Gambling Is Not A Disease

  1. Why Is Gambling Illegal
  2. Why Addiction Is Not A Disease
  3. What Is Gambling Disorder
  4. Gambling Addiction Is Not A Disease
Addiction is a chronic brain disorder, and not merely a behavioral problem or simply the result of taking the wrong choices, according to the American Society of Addiction Medicine (ASAM), which has given addiction a new and long definition. ASAM says that addiction is much, much more than a behavioral problem involving excessive drugs, sex, gambling or alcohol.

Addiction is not a Disease Why Addiction is not a Disease – Policy, Epidemiology, and Treatment Consequences of a Bad Idea The effect of conceptualizing addiction as a disease on policy and treatment has been predictably disastrous. The new definition also describes addiction as a primary disease, meaning that it's not the result of other causes, such as emotional or psychiatric problems. And like cardiovascular disease and diabetes, addiction is recognized as a chronic disease; so it must be treated.

When most of us witness compulsive and harmful behaviors in family members, friends, and even public figures, we generally focus on the use of the substance or the obsession target and their behaviors as the problem.
These noticeable behaviors, however, are really manifestations of a disease involving several areas of the brain, say ASAM authors of the new definition. ASAM is the USA's largest professional society of doctors dedicated to preventing and treating addiction.
Dr. Michael Miller, former president of ASAM, who oversaw the development of the new definition, said:
'At its core, addiction isn't just a social problem or a moral problem or a criminal problem. It's a brain problem whose behaviors manifest in all these other areas. Many behaviors driven by addiction are real problems and sometimes criminal acts. But the disease is about brains, not drugs. It's about underlying neurology, not outward actions.'

ASAM says the new definition is the result of a thorough, four-year process with input from over 80 experts, including top addiction authorities, addiction medicine doctors, and eminent neuroscience scientists from across the USA, as well as every member of ASAM's governing board, chapter presidents from several states, and experts from NIDA (National Institute on Drug Abuse).
Addiction is now described as a Notprimary disease - not caused by something else, such as a psychiatric or emotional problem.
Addiction is also a long-term (chronic) disease, and like other chronic diseases, such as diabetes or cardiovascular disease, treatment and monitoring has to be maintained throughout the patient's lifetime.
Neuroscience research has advanced tremendously over the last 20 years. New findings over the last two decades have convinced experts and ASAM members that the definition of addiction needed to be changed so that the focus is on what is happening in the brain.
In its web site, ASAM stated:

Why Is Gambling Illegal


'Research shows that the disease of addiction affects neurotransmission and interactions within reward circuitry of the brain, leading to addictive behaviors that supplant healthy behaviors, while memories of previous experiences with food, sex, alcohol and other drugs trigger craving and renewal of addictive behaviors.'

In this disease, brain circuitry that directs impulse control and judgment become altered - the patient has a dysfunctional pursuit of rewards when seeking out, for example, alcohol and other drugs. Early exposure to drugs and alcohol are linked to a higher risk of becoming addicted later in life because this area of the brain is still developing during a human's teenage years.
Whether or not people have a choice over antisocial and dangerous pursuits has been a controversial subject for many years.
Dr. Raju Hajela, former president of the Canadian Society of Addiction Medicine and chair of the ASAM committee on the new definition, said:
'The disease creates distortions in thinking, feelings and perceptions, which drive people to behave in ways that are not understandable to others around them. Simply put, addiction is not a choice. Addictive behaviors are a manifestation of the disease, not a cause.
Choice still plays an important role in getting help. While the neurobiology of choice may not be fully understood, a person with addiction must make choices for a healthier life in order to enter treatment and recovery. Because there is no pill which alone can cure addiction, choosing recovery over unhealthy behaviors is necessary.'

Why Addiction Is Not A Disease

Dr. Miller said:
'Many chronic diseases require behavioral choices, such as people with heart disease choosing to eat healthier or begin exercising, in addition to medical or surgical interventions. So, we have to stop moralizing, blaming, controlling or smirking at the person with the disease of addiction, and start creating opportunities for individuals and families to get help and providing assistance in choosing proper treatment.'

Written by Christian Nordqvist
doi: 10.1136/bmj.39176.363958.80
PMID: 17446577

Patients often are in substantial debt before the problem is recognised

Parkinson's disease is common. It is estimated to affect around one in 200 people in the developed world (between six and 11 people per general practice in the United Kingdom).1 For many patients, care is shared between general practitioners, geriatricians, general physicians, and neurologists, often alongside specialist nurses. Motor symptoms and signs of Parkinson's disease are well recognised, yet the behavioural problems are less well known, particularly the recently described problems of pathological gambling and other addictive behaviours.57Pathological gambling is an impulse control disorder characterised by excessive gambling. The prevalence of pathological gambling in Parkinson's disease is about 3.4%, rising to 7.2% in patients taking dopamine agonists. In contrast, the lifetime prevalence of pathological gambling in the general population in the UK is 1%.9 It can be associated with the presence of other compulsive disorders such as the compulsive use of dopaminergic drugs, compulsive shopping, and hypersexuality. People who develop Parkinson's disease at a younger age are reported to have a higher risk of pathological gambling.5

Although the pathophysiology of pathological gambling in Parkinson's disease is not well understood, it may relate to aberrant dopaminergic stimulation. It is not clear which dopamine agonist precipitates the disorder, as all such agonists have been implicated.5 Patients taking both a dopamine agonist and levodopa are at increased risk, although those who take either a single dopamine agonist or levodopa can be affected.7

What Is Gambling Disorder

About 5.8 million people in the UK—one in 10 internet users—log on to internet gambling sites each month.10 This is expected to rise as more households connect to the internet11 and as the use of broadband increases. Many internet gambling companies actively lure gamblers with pop-ups to place free bets. This marketing technique is pervasive and can make it hard for vulnerable people to wean themselves off gambling.

