Strategies for Starting the Conversation: Developing and Implementing a Problem Gambling SBIRT

1. Strategies for Starting the Conversation: Developing and Implementing a Problem Gambling SBIRT Lori Rugle, PhD, ICGC-II, BACC

2. 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 ACKNOWLEDGEMENTS

3. 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

4. ALCOHOL AND THOSE SCREENING FOR ALCOHOL RELATED DISORDERS! https://www.cdc.gov/vitalsigns/alcohol-screening-counseling/index.html

5. Browne & Rockloff, 2017

6. 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

7. 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. • National Epidemiologic Survey on Alcohol and Related Conditions (Morasco et al, 2006) 7

8. 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) 8 Funded by DHMH/BHA

9. “You know one if you see one” ---Director of Substance Abuse Treatment Program, Detroit VA

10. PREVALENCE OF PROBLEM GAMBLING IN MEDICAL TREATMENT SETTING

11. PHYSICAL HEALTH AND GAMBLING Morasco et al. Gen Hosp Psych. 2006

12. Health HabitsBlack 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

13. 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.

14. IOM Conceptualization and Problem Gambling Public Health Interventions Provide Screening for Problem Gambling No gambling Social gambling At Risk Gambling Problem Gambling Gambling Disorder Severe Moderate Mild None Brief Specialized Treatment Universal Selective Indicated Prevention Korn & Shaffer, 99

15. IOM Conceptualization and Problem Gambling Public Health Interventions No gambling Social gambling At Risk Gambling Problem Gambling Gambling Disorder Severe Moderate Mild None For those who screen positive provide brief intervention Brief Specialized Treatment Universal Selective Indicated Prevention

16. IOM Conceptualization and Problem Gambling Public Health Interventions No gambling Social gambling At Risk Gambling Problem Gambling Gambling Disorder Severe Moderate Then inform of and offer referral to treatment Mild None Brief SpecializedTreatment Universal Selective Indicated Prevention

17. Screening Questionnaire Short, Reliable, Valid & Interpretable Brief Intervention Acceptable & Implementable Referral to Treatment Specialty treatment available WHAT ARE THE KEY ELEMENTS FOR A SUCCESSFUL SBIRT INTERVENTION?

18. Defining Gambling

19. WHAT IS 38 grams of alcohol? http://www.health.govt.nz/your-health/healthy-living/addictions/alcohol-and-drug-abuse/alcohol

20. 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

21. WHAT IS “STANDARD” GAMBLING?

22. 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 ofvalue. For example, buying lottery tickets or scratch-offs, gambling at a casino, playing bingo, shooting dice, betting on sports, or playing keno.

24. Risk Levels for Gambling Disorder and Brief Interventions Risk Levels for Gambling Disorder and Brief Interventions

25. Study Sample: 100 randomly selected patients in an urban clinic Gold Standard DSM 5 Diagnostic Criteria Screening Instrument BBGS DETERMINE PREVALENCE OF PROBLEM GAMBLING AND PILOT USE OF BBGS

26. PREVALENCE (>4 DSM 5 CRITERIA) 12 %

27. DEMOGRAPHIC CHARACTERISTICS

28. HISTORY OF SUBSTANCE USE * Significance at p < 0.05 as determined by a Fisher’s exact test

29. GAMBLING BEHAVIORS * Significance at p < 0.05 as determined by a Fisher’s exact test

30. 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 PREVALENCE STUDY CONCLUSIONS

31. BRIEF INTERVENTIONS?

32. BRIEF INTERVENTIONS WORK Petry et al. J Consult Clin Psychol. 2016

33. Screening Questionnaire Short, Reliable, Valid & Interpretable Brief Intervention Acceptable & Implementable Referral to Treatment Specialty treatment available WHAT ARE THE KEY ELEMENTS FOR A SUCCESSFUL SBIRT INTERVENTION?

34. 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) STUDY AIM 1: DEVELOPING SBIRT INTERVENTION FOR GAMBLING

35. 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

36. RISK STRATIFICATION

37. Patients wanted materials that were: Easy to read Relatable Eye catching Clinicians recommended: MI elements for those screening high risk MATERIALS WERE ITERATIVELY ADAPTED

38. LOW RISK FOR GAMBLING

39. MEDIUM RISK FOR GAMBLING

40. MEDIUM RISK FOR GAMBLING

41. HIGH RISK FOR GAMBLING

42. HIGH RISK FOR GAMBLING

43. Participants, Clinicians and the Expert Panel found the final materials to be: Easy to read Useful Helpful AIM 1 CONCLUSIONS

44. 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 STUDY AIM 2: PILOT FEASIBILITY STUDY

45. CLINICIAN CHARACTERISTICS

46. PARTICPANT CHARACTERISTICS

47. PARTICPANT CHARACTERISTICS

48. RISK STRATIFICATION

49. PARTICIPANT FEEDBACK

50. BETTER UNDERSTAND GAMBLING BEHAVIOR AFTER THE INTERVENTION? 84.6%