The Brief Addiction Science Information Source (BASIS)

The Wager Vol. 13(7) - Binges and bets: Links between drinking problems and gambling problems

Few studies have examined the impact of drinking behavior among individuals experiencing gambling problems.  This week, the WAGER reviews a study by French, Maclean, and Ettner (2008), which examined the relationship between alcohol use and abuse and gambling-related problems among a large, representative sample of U.S. citizens. 

Methods:

• Data from the National Epidemiological Survey on Alcohol and Related Conditions (NESARC) using a sub-sample of participants who experienced 1 or more gambling-related problem(s) during the past year (N=1,203). 
• Measures included number of gambling-related problems experienced by participants during the past year, alcohol use frequency, drinking to intoxication, and alcohol abuse or dependence.
• Probit regression analyses assessed the relationship between the number of gambling problems and drinking behaviors/problems.

Results:

• Weekly or more frequent drinking was not significantly associated with number of gambling problems. 
• Individuals who drank to intoxication and those who met alcohol abuse or dependence criteria had significantly higher (p < .001) numbers of gambling problems, even when models controlled for potential confounding variables. See Figure 1.

Figure 1: Number of gambling-related problems with regard to various drinking behaviors among a sample of participants who have experienced gambling problems in the past year (adapted from French et al., 2008).

Limitations:

• Cross-sectional studies do not measure the temporal or causal relationship among variables of interest. 
• Potential self-report bias and/or recall bias.

Conclusion/Discussion:

French et al. (2008) found no association between gambling problems and frequent consumption of alcohol. They did, however, find a significant positive relationship between problematic drinking behavior patterns (i.e., drinking to intoxication and meeting criteria for alcohol abuse or dependence) and the number of gambling problems.  Thus, participants who drank alcohol to diagnostic level were more likely to have more problems related to their gambling behavior. This finding is consistent with models (e.g. Shaffer LaPlante, LaBrie, Kidman, Donato, & Stanton, 2004) that propose a broader characterization of addiction as including both substance-related and behavioral manifestations (See Wager 10(1)).

What do you think?  Comments can be addressed to Ryan J. Martin.

French, M., Maclean, J., & Ettner, S. (2008). Drinkers and bettors: investigating the complementarity of alcohol consumption and problem gambling. Drug and Alcohol Dependence, 96, 155-164.

Shaffer, H., LaPlante, D., LaBrie, R., Kidman, R., Donato, A., & Stanton, M. (2004). Toward a syndrome model of addiction: multiple expressions, common etiology. Harvard Review of Psychiatry, 12, 367-374.

STASH Vol. 4(7) - Do You Feel What I Feel? Amphetamine Exposure and Personality

Some scientists have speculated that substance misuse affects people differently depending on their personality (Nurnberger Jr et al., 1982; Reif & Lesch, 2003). This week we report on a study that examined the influence of personality-traits on individuals’ reactions to amphetamine exposure (White, Lott, & de Wit, 2006).

Participants: 128 healthy individuals recruited from the community
Experiment: In random order, researchers administered a placebo(1), 10mgs, and 20mgs of amphetamine to all participants, under double-blind conditions, over the course of three sessions separated by a minimum of 48 hours
Research Objective: To measure how personality traits (i.e., reward sensitivity, physical fear, and impulsivity) might moderate subjective responses to exposure to amphetamine
Measures: Multidimensional Personality Questionnaire-Brief Form (MPQ-BF) (Depue & Collins, 1999; Patrick, Curtin, & Tellegen, 2002; Tellegen, 1982)

Figure 1*: Association between Physical Fear & D-Amphetamine

*Adapted from: Figure 1: Trait physical fearlessness and positive activational responses to d-amphetamine. Higher-order positive drug effect (factor score) responses in participants with low [low physical fear] and high [high physical fear] scores on MPQ-BF Harm Avoidance.

Results, Figure 1:

• Individuals who scored low on physical fear had higher positive responses2 to low dose amphetamine compared to individuals who scored high on physical fear (p?0.005)
  • Physical fear did not significantly effect responses to medium dose amphetamine
• Amphetamine response was not related to having high or low reward sensitivity or impulsivity

Main limitations:

• Self-reports of sensitive information might have introduced recall bias
• Participant similarities (e.g., educated, physically/psychiatrically healthy, relatively young) limit our ability to generalize the results

Discussion:
White et al.’s findings show that personality-related factors moderate the activational effects of one dose of amphetamine in healthy volunteers.  The findings suggest that further research could help clinicians develop methods and materials to recognize whether and how personality-related factors influence addiction risk and recovery.

