Gambling Myths

MYTH– One has to Gamble everyday to be a Problem Gambler

FACT

A problem gambler may not need to gamble everyday. Problem gamblers may gamble everyday, frequently or infrequently. When gambling starts causing psychological, social, legal, employment and financial difficulties for the individual and/or for the people around them, then they may have a problem with gambling.

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Gambling Myths- 2

Myth
Problem Gambling is not a problem if the individual engaged in Gambling behaviour is able to afford it.

Fact
Affordability has got no association with Problem Gambling. When the relationship to gambling takes priority over other areas of life eg spending more time in Gambling and less time with significant others to fulfil the roles such as the role of a spouse, partner, parent, employee etc. that becomes Problem Gambling.

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Gambling and Alcohol Addiction

With DSM (Diagnostic Statistical Manual) version 5 being finalised, seeing Pathological Gambling under Addictions is not surprising. Looking at one end of the ‘Gambling Pendulum‘, research into addictions shows similarities between pathological gambling and alcohol addiction. The recent report from Wales shows results from a pilot survey.

What we can learn is that treatments for Alcohol addiction such as Naltrexone and psychosocial interventions can be helpful to treat Pathological Gambling or Gambling Addiction as well.

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Alcohol and ‘White Collar’ Professionals

Walking through the streets of Central London today and thinking of Alcohol Awareness Week I was deliberating with my thoughts- Alcohol problems are found only in ‘blue collar’ population- is that really true? Not in my experience. I see ‘white collar’ professionals in clinical practice who develop a problematic relationship with Alcohol.

As reported in a recent BBC interview and campaigned by Alcohol Concern- Cymru, it often starts with recreational use where the reasons could be many- including coping with stress, using alcohol as a social lubricant to facilitate a subjectively improved social interaction, part of business networking world to name a few. This, when continues gradually results in gradual development of tolerance to the effects of alcohol and before long can be above ‘Hazardous Use’ giving way to ‘Harmful Use’ and ‘Dependence’.

In case stress is the underlying reason to seek shelter in Alcohol, then there are alternative and healthier ways to manage stress which I will be writing about in the next post.

But for now knowing what the considered safe limits are would be a start for Alcohol Awareness. For men, it is no more than 21 units and for women, no more than 14 units a week. These have to be spread out through the week with at least 2 days gap between drinking days. You can check your units consumption and calories on
Drinkaware

Look out for ‘Managing Stress Healthily’ and ‘Acute Effects of Alcohol’ posts coming up shortly.

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National Addictions Conference- Cardiff 2012

It was a matter of pride for hosting the Royal College of Psychiatrists Addictions Annual Conference in Cardiff this year. It is the first time that it was hosted in Cardiff. The feedback of the conference had been very good spanning from the topics covered to the minute details of the venue, the organisation and the hospitality. Dr Tony Jewell’s opening set the Welsh flavour and that carried on throughout. It was timely for the press release regarding the minimum pricing of alcohol to be released just before the conference as well. Listening to the news today, I picked up that the national alcohol consumption is being reported as going down with more health concerns, rising taxes and increased price to buy alcohol and based on that it was being argued that ‘minimum pricing’ should not be a strategic direction.

Most importantly, it is clear that pricing does have an impact on levels of consumption and given all the evidence on price- elasticity, the ‘marketing- mix’ used by the alcohol industry, the impact of availability and licensing, in my opinion, it becomes even more important to endorse ‘minimum pricing’.

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Ecstasy

Ecstasy has been around for a very long time. Chemically it is 3, 4- methylenedioxymethamphetamine- MDMA. As the name suggests, it is a methamphetamine compound. It is taken orally usually in a tablet or capsule form and the effects start within 30- 60 minutes. Pharmacologically, there is a huge efflux of Serotonin in the brain along with effects on the Dopamine and Noradrenaline sytems as well.The acute effects can often lead to Hyperthermia (raised body temperature) which is compounded by its use in warm, humid climates typically found in the dance clubs and this can be life threatening. The euphoria that is often reported after its use seems to be more related to the contexts of the environment i.e. whether being used in isolation or with club goers and club environment. This has been seen in studies as reported in the 1st International Conference of Psychoactive Drugs in Budapest in March 2012.

Intoxication with Ecstasy has been described as occurring in three stages (Koesters et al, 2002; Parrott and Lasky, 1998)- initial stage of disorientation, second stage of ‘spasmodic jerking and tingling’ and the final stage of increased sociability, increased mental clarity, a feeling of emotional warmth and feeling close to others. Given the context dependent effects, higher doses can give rise to frank euphoria. In toxic doses it can lead to dehydration, hyperthermia (both these can be life threatening in club environment), raised pulse, hypertension, liver failure and/or renal failure (Jonas and Graeme- Cook 2001; Lester et al 2000). There may be anxiety, agitation and even confusion.

The post dose recovery time often leads to depressed mood, irritability, anxiety, sleep impairment, asociability. People who are regular users can experience mid week depression and there are reports of aggression as well.

