Emerging Issues in Problem Gambling Treatment: The Neurological Process of Addiction and Its Impact on Problem Gambling

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2. What does addiction look like? By the raise of hands, who here have been affected by addiction or by someone who you consider an addict of some sort? All of us are here today, in a sense, because we�re fascinated with addiction. So what does addiction look like? What consequences do you see with addiction? It�s a complex, multi-dimensional problem that often intersects the behavioral, mental, physical, emotional, biological, political, moral, cultural, and social boundaries. Obession, loss of control, family dysfunction, depression, isolation� Most of us know well these ripple effects of addiction�but is exactly happens to a person when they are addicted? By the raise of hands, who here have been affected by addiction or by someone who you consider an addict of some sort? All of us are here today, in a sense, because we�re fascinated with addiction. So what does addiction look like? What consequences do you see with addiction? It�s a complex, multi-dimensional problem that often intersects the behavioral, mental, physical, emotional, biological, political, moral, cultural, and social boundaries. Obession, loss of control, family dysfunction, depression, isolation� Most of us know well these ripple effects of addiction�but is exactly happens to a person when they are addicted?

3. What is Addiction? Is there a clear universal definition of addiction? Unfortunately, no there isn�t. To give you a few examples: According to the Am. Psychological Association, addiction is a condition in which the body must have a drug to avoid physical and psychological withdrawal symptoms, characterized by dependence and tolerance. Medical: A chronic relapsing condition characterized by compulsive drug-seeking and abuse and by long-lasting chemical changes in the brain Others: habitual psychological and physiological dependence on a substance or practice beyond one's voluntary control. FYI: pathological gambling is considered to be an impulse control disorder and is therefore not considered by the American Psychological Association to be an addiction. Is there a clear universal definition of addiction? Unfortunately, no there isn�t. To give you a few examples: According to the Am. Psychological Association, addiction is a condition in which the body must have a drug to avoid physical and psychological withdrawal symptoms, characterized by dependence and tolerance. Medical: A chronic relapsing condition characterized by compulsive drug-seeking and abuse and by long-lasting chemical changes in the brain Others: habitual psychological and physiological dependence on a substance or practice beyond one's voluntary control. FYI: pathological gambling is considered to be an impulse control disorder and is therefore not considered by the American Psychological Association to be an addiction.

4. WORKSHOP GOALS

5. VIDEO CASE STUDY Although addiction is still a very young science, we have made some advances in the drug addiction realm. We will watch a video produced by HBO called Addictions to help you gain a basic neuroscience perspective on addiction, and later, how it relates to problem gambling. Video Discussion Questions: What did you think of the video? How old is the patient? How old is his brain according to the doctors? What was his response to his brain images? What do you call a person who doesn�t believe in something even if there are real evidence and facts? Do you think the brain scan of a drug addict is different from a brain scan of a gambling addict? The brain imaging tool has become an essential part of neuroscience studies because we can measure real-time changes in people�s brains without harming them. The studies typically allow us to make general conclusions about how brains of addicts differ substantially from brains of non-addicts. Michael will get into the exciting details in just a moment. First� Although addiction is still a very young science, we have made some advances in the drug addiction realm. We will watch a video produced by HBO called Addictions to help you gain a basic neuroscience perspective on addiction, and later, how it relates to problem gambling. Video Discussion Questions: What did you think of the video? How old is the patient? How old is his brain according to the doctors? What was his response to his brain images? What do you call a person who doesn�t believe in something even if there are real evidence and facts? Do you think the brain scan of a drug addict is different from a brain scan of a gambling addict? The brain imaging tool has become an essential part of neuroscience studies because we can measure real-time changes in people�s brains without harming them. The studies typically allow us to make general conclusions about how brains of addicts differ substantially from brains of non-addicts. Michael will get into the exciting details in just a moment. First�

6. Brain Reward Pathway Because rewards and pleasures play key roles in the addiction process, it makes sense to study how our brain responds to rewards. Here - our brain�s natural reward pathway looks something like this - a very simplified model. We start with a source signal which travels to other parts of the brain. In this case, the signal starts at the VTA and is transmitted to 3 areas of the brain that play important roles in addiction: prefrontal cortex, nucleus accumbens, amygdala Because rewards and pleasures play key roles in the addiction process, it makes sense to study how our brain responds to rewards. Here - our brain�s natural reward pathway looks something like this - a very simplified model. We start with a source signal which travels to other parts of the brain. In this case, the signal starts at the VTA and is transmitted to 3 areas of the brain that play important roles in addiction: prefrontal cortex, nucleus accumbens, amygdala