Notes

1. A substance containing no medication and prescribed or given to reinforce a patient's expectation to get well.

2. Positive Activational Responses were defined as: greater activation, euphoria, vigor, arousal, elation, friendliness, and positive mood, and less sedation and fatigue.

References

Depue, R., & Collins, P. (1999). Neurobiology of the structure of personality: dopamine, facilitaion of incentive motivation, and extraversion. Behavioral and Brain Science(22), 491+569.

Nurnberger Jr, J., Gershon, E., Simmons, S., Ebert, M., Kessler, L., Dibble, E., et al. (1982). Behavioral, biochemical and neuroendocrine responses to amphetamine in normal twins and ‘well-state’ bipolar patients. Psychoneuroendocrinology, 7, 163-176.

Patrick, C., Curtin, J., & Tellegen, A. (2002). Development and validation of a brief form of the Multidimentional Personality Questionnaire. Psychological Assessment(14), 150-163.

Reif, A., & Lesch, K.-P. (2003). Toward a molecular architecture of personality. Behavioral Brain Research, 139, 1–20.

Tellegen, A. (1982). Brief Manual for the Multidimensional Personality Questionnaire. . University of Minnesoata.

White, T. L., Lott, D. C., & de Wit, H. (2006). Personality and the Subjective Effects of Acute Amphetamine in Healthy Volunteers. Neuropsychopharmacology, 31, 1064-1074.

Addiction & the Humanities Vol 4. (6) - Can the spirit move you?

Research has linked spirituality with both physical and mental well-being (Hawks, Hull, Thatma, & Richins, 2005; Kass, Friedman, Lesserman, Zuttermeister, & Benson, 1991). Moreover, Alcoholics Anonymous and Narcotics Anonymous, popular 12-step programs, endorse the concept of addiction as a combination of spiritual, biological, and psychological disorders. However, few studies have examined the influence of spirituality on addiction recovery. This week’s Humanities reviews a study focusing on the relationship between the development of spirituality and relapse among individuals receiving treatment for alcohol dependence.

Methodology:

• Study Design
  
  • Retrospective case-control study
    
  • Participants and their survey responses were selected from 278 individuals after they completed a larger study about spirituality and treatment outcomes
• Participants
  
  • Participants: 72 individuals completed intake and 3 month follow-up: 36 who relapsed (cases) & 36 who did not relapse (controls). 50 (69.4%) completed end-of-treatment assessment.
• Survey instrument
  
  • At intake and end-of-treatment, all participants completed the Addiction Severity Index (ASI, McLellan, Luborsky, Woody, O'Brien, & et al., 1980) and questionnaires regarding spiritual and religious experiences (e.g., Spiritual Experience Index (SEI), (Genia, 1997)

Results:

• At discharge, 82% of participants reported spirituality to be a critical component of substance abuse treatment.
• Participants experienced significant increases on measures of spirituality from intake to end-of-treatment (See Figure 1).
• However, as can be seen in Figure 1, those who did not maintain abstinence in the past thirty days reported significant decreases in spirituality post-treatment.
• At three month follow-up, participants who reported maintaining sobriety during the past 30 days, reported significant positive growth of spirituality.

Figure 1. Relationship of SEI measured spiritual growth and follow-up relapse (adapted from Sterling et al., 2007)

 

Limitations:

• Recall bias: retrospective self-report might have affected participants’ responses to survey instruments.
• Selection bias: a small number of participants completed all three phases of the study suggesting that the results might not be generalizable.
• Relapse: participants were asked to report substance use during the previous 30 days, which might not be enough time to measure recidivism.

Discussion:
The findings from previous studies as well as the present study indicate a positive correlation between spirituality and health, specifically alcohol recovery. However, due to the difficulty in defining spirituality, there is a paucity of research examining this relationship. Arnold, Avants, Margolin, and Marcotte (2002), for example, found that although some members of a focus group equated spirituality with organized religion, other participants felt that spirituality was related to inner strength and individuality. Prevention and treatment programs for other addictions such as marijuana, nicotine, and even gambling might benefit from further research examining the correlation between spirituality and addiction recovery. Given the preliminary evidence suggesting the value of spirituality, clinicians also might want to pursue the study of this relationship to determine if a general understanding of spirituality or a spiritual component to treatment could improve treatment outcomes.

What do you think?  Comments can be addressed to Sara Kaplan.

References
Arnold, R. M., Avants, S. K., Margolin, A., & Marcotte, D. (2002). Patient attitudes concerning the inclusion of spirituality into addiction treatment. Journal of Substance Abuse Treatment, 23, 319-326.

