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Gambling Harm Minimisation

ABACUS Feedback to the Ministry of Health
regarding
Emerging Trends in National & International Literature.

This summary of research has relevance to the clinical workforce,
it forms part of a regular six monthly report provided by ABACUS to the Ministry.

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Feedback to MOH
Emerging Trends in National & International Literature

Report No. 20 / Period covered:
1st January 2020 to 30th June 2020

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Literature:

Gamblers Anonymous as a recovery pathway: a scoping review (2016)

Authors: Schuler A, Ferentzy P, Turner N, Skinner W et al

J Gambling Studies 2016, 32(4), 1261-1278.

Findings:

  • Although this is a study from 2016, it links in topic to the following AA study released this year by the prestigious Cochrane Collaboration which overall, identifies the absence of research into the effectiveness of 12-step therapy and support groups in the field of addiction harm minimisation.
  • The authors noted that despite the presence of Gamblers Anonymous (‘GA’), ‘there has been relatively little effort to explore the existing evidence base on its effectiveness as a recovery approach for problem gambling’ (p1).
  • The authors conducted a scoping review on literature  between 2002-2015, identifying 17 eligible studies, most being cross-sectional designs.
  • They noted research found high levels of comorbid substance use disorders and mental illness with problem gamblers (Lorains et al, 2011) raised need for complex interventions, and that multi-focus 12-step programmes, such as Addictions Victorious and All Addictions Anonymous, may be useful, although again, no outcome evidence was available.
  • Although the design of the studies made causal conclusions between GA and treatment outcomes not possible, studies found associations of those attending GA having greater subsequent involvement with professional treatment, improvements in abstinence, increased readiness for change, and higher coping skills and leisure activity.
  • Becoming a member of a shared identity, a ‘homogeneous collective’ with a growing seniority and respect over time may replace a simple recovery outcome.
  • The authors noted that the research identified that those attending GA had more severe problems and were more motivated to attend treatment.
  • They concluded that evidence for the effectiveness of GA ‘either as a control condition or in conjunction with formal treatment or medication is inconsistent’.
  • The noted that within the programme, there was an emphasis on developing patience, accepting of financial problems and taking a realistic appreciation of their situation, accepting they were a ‘compulsive gambler’ as important aspects of the recovery culture.
  • They considered that there was a need for randomised controlled studies over a large scale, identifying the mechanisms of how GA worked, its barriers to recovery, as well as whether the programme was effectives for both males and females. Comparison of GA and natural recovery, the role of GamAnon, and gambler profiles best fitting GA were also absent.
  • The authors concluded that GA was a cost-effective, accessible/available treatment, especially for those with low incomes or high debt.

Comment:

  • There appears to be (anecdotally) differing views held by therapists in NZ as to the effectiveness of GA and this research identifies some of the gaps in research that might support inclusion of GA in a treatment plan, referral or support of GA with presenting clients, or knowledge of the availability of GA chapters.
  • This research provides some evidence for support of GA, but that research is not of design that can support causal conclusions.
  • There remains few chapters of GA in NZ (15 sites, two in most large centres, some in recess: http://www.12steps.nz/wp-content/uploads/2020/GANZ_20200702a.pdf
  • A case may be made for a continuing support organisation to be available for those impacted by their own gambling, especially post treatment, while integrating GA contemporaneously with treatment may be another possibility to consider in treatment planning.
  • Problems that can occur may be the expectation that GA has the expectation that the client has a desire to stop gambling, while harm minimisation approaches do not necessarily require abstinence.
  • This research highlighted that there was an  absence of research in the field from which to draw evidence-based conclusions.

Literature:

Alcoholics Anonymous and other 12-step programs for alcohol use disorder. (11 March 2020)

Authors: Kelly J, Humphreys K, Ferri, M.