7. Brain Reward Pathway

9. Limbic System The reward pathway includes parts of the limbic system. What is the limbic system? Often times referred to as the �Reptilian Brain� because it�s older, even dinosaurs had them. It�s the basic survival part of the brain. Linked to pleasure center.. How are rewards and subsequent feelings of pleasure related to survival? What kinds of general activities do we do that is necessary to live? Both necessary and pleasurable? Eating, socializing, sex� It�s also linked to the prefrontal cortex which controls your impulses to act upon your desires. This is normal for people: to have a part of the brain that tells us �what we like or desire� and parts that tell us �No, we should do that or should do just a little bit of that.� This is a very general picture of what kinds of functions our brain does. The reward pathway includes parts of the limbic system. What is the limbic system? Often times referred to as the �Reptilian Brain� because it�s older, even dinosaurs had them. It�s the basic survival part of the brain. Linked to pleasure center.. How are rewards and subsequent feelings of pleasure related to survival? What kinds of general activities do we do that is necessary to live? Both necessary and pleasurable? Eating, socializing, sex� It�s also linked to the prefrontal cortex which controls your impulses to act upon your desires. This is normal for people: to have a part of the brain that tells us �what we like or desire� and parts that tell us �No, we should do that or should do just a little bit of that.� This is a very general picture of what kinds of functions our brain does.

10. Neurotransmitters A bit about our brain�s biochemistry�relevant because drug treatments often target these mechanisms. Our brains are made up of many cells called neurons. Neurons are arranged in complex networks or pathways. The cells in our brains communicate with each other by electrical and chemical signals. The chemical signal between cells are called neurotransmitters. Neurotransmitters are released from the neuron that houses it and binds to specific receptors found on another cell, in the case of the brain another nerve cell. The type of neurotransmitter-receptor interaction is crucial in how the brain functions. A bit about our brain�s biochemistry�relevant because drug treatments often target these mechanisms. Our brains are made up of many cells called neurons. Neurons are arranged in complex networks or pathways. The cells in our brains communicate with each other by electrical and chemical signals. The chemical signal between cells are called neurotransmitters. Neurotransmitters are released from the neuron that houses it and binds to specific receptors found on another cell, in the case of the brain another nerve cell. The type of neurotransmitter-receptor interaction is crucial in how the brain functions.

11. Neurotransmitters Studies have revealed the importance of certain brain chemicals involved in the process of addiction. These are chemical clues to what happens in the brain and by no means tell the entire story.Studies have revealed the importance of certain brain chemicals involved in the process of addiction. These are chemical clues to what happens in the brain and by no means tell the entire story.

12. Serotonin We have learned that serotonin has broad effects on the human body and plays many different roles. Among them are regulation of mood, appetite�. When levels of serotonin are depleted or below optimal level, we often link it to depression�. Can someone describe recent commercials for anti-depressant drugs? What do these ads promise? SSRIWe have learned that serotonin has broad effects on the human body and plays many different roles. Among them are regulation of mood, appetite�. When levels of serotonin are depleted or below optimal level, we often link it to depression�. Can someone describe recent commercials for anti-depressant drugs? What do these ads promise? SSRI

13. Norepinephrine A study revealed that in mice without NA tend to not prefer drugs like cocaine, morphine�when NA is introduced, they sought these drugs. Seems necessary for motivational behavior. (Jasmin L, Narasaiah M, Tien D. , Vascul Pharmacol. 2006 Jul 7) A study revealed that in mice without NA tend to not prefer drugs like cocaine, morphine�when NA is introduced, they sought these drugs. Seems necessary for motivational behavior. (Jasmin L, Narasaiah M, Tien D. , Vascul Pharmacol. 2006 Jul 7)