Genia, V. (1997). The Spiritual Experience Index:  Revision and reformulation. Review of Religious Research, 38, 344-361.

Hawks, S., Hull, M., Thatma, R., & Richins, P. (2005). Review of spiritual health:  Definition, role and intervention strategies in health promotion. American Journal of Health Promotion, 9, 371-378.

Kass, J., Friedman, R., Lesserman, J., Zuttermeister, P., & Benson, H. (1991). Health outcomes and a new index of spiritual experience. Journal of the Scientific Study of Religion, 30, 203-211.

McLellan, A. T., Luborsky, L., Woody, G. E., O'Brien, C. P., & et al. (1980). An improved diagnostic evaluation instrument for substance abuse patients. Journal of Nervous & Mental Disease, 168, 26-33.

Sterling, R. C., Weinstein, S., Losardo, D., Raively, K., Hill, P., Petrone, A., et al. (2007). A retrospective case control study of alcohol relapse and spiritual growth. The American Journal on Addictions, 16, 56-61.

ASHES 4(8) - No Smoking (at home) Please

A new look for the Brief Addiction Science Information Source! The goal of the BASIS is to make addiction science information freely available to a diverse audience in a clear and concise way. The BASIS has evolved over time to facilitate the attainment of that goal. In the spirit of working toward a more efficient and informative BASIS, today, we have prepared a new style that makes greater use of bullet points, hyperlinks, and glossary definitions. Unchanged, however, is our commitment to publishing critical science reviews that will advance scientific, clinical, and public knowledge. Please let us know what you think about the new style! To leave us your thoughts, email us at basis@divisiononaddictions.org, or click on the comment link below.

In an international effort to educate people about the dangers of Second Hand Smoke (SHS), 168 nations participate in the World Health Organization Framework Convention on Tobacco Control (WHOFCTC). Article 8 of this convention asks that participating nations, “in areas of existing national jurisdiction” put operational measures in place to protect citizens from SHS in “indoor workplaces, public transport, indoor public places, and as appropriate, other public places”(World Health Organization, 2003).  However, home exposure to SHS is equally hazardous to health. Wipfli et al. examine the effect of SHS exposure by measuring the home air nicotine exposure and hair nicotine levels of women and children from 31 developing countries (Wipfli et al., 2008).

Methodology:

• Participants:
  • Women and children from 1284 households in 31 countries on 3 continents (Approximately 40 households per country)

• Data Collection:
  • A four section survey: (1) personal/socioeconomic characteristics; (2) smoking history; (3) SHS exposure; (4) viewpoints about dangers of smoking tobacco-control policies
  • Passive air monitors measured air nicotine concentrations from main family room during a 7 day period
  • Collected 30-50 strands from rear of the scalp from 1 child (≤11 years) and primary female caregiver from each household

• Laboratory Analysis:
  • Air nicotine: gas chromatography¹
  • Hair nicotine: gas chromatography¹ and mass spectrometry² (capillary column)

Result(s) of interest:

• The data in Table 1 suggest that the nicotine concentration in both women and children increases twofold if smoking is permitted in the home.
• 82% of smokers admitted to smoking around their children.
• Median hair nicotine concentration was higher in children (0.68ng/mg) than in women (0.40ng/mg).

Table 1: Adjusted Geometric Mean Ratios (GMRs) of Hair Nicotine Concentrations among Women and Children*

*Adapted from  Geometric Means (GMs) and Geometric Mean Ratios (GMRs) or Hair Nicotine Concentrations Among Women and Children Living in Households Exposed to Secondhand Smoke, by Household Characteristics: International Survey, 2006. (Wipfli et al., 2008)
*Median Hair Concentrations were skewed, log-10 transformed, and run through multilevel linear models.

Limitations:

• Investigators did not select households randomly and the number of households per country was limited, therefore the sample might not be representative of the households in each country.
• Continuous air nicotine measurements mean that the final reported concentrations of nicotine could be lower than actual exposure concentrations
• 60% of women had chemically treated hair, which could decrease measured nicotine  concentration (Al-Delaimy, 2002; Pichini, Altieri, Pellgrini, Pacifici, & Zuccaro, 1997)

Discussion:
More than three quarters of participants admit to smoking around their children. Differences in the uptake and metabolism of nicotine in children, compared to women, leads to an obvious difference in reported hair nicotine concentrations: children evidence greater concentrations than women. Despite the WHO attempt to restrict SHS Exposure in public places, the initiative needs to expand to include messages warning about SHS in the home. A lack of focus on SHS in the home suggests that public bans will be insufficient to decrease the health risks associated with SHS. An increase in advertising, more legislative bans on public smoking, education about SHS dangers, and clinical discussion about the dangers of smoking are a good place to start expanding the initiative.

