Probable and Potential Pathological Gambling in Methadone Maintenance

Probable and Potential Pathological Gambling in Methadone Maintenance Treatment (MMT) patients - a cross-sectional study Dr. Miriam & Sheldon G. Adelson Clinic for Drug Abuse Treatment & Research Tel-Aviv Sourasky Medical Center & Tel-Aviv University Sackler Faculty of Medicine Einat Peles, Shaul Schreiber, Miriam Adelson

Impulse-Control Disorders • • • Pathological Gambling (PG) Kleptomenia Pyromania Trichotillomania Impulse-control disorder not otherwise specified

Pathological Gambling DSM-IV-TR • Persistent and recurrent maladaptive gambling behavior that disrupts personal, family, or vocational pursuits

DSM-IV-TR Substance Dependence קיום 3 ≥ מהקריטריונים בשנה Pathological Gambling קיום 5 ≥ מהקריטריונים בשנה

Substance Dependence Pathological Gambling בילוי זמן ניכר בפעילות הקשורה עיסוק בהימורים בסם צורך להמר עם כמויות עולות של כסף סבילות להשגת הריגוש המצופה שימוש מעל לתכנון במשך/במינון, רצון מתמיד או כשלון בשליטה או בהפחתת או הפסקת ההימורים בהפחתת השימוש אי שקט ועצבנות כשמנסים להפחית/ תסמונת גמילה להפסיק להמר שימוש בא על חשבון עבודה/חברים פוגע במשפחה/ חברה/ עבודה בגלל הימורים

Pathological Gambling הימור כדרך בריחה מבעיות הימור כדי להתמודד עם כישלונות/הפסדים הסתרת מידת ההימורים על ידי שקרים לעבור על החוק כדי לממן הימורים להסתמך על כספי אחרים כדי להתמודד עם ההימורים Substance Dependence נמשך למרות המודעות לבעיה פיזית/ פסיכולוגית עקב השימוש

Mechanism ? (treatment) Opioid antagonist (naltrexone) Dopamine reuptake inhibitor (bupropion) Mood stabilizer (Litium) Serotonin reuptake inhibitor SSRI (paroxetine)

Prevalence- Pathological Gambling • General population: 0. 2% (Norway), 2. 1% (Australia), 3% (USA) Israel? • Drug abusers 5 -39% Israel? • MMT clinics: 7% - 52. 7% • Israel?

Methadone • • • Opiate agonist - long acting (Heroin short acting) T 1/2 24 -36 hrs (Heroin 4 hrs) Oral (Heroin injected) No euphoria (Heroin cause) No tolerance in steady dose (Heroin cause) Normalize the HPA (hypothalamic-pituitary-adrenal) axis (Disturbed even after Heroin abstinence )

Functional State (Heroin) Impact of Short-Acting Heroin versus Long-Acting Methadone Administrated on a Chronic Basis in Humans – 1964 Study "High" "Straight" "Sick" AM PM AM Functional State (Methadone) Days "High" "Straight" "Sick" AM PM AM Days H PM AM Dole, Nyswander and Kreek, 1966

MMT Main Goal: Stop Opiate • Secondary Goals: • Cocaine, Benzodiazepines, Amphetamines, THC, Alcohol • Infectious disease • Health status • Crime, Antisocial behavior (Family, Society) • Work • Patient retention in treatment

Aims: To find prevalence and characterize pathological gambling in Methadone Maintenance Treatment (MMT) patients.

Methods Study Population (N=300) • Former Heroin addicts patients (DSM-IV) • Adults (18+ years) • Patients admitted to the Adelson MMT clinic in Tel-Aviv medical center, Israel, since July 1993. Study group (n=101) • 101 non-selective group • Studied between July 2003 - July 2004

Methods Study Population (N=300) • Former Heroin addicts patients (DSM-IV) • Adults (18+ years) • Patients admitted to the Adelson MMT clinic in Tel-Aviv medical center, Israel, since July 1993. Study group (n=154) • Non-selective random sample • Studied between June - October 2006

South Oaks Gambling Screen (SOGS) (Lesieur and Blume, 1987). • 20 -item questions instrument Potential (problem gambler) = score 3 -4 Probable PG = score ≥ 5.