14. Dopamine Dopamine & NA very related. It is the neurotransmitter involved with the processing of rewards. Whenever we experience something pleasurable, such as winning a hand of blackjack or eating a piece of chocolate cake, our dopamine neurons get excited. These neurons help the brain learn about the pleasure, and attempt to predict when it will happen again. Parkinson�s: low DA levels --> inability to control muscle movements Interesting case of Parkinson�s patients on medication that raise DA levels: increase in problem gambling Dopamine & NA very related. It is the neurotransmitter involved with the processing of rewards. Whenever we experience something pleasurable, such as winning a hand of blackjack or eating a piece of chocolate cake, our dopamine neurons get excited. These neurons help the brain learn about the pleasure, and attempt to predict when it will happen again. Parkinson�s: low DA levels --> inability to control muscle movements Interesting case of Parkinson�s patients on medication that raise DA levels: increase in problem gambling

15. Dopamine: Reward & Learning Breakthrough in dopamine function - Schultz� monkey experiment (1990s): to learn about the roles of rewards and expectations in the process of learning and memory. Essentially, the experiment wanted to test whether our brains respond to (via dopamine levels) actual rewards or cues to rewards. Design was rather simple: monkeys (subject) + flash of light (cue to reward) + fruit juice (actual reward). First, the researchers flashed a light before giving monkeys the fruit juice. As expected, the dopamine response in the brain coincided with the actual consumption of the reward. As monkeys learned about cues that predict a reward, the brain response curiously changed. At this point, monkey�s brains activated upon the cue not the reward. Once the cells memorize the simple pattern � flash of light predicts the arrival of juice � they become sensitive to variations on the pattern. If the predictions proved correct and the mokeys experienced a surge of dopamine, the prediction was reinforced. However, if the pattern was violated � if the light flashed but the juice never arrived � then the monkey�s dopamine neurons abruptly decreased their firing rate Learning takes place only when something unexpected happens and dopamine firing rates increase or decrease. When nothing unexpected happens, as when the same amount of delicious apple juice keeps coming, the dopamine system is quiet. Conclusion: dopamine seems to be a �learning signal� about rewards rather than the actual mediator of pleasurable experience. Reveals the chemical nature of human behavior. Predictable parts of your life don�t have as much significance (both socially and chemically) unless something new or unpredictable happens. In people, food, sex, drugs, and gambling can trigger various dopamine responses. The random rewards of gambling are much more seductive than a more predictable reward cycle. When we pull the lever of a slot machine and win some money, we experience a potent rush of pleasurable dopamine precisely because the reward was so unexpected. (�Your brain on Gambling,� The Boston Globe, by Jonah Lehrer, Aug 19, 2007)Breakthrough in dopamine function - Schultz� monkey experiment (1990s): to learn about the roles of rewards and expectations in the process of learning and memory. Essentially, the experiment wanted to test whether our brains respond to (via dopamine levels) actual rewards or cues to rewards. Design was rather simple: monkeys (subject) + flash of light (cue to reward) + fruit juice (actual reward). First, the researchers flashed a light before giving monkeys the fruit juice. As expected, the dopamine response in the brain coincided with the actual consumption of the reward. As monkeys learned about cues that predict a reward, the brain response curiously changed. At this point, monkey�s brains activated upon the cue not the reward. Once the cells memorize the simple pattern � flash of light predicts the arrival of juice � they become sensitive to variations on the pattern. If the predictions proved correct and the mokeys experienced a surge of dopamine, the prediction was reinforced. However, if the pattern was violated � if the light flashed but the juice never arrived � then the monkey�s dopamine neurons abruptly decreased their firing rate Learning takes place only when something unexpected happens and dopamine firing rates increase or decrease. When nothing unexpected happens, as when the same amount of delicious apple juice keeps coming, the dopamine system is quiet. Conclusion: dopamine seems to be a �learning signal� about rewards rather than the actual mediator of pleasurable experience. Reveals the chemical nature of human behavior. Predictable parts of your life don�t have as much significance (both socially and chemically) unless something new or unpredictable happens. In people, food, sex, drugs, and gambling can trigger various dopamine responses. The random rewards of gambling are much more seductive than a more predictable reward cycle. When we pull the lever of a slot machine and win some money, we experience a potent rush of pleasurable dopamine precisely because the reward was so unexpected. (�Your brain on Gambling,� The Boston Globe, by Jonah Lehrer, Aug 19, 2007)