What do you think? Comments can be addressed to Ingrid Maurice

Notes
1. Separating a substance into its components by diffusing it, along with a carrier gas, through a liquid or solid absorbent.

2. Determining the masses of atoms or molecules by placing an electrical charge on the molecule and analyzing that mass/charge ratio of the resulting ions.

References

Al-Delaimy, W. (2002). Hair as a biomarker for Exposure to Tobacco Smoke. Tobacco Control, 11, 176-182.

Pichini, S., Altieri, I., Pellgrini, M., Pacifici, R., & Zuccaro, P. (1997). Hair Analysis for Nicotine and Cotinine: Evaluation of Extraction Procedures, Hair Treatments, and Development of Reference Material. Forensic Science International, 87(1-3), 243-252.

Wipfli, H., Avila-Tang, E., Navas-Acien, A., Kim, S., Onicescu, G., Yuan, J., et al. (2008). Secondhand Smoke Exposure Among Women and Children: Evidence from 31 Countries. American Journal of Public Health, 98(4), 672-679.

World Health Organization. (2003). Framework Convention on Tobacco Control. Article 8: Protection from Exposure to Tobacco Smoke   Retrieved July 21, 2008, 2008, from http://www.who.int/tobacco/framework/WHO_FCTC_english.pdf

Broadening our treatment systems: Offering self-directed relapse prevention for gambling problems

Dr. David Hodgins
Professor, Department of Psychology, University of Calgary,
Researcher, Alberta Gaming Research Institute

Since the beginning of the surge in gambling opportunities and interest around the world in the 1990s, many jurisdictions have struggled with designing and implementing treatment programs for people struggling with problem gambling.  In some jurisdictions only basic services are offered such as a toll free helpline that offers referral to Gamblers Anonymous. In other locations, responses have been comprehensive and coordinated with an accessible continuum of interventions of different intensities ranging from outpatient counselling, to mutual support groups such as Gamblers Anonymous (GA) to residential programs and emergency respite beds.  I am fortunate to be living in Alberta, Canada, one of the jurisdictions with a comprehensive system.  But even in our system, it is clear that when you compare the results of our prevalence surveys with our treatment attendance data, most of people who are suffering significant problems with gambling are not choosing to attend our treatment programs. It is essential that we gain a better understanding of this paradox.  Why don’t more people seek treatment? What can we do about it?

Our research group is tackling this issue from a number of perspectives.  One line of research involves designing and evaluating ways of promoting self-recovery among individuals with gambling problems (Hodgins, 2004).  We know that many individuals recover from significant gambling difficulties using their own resources.  In fact the processes that they describe using are remarkably similar to those used by individuals with treatment-assisted recoveries (Hodgins, 2001; Hodgins & el-Guebaly, 2000). We have found that providing telephone and self-help workbook brief interventions can be an attractive and helpful option for some people who wish to tackle recovery on their own (Hodgins et al., 2001; Hodgins et al., 2004). Offering such alternatives to traditional forms of treatment may be one way to increase treatment uptake.

A second line of research involves verifying some of the assumptions we hold about gambling addictions that we have imported from substance abuse treatment. Specifically we have been interested in the process of relapse after a person has attempted to stop gambling.  To explore this issue we recruited a group of 101 pathological gamblers who had recently quit gambling and tracked them for a five year period (Hodgins & el-Guebaly, 2004).   During the first year we conducted regular interviews to obtain detailed descriptions about what led individuals back to gambling.  Remarkably, 92% of individuals relapsed. Unlike in substance abuse where negative feelings (e.g., anxiety, depression, anger) are most likely to precipitate relapses, the gamblers were just as likely to report that positive feelings (e.g., happy, active, relaxed) preceded their return to gambling. The most common situation associated with relapse was a resurgence in optimism about winning - People retuned to gambling because they believed they could win.  This difference from substance abuse relapse, which is more likely associated with negative experiences, supports a strong focus on cognitive restructuring of gambling fallacies in gambling treatment (e.g.,(Ladouceur et al., 2001; Wulfert et al., 2003). The second most frequent high risk situation for relapse was boredom, supporting the need for behavioural strategies to increase involvement in activities incompatible with gambling.