Cochrane Systematic Review 2020. Doi.org/10.1002/14651858.CD012880.pub2

Findings:

  • Although focusing upon Alcoholics Anonymous, this study released this year addresses many of the gaps in research for 12-step programmes, and upon the assumptions that similarities may outweigh differences between the various 12-step services and programmes (where 12-step and therapy integrate or co-exist), this prestigious research (Cochrane Collaboration) may help to inform the impact of GA on positive outcomes where gambling harm exists.
  • Schuler et al (2016; above) noted that there may be differences with GA (from AA, NA) in one respect, that ‘in certain ways (as a unique culture of recovery) it distinguishes itself from fellowships such as AA and NA in the need to focus upon crippling financial difficulties many may face’p2. In addition, Lorains et al (2011) considered that those impacted by gambling harm may also be more likely to suffer from other addictions and mental health. In many cases this may be coexisting alcohol problems, which may also support AA attendance benefits.
  • In this Cochrane study, the authors noted that previous absence of research had been improved over the last decade, enabling comparison evidence for 12-step programmes (AA integrated or associated) versus other programmes.
  • The authors noted that 27 high quality studies, of which 21 were randomised studies, were able to support causal conclusions.
  • They identified that between 22%-37% of those attending AA or programmes including facilitation to AA remained abstinent compared with other (non-AA) programmes where 15%-25% remained abstinent. They did, however, note a possible bias that AA people self-select attendance at AA and therefore may be more motivated to abstain from alcohol.
  • The authors also noted that AA was more effective in the longer term (than other non-AA therapies).
  • Also, they concluded that AA works as well as other (non-AA) therapies in the treatment of reducing the intensity of alcohol drinking, and reducing the impact of consequences and severity of alcohol problems.
  • They also concluded that programmes that increased AA attendance  led to better outcomes over years through continued abstinence following treatment. Those that encouraged attendance, even if brief programmes, helped those with alcohol problems to engage with AA long-term and to assist them to sustain remission.
  • The authors also identified substantial cost-saving healthcare benefits of AA.
  • Despite the comprehensiveness of the findings, the authors did note that none of the research studies measured outcomes on quality of life, improved functioning, or psychological well-being. These factors were considered to be increasingly of importance in addition to the focus upon the use of alcohol.

Comment:

  • This comprehensive systematic review of 12-step programmes (AA) as a separate or conjunct to treatment provides good evidence for the effectiveness of this approach/support. Although the research is not GA, the similarities in the support books, 12-step model, and rules, enables ‘face conclusions’ to be drawn in the absence of such high level causation conclusions available for GA.
  • Those impacted by their gambling are often isolated, secretive and have high risk for relapse. Ongoing posit-treatment membership of a support organisation such as 12-step based membership (e g GA) may enable these people to engage over the longer term with like-minded and similarly impacted others.
  • The current research notes that AA attending clients were more likely to remain abstinent, were more likely to reduce the impact of their behaviour on their lives, and these extended over years.
  • There is the difficulty that GA chapters are few and far between in NZ, with only two available in Auckland. This would compare poorly with AA and NA, and act as a barrier to such integration in treatment in NZ.
  • This research may act to inform and motivate practitioners working in addictions, and including gambling harm specialists, to recommend, motivate and support clients to attend GA in their area, not just during treatment, but as an ongoing support to address relapse risk for their futures.

Literature:

Gambling before and during the COV-19 pandemic among European regular sports bettors: an empirical study using behavioural tracking data (2020)

Authors: Auer M, Malischnig D, Griffiths M.

International J of Mental Health and Addiction doi.org/10.1007/s11469-020-00327-8

Findings:

