMPLE (N=100) Used Tobacco 54.0% 66.7% 52.3%
Used MJ* 17.2% 41.7% 13.8% Used heroin* 3.0% 25.0%
0.0% Used crack 4.0% 16.7% 2.3% 39.0%
66.7% 35.2% Used alcohol DSM5 POSITIVE DSM5 NEGATIVE FOR GAMBLING FOR GAMBLING (N=12) (N=88) * Significance at p < 0.05 as determined by a Fishers exact test
GAMBLING BEHAVIORS CHARACTERISTIC Gambled (at all) * Played card games* Bet sports games* Played dice* Scratch offs Lottery tickets SAMPLE DSM5 POSITIVE (N=100) FOR GAMBLING (N=12)
66.7% * Significance at p < 0.05 as determined by a Fishers exact test DSM5 NEGATIVE FOR GAMBLING (N=88) 37.5% 18.2% 12.1% 3.0% 63.6%
78.8% PREVALENCE STUDY CONCLUSIONS Gambling appears to be highly prevalent in this clinic sample Predictors of gambling are associated with substance use and impulsivity BBGS appears to be an effective screening tool BRIEF INTERVENTIONS? BRIEF INTERVENTIONS WORK
Petry et al. J Consult Clin Psychol. 2016 WHAT ARE THE KEY ELEMENTS FOR A SUCCESSFUL SBIRT INTERVENTION? Screening Questionnaire Short, Reliable, Valid & Interpretable Brief Intervention Acceptable & Implementable Referral to Treatment Specialty treatment available
STUDY AIM 1: DEVELOPING SBIRT INTERVENTION FOR GAMBLING Part 1: Adapt SBIRT Intervention Part 2: Expert Panel Review & Advice Part 3: Qualitative Interviews Gamblers (n=6) Non-gamblers (n=6) Primary care clinicians (n=6) ASPECTS OF BRIEF INTERVENTION
Motivational interviewing Personalized feedback Simple strategies for decreasing gambling Not meant to substitute for treatment Less than 10 minutes Petry et al. J Consult Clin Psychol. 2008 RISK STRATIFICATION
RISK LEVEL LOW MEDIUM HIGH GAMBLED 5 TIMES IN ONE YEAR? NO YES YES
1 OR MORE ON BBGS NO NO YES MATERIALS WERE ITERATIVELY ADAPTED Patients wanted materials that were: Easy to read Relatable Eye catching Clinicians recommended:
MI elements for those screening high risk LOW RISK FOR GAMBLING MEDIUM RISK FOR GAMBLING MEDIUM RISK FOR GAMBLING HIGH RISK FOR GAMBLING HIGH RISK FOR GAMBLING AIM 1 CONCLUSIONS
Participants, Clinicians and the Expert Panel found the final materials to be: Easy to read Useful Helpful STUDY AIM 2: PILOT FEASIBILITY STUDY Design: Train 3 clinicians to deliver intervention Evaluate the clinicians use of the SBIRT intervention on 15 participants Outcome:
Evaluate feasibility of utilizing SBIRT intervention and preliminarily monitor clinician fidelity CLINICIAN CHARACTERISTICS CHARACTERISTIC Male African-American NP MD SAMPLE (N=3)
100.0% 33.3% 33.3% 66.7% PARTICPANT CHARACTERISTICS CHARACTERISTIC Male African-American HS or > Single Unemployed or disabled Stable Housing
Male African-American HS or > Single Unemployed or disabled Stable Housing CAGE positive SAMPLE (N=15) 60.0% 86.7% 73.3% 73.3%
60.0% 86.7% 33.3% RISK STRATIFICATION RISK STRATIFICATION Low Medium High SAMPLE (N=15) 40.0%
46.6% 13.3% PARTICIPANT FEEDBACK BETTER UNDERSTAND GAMBLING BEHAVIOR AFTER THE INTERVENTION? 100% 84.6% 80% 0.54
60% 40% 0.31 20% 0% 0.08 0 0
IT WAS HELPFUL FOR ME TO LEARN ABOUT MY GAMBLING BEHAVIORS? 100% 84.6% 80% 0.54 60% 40%
0.31 0.15 20% 0% 0 0 BETTER UNDERSTAND MY GAMBLING BEHAVIORS AFTER SBIRT INTERVENTION?
100.0% 69.3% 80.0% 60.0% 38.5% 40.0% 20.0% 0.0%
7.7% 7.7% 15.4% 30.8% HOW FREQUENTLY SHOULD YOUR CLINICIAN SCREEN YOU FOR GAMBLING? 100% 80%
61.5% 60% 40% 20% 0% 23.1% 7.7% NEVER 7.1% EVERY 3 MONTHS TWICE A YEAR
EVER YEAR CLINICIAN FEEDBACK INTERVENTION IS USEFUL Even though it was only 4 questions, if you dont ask the questions, you wont know the response. I was able to unveil a possible problem. LEAD TO IMPORTANT CHANGE later he reached out to one of the nurses
that works with me and asked to get some more information because he must have incurred something that triggered a need for him. He didnt want an intervention right then and there, but clearly afterwards, it seemed like there might have been something more going on. TIME WAS WELL SPENT I think the key was that it didnt interrupt the flow and I could run through it very quickly. Doesnt have to necessarily turn into an extra 20 minutes.
AIM 2 CONCLUSIONS Participants found the intervention: Useful Helpful Clinicians found the intervention: Easy to implement With noticeable outcomes AIM 3 PILOT RCT Design: Randomized Control Trial
100 participants 10 clinicians Primary Outcome: Thirty Day Timeline Follow Back number of days gambled amount of money spent Considerations for Substance Use and Mental Health Settings Perspective Change: Disordered Gambling Integration (DiGIn)
Addressing gambling and gambling problems for individuals presenting with a primary concern of a substance use or mental health disorder is not just about making a diagnosis or finding cases of gambling disorder. Rather this approach involves assuring that the impact of gambling on mental health and substance use recovery is an ongoing topic of conversation in treatment, recovery and prevention settings. 61 PG Screening Bad News
Screens dont work well in clinical practice Give illusion of addressing issue Funded by DHMH/BHA 62 Typical Results of Use of Brief Screens
What happens in actual clinical practice Use screen No one endorses items What does counselor think None of my clients have any gambling problems Dont care about the research, my clients are different NIMBY (Not in my back yard or treatment program) Funded by DHMH/BHA Iowa Study: Data collected by 4 SA Block Grant Agencies
Baseline 368 Lie/Bet 4 positives (1%) Follow-up 2 agencies switched to BBGS and 2 to NODS-CLiP BBGS: 267 Screens 6 positives (3%) NODS CliP: 89 screens 3 positives (3%) Maryland data SMART data 2.5% across all SUD settings screen positive for gambling disorder Screening Best Practices Include brief screen on intake (and dont expect much)
Repeat screen after relationship and trust established (at treatment plan updates?) Conduct screen in conjunction with psychoeducation on impact of gambling on recovery/problem gambling Assessing Impact on Recovery Beyond diagnosis and labeling Integrate gambling throughout the assessment in addition to specific screening items In what ways does gambling support or detract from mental health or substance abuse recovery? In what ways does gambling support or detract from life
goals? 66 Alternative Strategies Subtle Questions How would you start the conversation with your grandmother? Goals of screening and assessment Goals of screening and assessment
Open the conversation Increase curiosity Begin to move from pre-contemplation Give permission to talk about gambling Begin to make connections between gambling and other major life areas 68
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