16. BRAIN IMAGING

17. This Is Your Brain on Gambling Breiter et al. 2001 Participants (12, male) participated in a simulated gambling game (Roulette). They were given $50 endowment and they were told they could retain, lose, or gain money as they go along. It was found that during the �Prospect� phase when participants are anticipating to win money � the NAc is activated, in the same way that those anticipating to receive a small amount of cocaine is activated. If you recall, NAc is part of the dopaminergic pathway in our brain that processes rewards. What this means is that winning money in our culture is SO powerful and so rewarding that in some instances it can be as powerful as drugs like Cocaine, Meth, etc. Breiter et al. 2001 Participants (12, male) participated in a simulated gambling game (Roulette). They were given $50 endowment and they were told they could retain, lose, or gain money as they go along. It was found that during the �Prospect� phase when participants are anticipating to win money � the NAc is activated, in the same way that those anticipating to receive a small amount of cocaine is activated. If you recall, NAc is part of the dopaminergic pathway in our brain that processes rewards. What this means is that winning money in our culture is SO powerful and so rewarding that in some instances it can be as powerful as drugs like Cocaine, Meth, etc.

18. Are brains of problem gamblers different? ***Enlarged pictures*** Reuter et al. (2005) PG is linked to reduced mesolimbic On the left are fMRI scans of 12 healthy control subjects who participated in a guessing game (Guessing cards, depending on red/black they won or lost money, participants were told they can keep the $ won at the end). To the right are the scans of 12 pathological gamblers undergoing the same guessing activities. The game has been demonstrate to activate the Ventral Striatum, which again is part of the larger reward circuitry, and related to the dopaminergic pathway. What this means is that in healthy subjects this activity is supposed to stimulate you. What is the difference between the two groups? Although both groups underwent the same activities, gambling addicts show less color or less activity which means that even though doing the same activity, they were not as stimulated compared to the controls. WHY IS THAT? COMPENSATORY THEORY. Normal day to day reinforces are too weak and don�t do it for addicts. What will do it? The next opportunity to play at the high stakes table, or the next opportunity to take a hit of cocaine. They in addition found that the more severe the pathological gambling, the less activity in this brain region. What is this called?? Tolerance: It�s like hearing loud music and turning the volume down. When excessively stimulated, the brain adjusts the level of dopamine, turning it down. Addicts naturally aim to increase stimulation of the dopamine to feel that �pleasurable high.� The bad news, it takes a lot more to reach that same level the more the system is overstimulated. ***Enlarged pictures*** Reuter et al. (2005) PG is linked to reduced mesolimbic On the left are fMRI scans of 12 healthy control subjects who participated in a guessing game (Guessing cards, depending on red/black they won or lost money, participants were told they can keep the $ won at the end). To the right are the scans of 12 pathological gamblers undergoing the same guessing activities. The game has been demonstrate to activate the Ventral Striatum, which again is part of the larger reward circuitry, and related to the dopaminergic pathway. What this means is that in healthy subjects this activity is supposed to stimulate you. What is the difference between the two groups? Although both groups underwent the same activities, gambling addicts show less color or less activity which means that even though doing the same activity, they were not as stimulated compared to the controls. WHY IS THAT? COMPENSATORY THEORY. Normal day to day reinforces are too weak and don�t do it for addicts. What will do it? The next opportunity to play at the high stakes table, or the next opportunity to take a hit of cocaine. They in addition found that the more severe the pathological gambling, the less activity in this brain region. What is this called?? Tolerance: It�s like hearing loud music and turning the volume down. When excessively stimulated, the brain adjusts the level of dopamine, turning it down. Addicts naturally aim to increase stimulation of the dopamine to feel that �pleasurable high.� The bad news, it takes a lot more to reach that same level the more the system is overstimulated.