We have noted that our patients are often secretive about their gambling and may end up thousands of pounds in debt before the problem is realised. Patients and families often do not suspect drug treatment as the cause of pathological gambling and therefore do not mention it to the doctor. Better awareness of the problem among patients and carers, coupled with routine direct questioning by clinical staff about changes in behaviour and development of new compulsions and gambling, will help to identify the problem early.

Once recognised several strategies may help. Reducing or stopping dopamine agonists may be considered, as anecdotal evidence suggests this helps improve or stop the pathological gambling behaviour. If this results in deterioration of the motor state, then combinations of other drugs for treating Parkinson's disease may be tried, including levodopa, apomorphine, catechol-O-methyltransferase inhibitors (such as entacapone), and monoamine-oxidase-B inhibitors (such as selegiline). Cognitive behaviour therapy and serotonin selective reuptake inhibitors have been tried with variable success. Nalmefene (Revex), an opioid antagonist, was recently reported in a randomised controlled trial to be effective in pathological gambling. However, the lack of good quality clinical trials in pathological gambling that assess the long term impact of interventions means that patients need to be closely monitored for signs of relapse, by sensitive but direct questioning to patients and their families. Advice given by clinicians to the patient and family on practical ways to avoid the temptation to gamble (such as installing firewalls against internet pop-ups for internet gamblers, or tearing out the newspaper racing pages), together with support from family, friends, and carers to control finances may help resolve the problem.

Details of the UK's proposed regulations on the internet gambling industry are due to be announced shortly.11 The current debate on regulating gambling is relevant to this group of patients. This provides an ideal opportunity to deal with the problem through appropriate legislation to protect a small, though highly vulnerable, group in our society.

Notes

Competing interests: MJS has received financial support from GlaxoSmith Kline the manufacturers of ropinirole to attend several conferences; MJS acts as an adviser and is involved in clinical research trials for Schwarz Pharma, the manufacturer of rotigotine.

Gambling Addiction Is Not A Disease

Provenance and peer review: Non-commissioned; externally peer reviewed.

References

1. Koroll M, Tanner CM. Epidemiology of Parkinson's disease: an overview. In: Ebadi M, Pfeiffer FR, eds. Parkinson's disease. Boca Raton: CRC Press, 2005:39-50.
2. Dodd ML, Klos KJ, Bower JH, Geda YE, Josephs KA, Ahlskog JE. Pathological gambling caused by drugs used to treat Parkinson's disease. Arch Neurol 2006;62:1377-81. [PubMed] [Google Scholar]
3. Wong SH, Cowen Z, Allen EA, Newman PK. Internet gambling and other pathological gambling in Parkinson's disease: a case series. Mov Dis 2007;22:591-3. Epub ahead of print. [PubMed] [Google Scholar]
4. Giovannoni G, O'Sullivan JD, Turner K, Manson AJ, Lees AJL. Hedonistic homeostatic dysregulation in patients with Parkinson's disease on dopamine replacement therapies. J Neurol Neurosurg Psychiatry 2000;68:423-8. [PMC free article] [PubMed] [Google Scholar]
5. American Psychiatric Association. Diagnostic and statistical manual of mental disorders 4th ed. Text revision ed. Washington, DC: American Psychiatric Association, 2000
6. Voon V, Hassan K, Zurowski M, Duff-Canning S, de Souza M, Fox S, et al. Prospective prevalence of pathologic gambling and mediation association in Parkinson's disease. Neurology 2006;66:1750-2. [PubMed] [Google Scholar]
7. Sproston K, Erens R, Orford J. Gambling behaviour in Britain: results from the British gambling prevalence survey. London: National Centre for Social Research, 2000
8. Voon V, Hassan K, Zurowski M, de Souza M, Thomsen T, Fox S, et al. Prevalence of repetitive and reward-seeking behaviours in Parkinson disease. Neurology 2006;67:1-4. [PubMed] [Google Scholar]
9. Tyne HL, Medley G, Ghadiali E, Steiger MJ. Gambling in Parkinson's disease. Poster presentation. Eighth international congress of Parkinson's disease and movement disorders. Mov Dis 2004;19(suppl 9):S195 [Google Scholar]
10. BBC News. Broadband UK needs “more speed.” http://news.bbc.co.uk/1/hi/technology/6041446.stm. 18 Oct 2006
11. BBC News. Panorama: online gambling Transcript of transmission on BBC1 26 Nov 2006. http://news.bbc.co.uk/1/hi/programmes/panorama/6198212.stm.
12. Toneatto T, Ladouceur R. Treatment of pathological gambling: a critical review of the literature. Psychol Addictive Behav 2003;17:284-92. [PubMed] [Google Scholar]
13. Grant JE, Potenza MN, Hollander E, Cunningham-Williams R, Nurminen T, Smits G, et al. Multicenter investigation of the opioid antagonist nalmefene in the treatment of pathological gambling. Am J Psychiatry 2006;163:303-12. [PubMed] [Google Scholar]
Articles from The BMJ are provided here courtesy of BMJ Publishing Group