Our sample of 101 was recruited using media announcements and, therefore, some participants were involved in either treatment or GA (25%) and some were not (75%).  Analysis revealed that involvement in treatment or GA was associated with less gambling over the five year follow-up (Hodgins et al., 2005). People did better with their goal of quitting gambling if they attended treatment or aftercare but only one in four made this choice.  We were challenged with the question of what to do with the other 75% to help them improve their outcomes. Based upon a model that has been successfully used in smoking relapse prevention (Brandon et al., 2000), we designed a series of relapse prevention booklets to send to people through the mail about once per month. The first booklet was an overview booklet that described a variety of relapse prevention strategies such as dealing with urges, predicting high risk situations, managing money, identifying concurrent problems such as depression and substance abuse and developing leisure activities.  The other booklets were expanded versions of these topics. Each booklet contained information about local treatment services such as counselling centres and GA groups. 
We conducted a clinical trial of these relapse prevention booklets with 169 pathological gamblers who had recently quit gambling but who did not want to attend treatment or aftercare(Hodgins et al., 2007). Half received simply the overview booklet and half received all the booklets.  People who received all the booklets were more likely to report that they achieved their goal over the next 12 months and were more likely to maintain a stringent goal of abstinence from all types of gambling.  When interviewed at 12 months, about half of both groups no longer met the diagnostic criteria for pathological gambling and 44% had been abstinent for a least the past two months.  We were particularly pleased that almost a quarter of the sample had engaged in some type of treatment or support.

A limit of this clinical trial was the lack of a “no treatment” control group. All participants received either the single booklet or the series of booklets, which limits our ability to attribute improvements to the intervention versus natural recovery. Nonetheless, this low cost intervention appeared attractive to individuals reluctant to seek treatment.  Moreover, we speculate, based upon our other brief intervention projects, that a more clear focus on motivation in the relapse prevention materials would improve their impact even more.

It is clear that there are numerous other reasons that individuals with gambling problems do not seek treatment including stigma, cost, and readiness of the individual to tackle the issue. However, our creative efforts to provide treatment in non-traditional formats, promoting self-recovery, are likely to be rewarded.

References

Brandon, T. H., Collins, B. N., Juliano, L. M., & Leavey, S. B. (2000). Preventing relapse among former smokers: A comparison of minimal interventions through telephone and mail. Journal of Consulting and Clinical Psychology, 68, 103-113.

Hodgins, D. C. (2001). Processes of changing gambling behaviour. Addictive Behaviors, 26, 121-128.

Hodgins, D. C. (2004). Workbooks for individuals with gambling problems: Promoting the natural recovery process through brief intervention. In L.L'Abate (Ed.), Using workbooks in mental health: Resources in prevention, psychotherapy, and rehabilitation for clinicians and researchers (pp. 159-172). Bingham, NY: The Haworth Reference Press.

Hodgins, D. C., Currie, S. R., el-Guebaly, N., & Peden, N. (2004). Brief motivational treatment for problem gambling: A 24-month follow-up. Psychology of Addictive Behaviors, 18, 293-296.

Hodgins, D. C., Currie, S. R., & el-Guebaly, N. (2001). Motivational enhancement and self-help treatments for problem gambling. Journal of Consulting and Clinical Psychology, 69, 50-57.

Hodgins, D. C., Currie, S. R., el-Guebaly, N., & Diskin, K. M. (2007). Does providing extended relapse prevention bibliotherapy to problem gamblers improve outcome? Journal of Gambling Studies.

Hodgins, D. C. & el-Guebaly, N. (2000). Natural and treatment-assisted recovery from gambling problems: A comparison of resolved and active gamblers. Addiction, 95, 777-789.

Hodgins, D. C. & el-Guebaly, N. (2004). Retrospective and prospective reports of precipitants to relapse in pathological gambling. Journal of Consulting and Clinical Psychology, 72, 72-80.

Hodgins, D. C., Peden, N., & Cassidy, E. (2005). The association between comorbidity and outcome in pathological gambling: A prospective follow-up of recent quitters. Journal of Gambling Studies, 21, 255-271.

Ladouceur, R., Sylvain, C., Boutin, C., Lachance, S., Doucet, C., Leblond, J. et al. (2001). Cognitive treatment of pathological gambling. Journal of Nervous & Mental Disease, 189, 774-780.

Wulfert, E., Blanchard, E. B., & Martell, R. (2003). Conceptualizing and treating pathological gambling: A motivationally enhanced cognitive behavioral approach. Cognitive and Behavioral Practice, 10, 61-72.