19. Are brains of problem gamblers different? So a lot of what we�ve talked about helps explain to me the reason why many addicts describe this overwhelming urge and craving to engage in the activity. But what it doesn�t explain to me, is why they continue to give in to these cravings and urges, despite so many adverse consequences? MY STEP DAD. Current research is shedding light on this. We are learning that addicts in addition having a differently wired reward circuitry, also has less activities in a region of the brain known as the pre-frontal cortex (darker the color = less activation). POP QUIZ: what is the pre-frontal cortex responsible for? � Decision-making, judgment, executive functioning, etc. PGs have shown pre-frontal cortex impairments similar to those of meth addicts. So what this means is that not only do addicts have powerful urges to do these things, they also don�t have the brakes to slow them down. In a healthy individual, after losing say a few hundred dollars, might say Hmmm�what are the consequences if I lose more money? In my step father, that part of the brain was hijacked. But we must remember, this doesn�t remove the PG of personal responsibility. Let me ask you a question, since the pre-frontal cortex is impaired, do you think PGs are unable to tell right from wrong? RESEARCH ON OUTCOME EXPECTANCIES: 1) PG youth more like to continue to expect positive outcomes despite negative consequences. 2) PG youth may endorse more immediate positive outcomes (fun, excitement, money, social, feel in control) than more delayed costs like emotional impact (guilt), preoccupation, loss of control, etc. / positive outcomes may outweigh potential negative We shouldn�t confuse this with an inability to know right from wrong. Research actually shows that what differentiate PGs from say social or at-risk gamblers is that they are more likely to anticipate both positive and negative expectations of gambling. Meaning, not only were they more likely to anticipate that they are going to have fun, they�ll socialized, and win money, they are also more likely to anticipate negative consequences � like getting preoccupied, or the emotional impacts like feeling guilty. The theory is that while PGs recognize that there are negative consequences, the key here is the temporal relationship. The more �immediate� positive outcomes tend to exert a greater influence, whereas the long term impacts are delayed costs. What are some behavorial characteristics of people who have dysfunctions in the pre-frontal cortex? moodiness, negativity, irritability, low energy, headaches, sleep and appetite problems and poor concentration - loss of self-directed/willed behavior in favor of automatic sensory-driven behavior (loss of inhibitory controls) So a lot of what we�ve talked about helps explain to me the reason why many addicts describe this overwhelming urge and craving to engage in the activity. But what it doesn�t explain to me, is why they continue to give in to these cravings and urges, despite so many adverse consequences? MY STEP DAD. Current research is shedding light on this. We are learning that addicts in addition having a differently wired reward circuitry, also has less activities in a region of the brain known as the pre-frontal cortex (darker the color = less activation). POP QUIZ: what is the pre-frontal cortex responsible for? � Decision-making, judgment, executive functioning, etc. PGs have shown pre-frontal cortex impairments similar to those of meth addicts. So what this means is that not only do addicts have powerful urges to do these things, they also don�t have the brakes to slow them down. In a healthy individual, after losing say a few hundred dollars, might say Hmmm�what are the consequences if I lose more money? In my step father, that part of the brain was hijacked. But we must remember, this doesn�t remove the PG of personal responsibility. Let me ask you a question, since the pre-frontal cortex is impaired, do you think PGs are unable to tell right from wrong? RESEARCH ON OUTCOME EXPECTANCIES: 1) PG youth more like to continue to expect positive outcomes despite negative consequences. 2) PG youth may endorse more immediate positive outcomes (fun, excitement, money, social, feel in control) than more delayed costs like emotional impact (guilt), preoccupation, loss of control, etc. / positive outcomes may outweigh potential negative We shouldn�t confuse this with an inability to know right from wrong. Research actually shows that what differentiate PGs from say social or at-risk gamblers is that they are more likely to anticipate both positive and negative expectations of gambling. Meaning, not only were they more likely to anticipate that they are going to have fun, they�ll socialized, and win money, they are also more likely to anticipate negative consequences � like getting preoccupied, or the emotional impacts like feeling guilty. The theory is that while PGs recognize that there are negative consequences, the key here is the temporal relationship. The more �immediate� positive outcomes tend to exert a greater influence, whereas the long term impacts are delayed costs. What are some behavorial characteristics of people who have dysfunctions in the pre-frontal cortex? moodiness, negativity, irritability, low energy, headaches, sleep and appetite problems and poor concentration - loss of self-directed/willed behavior in favor of automatic sensory-driven behavior (loss of inhibitory controls)