  • The authors noted that COVID-19 has had a major impact upon the cancellation of sports events and the sports betting industry.
  • The authors were granted access to a large European online gambling operator with players (betters) from Sweden, Germany, Finland and Norway. From this record, the authors were able to compare betting before and after the onset of restrictions in this region (March 7, 2020).
  • N=5396 bettors’ records were analysed and provided evidence that there were statistically significant reductions in sports bettors’ wagering in online casinos.
  • The authors noted that there was therefore no evidence that sports betters moved to online casino games, and there was a significant decrease in the amount of money wagered by sports betters during the post COVID-19 period compared with the similar period before this impact.
  • Many (78%) of betters prior to the impact date bet on both sports and online casino games. After the impact date, sports betting reduced and so did their betting on casino games, while percentage of bettors’ gambling on casinos reduced also (76%). Those gambling less often prior to the impact date reduced even further (and were more likely to stop betting altogether) post the impact date. There were no significant changes in the amount gambled in a bet/session, but they gambled less often.
  • The authors concluded that there was no relationship between availability of sports events to gambling on and increased conversion of gambling to online casinos.
  • They further concluded that the speculation that individuals being confined to their house for long periods as a result of COVID-19 did not spend more time or money gambling. This may have been a result of having less money during the lockdown period, not wanting to gamble in front of family members, or they may have wanted to spend more time with family members/complete large home projects.

Comment:

  • The hypothesis that gambling harm could increase during the Covid-19 lockdown or after, has been raised with the possibility that the stress of lockdown or financial downturn after, may increase gambling harm.
  • The Otago Daily Times (July 17, 2020; ‘Concerns Problem Gambling could rise under Covid-19 climate’) cited practitioners and a professor stating that the link between gambling and lockdown may result in increased gambling behaviour and harm, if not during lockdown, following lift of lockdown as a result of likely financial stress (job loss, national economic downturn).
  • This reviewed research appears to suggest the opposite (during lockdown) and warrants further enquiry.
  • Limitations are acknowledged in that the study is based upon a single provider data source, that variations will occur between different regions (this is Scandinavia) of the world, varying availability to continuing sports to bet upon, focused upon sports gambling, and other issues.
  • Nevertheless, the evidence, if supportable and generalisable, suggests there may be less inclination for gamblers to transfer their gambling to other forms of gambling (in this case, casino games) even if casino games were existing modes of gambling alongside sports gambling prior to the lockdown.
  • It may well be that this research applies to gamblers rather than those ‘gamblers exhibiting gambling harm’ who may be inclined to transfer their gambling, and whose gambling may exhibit a different profile. However, intensifying gambling by online gamblers who continue their gambling during a pandemic with its uncertainty, would suggest that a risk for gambling harm may be an important factor amongst this much larger population (than those impacted by gambling harm) and is an important population health consideration for enquiry.

Literature:

Changes in gambling behaviour during the COVID-19 pandemic – a web survey study in Sweden. (2020)

Author: Hakansson A.

International J of Environmental Research and Public Health 2020, 17, 4013, doi:10.3390/ijerph17114013

Findings:

  • This study sought, through a self-reported survey (Sweden), whether gambling had increased during the pandemic. N=2016 responses were received, (51% male), and a PGSI score identified those moderate/problem gamblers or above (9%). There was a specific focus upon cancellation of sports as a driver for gambling change (if any).
  • 69% stated that they did not gamble on sports and were therefore unaffected by decreased sports events to gamble upon during the pandemic. However, of those who did bet, 2% reported increased betting on other available sports, 6% more on horse racing, 4% more on casino gambling, and 5% on other games and 19% reported gambling less. Increased sports gambling on other sports during the pandemic was associated with being a moderate risk (11%), or existing problem gamblers (71%).
  • Four percent of responders acknowledged increasing their gambling during the pandemic, with those having existing possible gambling problematic behaviour levels, and/or increased alcohol consumption, more likely to increase their gambling from pre-pandemic to pandemic.
  • Where such gambling occurred in this subgroup (problem and/or alcohol increase), rates of gambling harm were high.
  • The author concluded that although it was only a minority who reported increased gambling during the pandemic, these responders had ‘markedly higher gambling problems and changes in alcohol consumption, and may represent a sub-group with particularly higher gambling risks’.
  • The authors concluded ‘Thus when the world of sports is nearly entirely cancelled, those who still seek other gambling involvement may be a group that are important to address with preventative measures’ p11. They also referred to this confirming ‘the high addictive potential of online casino gambling’p11. They referred to increased alcohol use clearly with increased gambling and was seen as an important issue to address.