Results

Group Characteristics (N=154) • • • Age MMT onset 37. 9± 9 y Age 43. 4± 9 y Male 64. 9% Female 35. 5%. Opiate abuse before MMT 15. 4± 8. 3 y Duration in MMT 5. 5± 4 y Any Axis I psychiatric disorder 48. 4%

Lifetime Potential and Probable Pathological Gamblers (N=154) n=9 Potential n=36 Probable

Lifetime Potential and Probable Pathological Gamblers (N=154) PG (n=45)

Type of gambling by PG and non PG <5% - bet on animals, sports, play game of skill for money

Perceived pathological gambling

PG by gender Male (N=100) Female (N=54) 14. 8% * Fisher's Exact Test, p=0. 005 37%

Differences between PG groups Total Age admission PG N(%) 45(100) 41. 2± 9. 5 Duration in MMT (y) 5. 4± 4. 3 Years of education 9. 1± 2. 5 Any Axis I 17(38. 6) Any Medication use 29(64. 4) BDZ/ (self report) 24(53. 3) Any Drug abuse 30(68. 2) Nicotine addiction 3± 1. 3 Methadone dose 137± 40. 8 Father and/or Mother 13(28. 9) No N(%) 109(100) 36. 5± 8. 4 5. 6± 3. 9 10. 1± 2. 2 53(48. 6) 57(52. 3) 40(36. 7) 66(60. 6) 3± 1. 4 140. 6± 50. 3 22(20. 2) 0. 003 0. 02 0. 07

Differences by gender Male (n=100) 100(%) Female (n=54) 100(%) Age admission 39. 5± 8. 7 34. 9± 8. 9 0. 002 Years of education 9. 5± 2. 1 10. 7± 2 0. 001 BDZ/ (self report) 42(42) 22(40. 7) N. S

Logistic Regression for PG (yes/no) Variable OR 95% CI P Male 3. 1 1. 3 -7. 4 0. 01 Admission age ≥ 40 y 2. 5 1. 2 -5. 3 0. 01

Yale-Brown Obsessive Compulsive Scale 10 -item scale, ranged: 0 none -4 extreme symptoms (total range, 0 to 40) Clinical OCD defined if scored were ≥ 16 Moderate to Extreme OCD.

Clinical Obsessive Compulsive Disease (OCD) (N=154) OCD 43%

OCD by gender Male (N=100) Female (N=54) * 57. 4% Fisher's Exact Test, p=0. 01 35%

OCD by PG No PG (N=109) PG (N=45) 51. 1% Fisher's Exact Test, p=0. 2 39. 4%

Proportion of Clinical OCD by gender and PG N=37 N=8 * N=63 Fisher’s Exact Test *p≤ 0. 05 * N=46

Logistic Regression for PG (yes/no) Variable OR 95% CI P Male 3. 6 1. 5 -8. 8 0. 005 Clinical OCD 1. 07 1. 0 -1. 1 0. 03 Admission age ≥ 40 y 2. 4 1. 1 -5 0. 02

When PG started? Before ? After Together? with Opiate abuse (N=45) 21. 3± 5. 2 After Together Before opiates 21. 7± 7. 9 16. 6± 6. 2 24. 4%

When PG stopped? Before /after opiate start? (N=45) Continued After opiate 40. 1± 12 Before opiate 16± 5. 9

When PG stopped? Before MMT ? During MMT? (N=45) 43. 1± 10. 9 Before MMT During Continue 51. 4± 10. 7 30± 10. 7 24. 4%

Summary Adequate diagnosis and interventional treatment should be considered due to the expected high rate (23%) of pathological gambling among MMT patients. Male gender, current OCD, and older age on admission to MMT are at greatest risk of lifetime pathological gambling.

Treatment? Opioid antagonist (naltrexone) Dopamine reuptake inhibitor (bupropion) Mood stabilizer (Litium) Serotonin reuptake inhibitor (paroxetine)

PG by gambling legality Las Vegas (N=113) Tel Aviv (N=178) 19. 5% Fisher's Exact Test, p=0. 05 27%