The chronic effects after regular heavy use can be damaging. Several studies have now indicated that the SERT (Sertraline Transporter) is reduced with chronic use which highlights the diminution of Serotonin in various regions of the brain. As the effects of Ecstasy are on the Frontal Cortex (the part of the brain responsible for planning and executive function), cognitive and memory deficits can be significant. Interestingly, for me working as a Consultant Psychiatrist in Addictions in Wales, what I learnt new from the conference is also that heavy regular use can be associated with Sleep Apnea (serotonin being an important chemical in maintaining lung function).

Whilst experimenting with the drug may be tempting but it can lead to long lasting damage if it becomes persistent or heavy or dependent use.

 

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Legal highs and Novel Psychoactive Substances (NPS)- Beyond Cocaine, Ecstasy and Amphetamines

The debate regarding the legislating evolving new drugs persists for Addiction Psychiatry. Whilst ‘Legal Highs’ (so called as they are not yet under legislation and illegal) keep growing, the issue of legislation needs to be carefully balanced by the understanding of scientific effects of these drugs.

The 1st International Conference on Novel Psychoactive Substances in Budapest, Hungary on 12- 13 March 2012 was a very useful conference which highlighted its theme of the rapidly changing world of ‘Legal Highs’. The biggest challenge for Addiction Psychiatry seems to be keeping pace with this rapid developments where newer drugs are coming out along with newer market evolution and the trends that are transgressing national and international borders- an impact of globalisation and the internet becoming a massive global market. Also, the epidemiology of these is not yet clear as the new drugs have been not around with us long enough. Fortunately though, EMCDDA is reporting that there are some prevalence studies coming up which may be reflecting the wide variation of use of these substances in different regions and countries. Other information reported in this conference, that is useful to me as a Private Psychiatrist in Wales, UK is that the Novel Psychoactive Substances are not probably the first preference of drug users and that stimulants- Amphetamines, Cocaine, MDMA & Ketamine remain drugs of preference. From the reported results, it seems that the Mephadrone might be on the decline. From Dr Paul Dargan’s findings, the other challenge that faces us in Addiction Psychiatry is that there are no systematic data on toxicology, the ICD coding takes a long time to code for new drugs and when faced with acute presentations which may be in A&Es, general medical wards, Psychiatry Wards or in Addiction services, the analytic confirmation is still not up to speed to be able to confirm or refute the drug in the body. Whilst most NPS seem to be falling under the categories of Piperazine, Cathinone and Synthetic Cannabinoids- variations in these poses clinical management challenges. Piperadole derivatives like DPMP and D2PM have been on the increase as highlighted in the conference and people after having used these have developed neuropsychiatric syndromes.

Similarly, the  marketing of these has changed a lot and the newer social networking sites have been used a lot for advertising. Another MixMag survey had highlighted that the number of online shops has increased exponentially and the number of head shops have gone up as well. What struck me as well is that the products being sold with the same brand name such as ‘Ivory Wave’ has been found to be having no standardization, therefore the person buying the same brand may never be assured of getting the same drug on repeat orders. And Methoxetamine (Ketamine derivative) is being branded as “Bladder Friendly”.

What effects do these have in the long run is a difficult question to answer at the moment and a collaborative effort by clinicians, researchers, policy makers, criminal justice systems and governments is needed to address this new epidemic!

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Buprenorphine Implants

Working in Wales as a Consultant Psychiatrist specialising in Addictions, it is exciting to know and share the developments happening in Addiction Psychiatry.

Opiate dependence is a serious cause for concern and the dependence has evolved from illicit Heroin to other sources of Opiates as well such as Prescription Opioid Dependence. Buprenorphine is a valid treatment option and as with any other Chronic Health condition like Diabetes, Hypertension, Enduring Mental Health Problems- concordance to medication is a real clinical issue. We use Depot medication in cases of mental health disorders to improve medication concordance. The trial of Buprenorphine Implants may hold a promising future for Opiate Dependence Management as well. Watch the space!!

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Legal Highs- Getting a grip fast!!

According to EMCDDA report of 2011, UK has become number one in terms of online shops for the ‘Legal Highs’. Working as a Consultant Addiction Psychiatrist in Wales (UK), it is not surprising to see this in the clinical settings as well. The number of young people referred to integrated drug and alcohol services has gone up over the last couple of years and the nature of drugs has constantly evolved as we persistently get bombarded with newer drugs almost every time. The speed of input of the drugs in the market is far higher than the time taken and the resources spent on trying to understand the effects and management of these drugs. Guardian reports on the current state of resource allocation in UK.

I am going to be delivering a talk on some of these drugs- Mephadrone, GHB in Dublin next week in the Royal College of Psychiatrists- Liaison Coneference. Though we remain limited in knowledge of the management principles of the newer drugs coming in, it becomes important to monitor the trends.  RedNet project and EMCDDA are doing a good job by keeping us informed of these trends.

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Addiction Psychiatry- Prescription Opioid Dependence

Prescription opioid dependence is becoming a cause for concern for addiction psychiatry as many people are started on these drugs for pain or many start using opioid based Over-The-Counter(OTC) medication and develop a dependence on them. Some research has shown that the prognosis of this is better than Heroin dependence. A recent paper further confirms my personal experience of treating this problem in Wales. The good news is that prescription opioid dependence can be managed well with Subutex or Suboxone along with psychosocial support. A long term maintenance may not be required in such instances.

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