20. Nature vs. Nurture Temporal relationship unclear � which came first? Evidence of heritability of PG: Twin study: PG heritability = 54% (Eisen et al, 1998) Genetic study: D2A1 Allele in 51% of PGs (Comings et al, 1996) Etiology of PG: (Moore 2002) 20% Family History, 75% Trauma, <5% No History Progressive vs Episodic? Natural Recovery? All this is very brand new research. There are a few things that we just don�t yet know: Which came first? Do addicts have a pre-wired condition that causes them to be predisposed to addictions? Or do people start abusing drugs, excessively gamble, and then the brain changes to cause addictions? The answer is we don�t know, but the answer is probably �All of the above�. In a twin study of over 3,000 twin pairs, it was found that while 35% of excessive gambling could be attributed to genetics, when there were at least 2 symptoms of PG, the heritability jumped to 54%. Relatedly, genetic studies have located a component of a gene thought to be responsible for addictions � the Taq A1 variant of the human Dopamine receptor gene was significantly more likely to be found in addicts � in this study it was present in 51% of the PGs, compared to 26% of the controls. The same gene variant has been found in alcoholism and other drug addictions. But we know that genetics isn�t the entire picture. When the state of Oregon looked at a group of close to 100 pathological gamblers and tried to determine some common causal pathways, what they found were that for about 20% of the PGs had a family history of PG, addiction or mental illness. For this group, genetics and social learning probably played a big role. Then for the majority of the PGs, traumatic life experiences were the pathway to addiction � including childhood sexual or physical abuse, or more recent experiences with PTSD, etc. Just less than 5% are PGs who had no family history, no traumatic history, these are people who for whatever reason escalated their gambling to pathological levels. But these are also the people who we often find to recover naturally � without professional intervention. HAVE YOU HEARD OF NATURAL RECOVERY? New, longitudinal research is really showing while many PGs go through a linear progression from social to at-risk to problem to pathological, that is not the case for everyone. Research has found that for some PGs, their addiction is more episodic. Natural recovery also shows us that at times a PG for whatever reason, may reduce their gambling back to a more manageable level or stop completely. All this is very brand new research. There are a few things that we just don�t yet know: Which came first? Do addicts have a pre-wired condition that causes them to be predisposed to addictions? Or do people start abusing drugs, excessively gamble, and then the brain changes to cause addictions? The answer is we don�t know, but the answer is probably �All of the above�. In a twin study of over 3,000 twin pairs, it was found that while 35% of excessive gambling could be attributed to genetics, when there were at least 2 symptoms of PG, the heritability jumped to 54%. Relatedly, genetic studies have located a component of a gene thought to be responsible for addictions � the Taq A1 variant of the human Dopamine receptor gene was significantly more likely to be found in addicts � in this study it was present in 51% of the PGs, compared to 26% of the controls. The same gene variant has been found in alcoholism and other drug addictions. But we know that genetics isn�t the entire picture. When the state of Oregon looked at a group of close to 100 pathological gamblers and tried to determine some common causal pathways, what they found were that for about 20% of the PGs had a family history of PG, addiction or mental illness. For this group, genetics and social learning probably played a big role. Then for the majority of the PGs, traumatic life experiences were the pathway to addiction � including childhood sexual or physical abuse, or more recent experiences with PTSD, etc. Just less than 5% are PGs who had no family history, no traumatic history, these are people who for whatever reason escalated their gambling to pathological levels. But these are also the people who we often find to recover naturally � without professional intervention. HAVE YOU HEARD OF NATURAL RECOVERY? New, longitudinal research is really showing while many PGs go through a linear progression from social to at-risk to problem to pathological, that is not the case for everyone. Research has found that for some PGs, their addiction is more episodic. Natural recovery also shows us that at times a PG for whatever reason, may reduce their gambling back to a more manageable level or stop completely.

21. Current Research Gap Lacking data on the experience of women problem gamblers More research is needed on the youth population Further research on ethnic minorities Longitudinal research needed More research/eval on treatment effectiveness