Comment:

  • This research identified that people with gambling harm were clearly associated with increased gambling during the pandemic, that this extended to moderate-risk gamblers, and even though 28% had excluded themselves from gambling previously, they continued online.
  • In addition, moderate and ‘problem’ gamblers were more likely to comprise those who had swapped from the sports gambling on sports that had ceased, to other (continuing) sports, with four out of five in these categories of harm. Of those that reported switching to online casino gambling, ‘nine out of ten were moderate-risk or ‘problem gamblers’ p11.
  • It would appear that those with pre-existing gambling harm are at greater risk during the pandemic, while increased alcohol use is an additional factor for harm during this period.
  • Although this study describes self-reported harm, ‘problem gambling’ assessment relies upon self-report in the absence of physical or clear external symptoms, as do screens.

Literature:

Online gambling in the midst of COVID-19: a nexus of mental health concerns, substance use and financial stress (2020)

Author: Price A.

International J of Mental Health and Addiction, July 13, 2020, 10.1007/s11469-020-00366-1

Findings:

  • This study reports upon a survey of N=2005 gamblers (including n=1081 online gamblers) during the first six weeks of emergency pandemic measures in Canada.
  • Equal numbers of male and female gamblers were surveyed. Mental health and gambling harm were assessed.
  • Twelve months prior to the pandemic, 76.7% of those surveyed had gambled on land-based gambling sites only, 9.7% only on online gambling, and 13.6% mixed land-based and online gambling. During the 6-weeks of the pandemic measures, 54% had gambled online.
  • High-risk gamblers assessed by the PGSI and those who had previously gambled online were most likely to use online gambling during the pandemic (although there was also apparent migration from land-based to online gambling during this time).
  • Risk factors for high-risk online gambling were moderate and severe anxiety and depression, and gambling under the influence of cannabis or alcohol, amongst other factors.
  • 85.2% of surveyed responded that they had self-diagnosed anxiety or depression, while 71.3% had been clinically diagnosed with these conditions.
  • Just under 70% used alcohol during the 6-week pandemic period, and of these, 41% had increased their alcohol use during this period. 16.4% had used cannabis during this period, and 49% had increased its use during this time.
  • The authors identified that gambling under the influence of alcohol or cannabis ‘increased the odd of high risk gambling status by approximately 9 times’p6. They also identified that those who gambled online were more deeply affected financially by the pandemic.

Comment:

  • Although this study addresses only a period of 6-weeks of the pandemic, there are significant findings. Because of the brief period of time, just over half of the gamblers had gambled online, however, there were clear findings that alcohol and drugs increased gambling in a harmful way, and that mental health problems were strongly associated with gambling harm.
  • Again, those with existing harm from their gambling were more likely to gamble online, although many with lower/no risk also transitioned across to online gambling.

Commentary

  • The first two reviewed papers address the benefits of GA and AA as a positive tool in gambling recovery, with the second Cochrane Review, although addressing alcohol dependence, can inform the benefits of GA because of the strong common steps, goals, tools and support between the various 12-Step programmes. Isolation, high continuing triggers for those impacted by gambling harm (mental health, stress), and relapse risk, as well as high coexisting problems with AOD would support the inclusion of GA in any treatment plan, either during or post treatment. This strong research supports the inclusion of 12-Step programmes in treatment and support and fills the gap resulting from the absence of research in AA and arguably, GA.
  • The following papers support the possibility of increased gambling harm during the pandemic. Whereas there is less evidence for the adoption of online gambling (and this may evolve over time) by those new to gambling, there is evidence in the last two papers, that those with existing problems will increase their risk and harm during the pandemic.
  • In NZ, sports have recommenced, (before other countries), and there are yet to be papers published that identify whether the risk increases or decreases as a result of changed social environments (financial, social and psychological impacts). What appears to be the concern of treatment providers and academics (see above)  is that these undesired changes will result in greater gambling to escape, and earn money through changed circumstances, and stressors from a severely changed world. Online gambling will create a challenge for countries to manage, whereas accessibility, and now new gambling experiences learned through lockdown, will create new demand, and following these examples of research, increased risk for gambling harm.