22. PROBLEM GAMBLING vs.SUBSTANCE/DRUG ADDICTION

23. Similarities / Difference

24. Implications for Pharmacological Treatment of PG

25. Valproate (Depakote) is prescribed for bipolar disorder. Carbamazepine: anti-convulsant for epilepsy and bipolar disorder MOOD STABILIZERS are found to help by blunting the excitement associated with gambling (manic) ***Mean scores on the Yale Brown Obsessive Compulsive Scale modified for Pathological Gambling (PG-YBOCS) were found to decrease by approximately one-third over the course of 14 weeks following treatment with lithium (n 23) or valproate (n 19). *** Clomipramine: (Anafranil) - SRI Citalopram (Celexa) - SSRI Paroxetine (Paxil) -SSRI Fluvoxamine (Luvox) � SSRI ALSO USED TO TREAT OCD � helps with the obsessive thoughts. Requires higher doses than for treating Depressive disorders. *** Naltrexone (opioid receptor antagonist): Been used in a wide range of disorders where �urge� is a primary characteristic � including substance dependence (opiate, alcohol, nicotine, and cocaine), kleptomaniac, eating disorders, etc. -REDUCTION IN INTENSITY OF URGES AND CRAVINGS *** Bupropion (Wellbutrin) - Bupropion is structurally related to amphetamine. Been used to treat substance addictions such as cocaine, amphetamine, and nicotine. Valproate (Depakote) is prescribed for bipolar disorder. Carbamazepine: anti-convulsant for epilepsy and bipolar disorder MOOD STABILIZERS are found to help by blunting the excitement associated with gambling (manic) ***Mean scores on the Yale Brown Obsessive Compulsive Scale modified for Pathological Gambling (PG-YBOCS) were found to decrease by approximately one-third over the course of 14 weeks following treatment with lithium (n 23) or valproate (n 19). *** Clomipramine: (Anafranil) - SRI Citalopram (Celexa) - SSRI Paroxetine (Paxil) -SSRI Fluvoxamine (Luvox) � SSRI ALSO USED TO TREAT OCD � helps with the obsessive thoughts. Requires higher doses than for treating Depressive disorders. *** Naltrexone (opioid receptor antagonist): Been used in a wide range of disorders where �urge� is a primary characteristic � including substance dependence (opiate, alcohol, nicotine, and cocaine), kleptomaniac, eating disorders, etc. -REDUCTION IN INTENSITY OF URGES AND CRAVINGS *** Bupropion (Wellbutrin) - Bupropion is structurally related to amphetamine. Been used to treat substance addictions such as cocaine, amphetamine, and nicotine.

26. Treatment Issues Medication alone; in combination; or in conjunction with conventional therapy When to prescribe what? Comorbid depression, obsession Those with strong urge-driven gambling Treatment-refractory PGs? Unclear: Duration of treatment, relapse rates with discontinuation Challenge: How to pay for it? So when should medication be introduced? How should they be prescribed and used? A: We don�t know! But we have some general guidelines: One thing is clear however, when medication is used in conjunction to convention therapy such as CBT, the efficacy is improved. We do not recommend medication alone. There is no cure-all pill. Medication can help clients abstain and be more successful in therapy, so it should be used as an aid. You all may know also, talk therapy also changes the brain. All these therapies are important to help addicts heal. The involvement of significant others in any PG treatment is recommended, and in this case, it can possibly help with treatment adherence. WHEN TO PRESCRIBE WHAT? We are not qualified to tell you which medication works for whom. Only a psychiatrist can do that. But generally, SSRIs may be recommended as a first line in the Tx of PGs. They have the most research, and better demonstrated safety and minimal adverse side-effects. Esp. for PGs who have a comorbid mood disorder like major depression, the use of SSRIs is warranted. However, for those PGs whose symptoms are characterized by strong urges or cravings, the use of Naltrexone and possibly Bupropion (Wellbutrin) may be warranted as these medications target the parts of the brains reward system. What about those that do not respond to or only has partial response to an SSRI or Naltrexone? There is some evidence that for some PGs the combination of Naltrexone and SSRI may be effective, as the two work on different pathways and may be targeting different types of compulsive gambling. In addition, another possibility may be putting the PG on mood stabilizers, either as a monotherapy or an augment, this is especially relevant if the PG also exhibits co-morbid bi-polar spectrum symptoms. WHAT WE STILL DON�T KNOW: Research so far is plagued with small samples, all male, inconsistent measures and study design. So it is impossible to say with any certainty how long a person may need to be on a medication, and what are the rates of relapse with discontinuation. Clinicians will have to use their judgment and in consultation with a psychiatrist to determine the best approach. Finally, a challenge for most of our clients is � how do we pay for it? Most insurance companies generally will not reimburse for the treatment of PG where it is the primary diagnosis, and there is still no FDA approved medication to treat PG. So clients may have to pay out of pocket for the medication. The reality is that for a majority of PGs who are seeking help are in debt. Of course most PGs have a comorbid disorder such as major depression, anxiety, etc. So often clinicians may treat these as primary diagnoses and PG as a secondary. But the challenge remains for many PGs to have access to medication. So when should medication be introduced? How should they be prescribed and used? A: We don�t know! But we have some general guidelines: One thing is clear however, when medication is used in conjunction to convention therapy such as CBT, the efficacy is improved. We do not recommend medication alone. There is no cure-all pill. Medication can help clients abstain and be more successful in therapy, so it should be used as an aid. You all may know also, talk therapy also changes the brain. All these therapies are important to help addicts heal. The involvement of significant others in any PG treatment is recommended, and in this case, it can possibly help with treatment adherence. WHEN TO PRESCRIBE WHAT? We are not qualified to tell you which medication works for whom. Only a psychiatrist can do that. But generally, SSRIs may be recommended as a first line in the Tx of PGs. They have the most research, and better demonstrated safety and minimal adverse side-effects. Esp. for PGs who have a comorbid mood disorder like major depression, the use of SSRIs is warranted. However, for those PGs whose symptoms are characterized by strong urges or cravings, the use of Naltrexone and possibly Bupropion (Wellbutrin) may be warranted as these medications target the parts of the brains reward system. What about those that do not respond to or only has partial response to an SSRI or Naltrexone? There is some evidence that for some PGs the combination of Naltrexone and SSRI may be effective, as the two work on different pathways and may be targeting different types of compulsive gambling. In addition, another possibility may be putting the PG on mood stabilizers, either as a monotherapy or an augment, this is especially relevant if the PG also exhibits co-morbid bi-polar spectrum symptoms. WHAT WE STILL DON�T KNOW: Research so far is plagued with small samples, all male, inconsistent measures and study design. So it is impossible to say with any certainty how long a person may need to be on a medication, and what are the rates of relapse with discontinuation. Clinicians will have to use their judgment and in consultation with a psychiatrist to determine the best approach. Finally, a challenge for most of our clients is � how do we pay for it? Most insurance companies generally will not reimburse for the treatment of PG where it is the primary diagnosis, and there is still no FDA approved medication to treat PG. So clients may have to pay out of pocket for the medication. The reality is that for a majority of PGs who are seeking help are in debt. Of course most PGs have a comorbid disorder such as major depression, anxiety, etc. So often clinicians may treat these as primary diagnoses and PG as a secondary. But the challenge remains for many PGs to have access to medication.

27. Resources National Institute on Drug Abuse Resources, literature, publications http://www.drugabuse.gov/ TIME Online � Health & Science Interactive educational tool http://www.time.com/ Dept. of Alcohol and Drug Programs, Office of Problem Gambling Resources, Tools in Multiple Languages www.problemgambling.ca.gov NICOS Chinese Health Coalition Curriculum for youth on Addiction & the Brain, and soon, publication for Tx providers http://www.nicoschc.org

28. Self-Exclusion Helplines 1-800-GAMBLER (California Council on Problem Gambling) All languages available upon request 1-888-968-7888 (NICOS, SF Bay Area) English, Chinese (Mandarin & Cantonese), other languages may be available upon request Gamblers Anonymous/ Gam Anon Gamblers Anonymous (National) http://www.gamblersanonymous.org/ GamAnon (National) http://www.gam-anon.org/ Resources

29. Counseling/ Treatment programs Chinese Community Problem Gambling Project (SF Bay Area) English, Chinese (Mandarin & Cantonese), other languages may be available upon request @ 1-888-968-7888 Center for Addiction Recovery & Empowerment (SJ Bay Area) English, Vietnamese, Chinese (Mandarin & Cantonese), other languages may be available upon request @ 408-975-2730 Private Practitioners (statewide) Certified counselors: http://www.calproblemgambling.org/help_counselors.html Office of Problem Gambling Treatment Initiative (statewide) Soon to provide state-funded outpatient & Inpatient services http://www.adp.ca.gov/opg/ CPGTSP � Face-to-Face & Telephone Interventions Self Screening / Assessment National Problem Gambling Awareness Website http://www.npgaw.org Resources