The Brief Addiction Science Information Source (BASIS)

Op-Ed/Editorials - On the flip side: Unintended consequences of public health programs

The views expressed in the Op-Ed/Editorials page are solely the views of the author(s) and do not necessarily reflect the views of the BASIS, its sponsors, or affiliated organizations.

Howard J. Shaffer, Ph.D., C.A.S.
Debi A. LaPlante, Ph.D.
Division on Addictions

Our job as scientists is to challenge conventional wisdoms, even when such challenges will be unpopular. Our profession charges us with finding the exceptions to rules and the caveats that end stories. With that in mind, in this editorial we consider the potential for unintended consequences of generally admired policies and programs.

Although public policy and regulations often seek to protect the public and the public’s interests, the best of intentions occasionally have the power to steer us in unexpected directions. LaBrie & Shaffer (2003) recently argued that “while regulation is generally viewed as a means to achieve a desired outcome, practice indicates that regulatory action in itself can be problematic.” A recent paper by Bernhard & Preston (2004) provides an example for this argument by suggesting that mandatory closing periods for casinos and other gambling venues have the potential to increase “binge” gambling before closing time.

Gambling policy isn’t the only occasion for good intentions to go awry. The American Psychological Association Committee on Psychology and AIDS recently suggested that abstinence only sex education programs show “an unintended consequence of unprotected sex at first intercourse and during later sexual activity.”1 This is important considering policy initiatives supporting abstinence only programs currently underway and research suggesting the comprehensive and abstinence only education programs do not substantially differ in the length of time they delay first intercourse. The logical extension of unprotected sex is increased STD rates.

Such unexpected consequences might stem from a shift in the psychology of individuals. For example, research shows that individuals believe that their own instances of nondiscriminatory behavior bestow upon them moral credentials, which in turn allow them to discriminate without being labeled as prejudiced (Monin & Miller, 2001). Does volunteering as a designated driver bestow similar license upon individuals’ drinking behavior?

Some research suggests that individuals who ride with designated drivers drink more than those who do not (e.g., Cuadill, Harding, & Moore, 2001). Though some might perceive this suggestion as radical or even dangerous, consider the potential harmful effects that designated driving programs might have on individuals. Imagine, if you will, a group of friends who rotate designated driver responsibilities. On the surface, we might assume that these friends are forward thinking and acting responsibly; however, consider their behavior on nights when they are not the designated driver. Do individuals, particularly young people, feel special license for excess on those driving free nights as a kind of reward or compensation for the nights in which they act responsibly? During those nights, are they placing themselves at considerable physical risk, due to excessive drinking: risk for liver, brain, or gastrointestinal damage, poor choices regarding sexual partners, or increased aggression and risk-taking?

By describing these possibilities, we are not arguing that society dismantle designated driver programs - or other common and popular public health initiatives. Rather, we are encouraging more study of this issue. We also are suggesting that people become more aware of the potential unintended harmful consequences of well-intentioned programs.

This discussion raises larger questions about the purpose of and origins of regulatory policy and public health programs. For designated driver programs, the policy would stand if the primary purpose is to protect the public from harm and protecting drinkers from themselves is secondary. In addition, are we dismissing these secondary effects too easily in our efforts to curtail primary effects of drinking and driving? Using science early and often during the development of public health programs permits us to evaluate both the intended and unintended effects of these efforts. Science will help to guide and identify the range of consequences that result from public policies and programs, leaving public policy makers in the best position to optimize intended effects and minimize unintended consequences.

What do you think? You can address comments to Dr. Howard Shaffer and Dr. Debi LaPlante.

Notes

1 http://www.apa.org/releases/sexeducation.html

References

Bernhard, B. J., & Preston, F. W. (2004). On the shoulders of Merton: Potentially sobering consequences of problem gambling policy. American Behavioral Scientist, 47(11), 1395-1405.

Caudill, B. D., Harding, W. M., & Moore, B. A. (2001). DWI prevention: Profiles of drinkers who use designated drivers. Addictive Behaviors, 26, 155-166.

LaBrie, R. A., & Shaffer, H. J. (2003). Toward a science of gambling regulation: a concept statement. AGA Responsible Gaming Lecture Series, 2(2), 1-7.

Monin, B., & Miller, D. T. (2001). Moral credentials and the expression of prejudice. Journal of Personality and Social Psychology, 81(1), 33-43.

The WAGER Vol. 10(5) - Growing Pains: The progression of gambling problems from adolescence to young adulthood

Growing Pains: The progression of gambling problems from adolescence to young adulthood
Researchers (Gupta & Derevensky, 1998; Jacobs, 2003; Shaffer, Hall, & Vander Bilt, 1999) have noted higher past-year prevalence rates of problem gambling among young people than among adults. Difference in the past-year prevalence could be due to a decrease in problem gambling with greater maturity. The differences might also be due to real differences between young people and adults or more basic measurement problems (e.g., inaccurate adolescent estimates and lack of commonality across populations in defining gambling problems). Without prospective study, any of these interpretations is possible. This week, the WAGER examines a longitudinal study by Winters, Stinchfield, Botzet and Slutske (2005) that identifies and compares the course of at-risk and problem gambling during the transition from adolescence to young adulthood. This study uses a methodological and data analytic approach similar to Slutske, Jackson, and Sher’s (2003) prospective study reviewed previously in WAGERs 8(26) 8(27), and 8(28).

Researchers recruited 350 young people to participate in a longitudinal study.1 Of these, 305 participants completed telephone assessments at all three time periods: T1 (1992), T2 (1994), and T3 (1997-1998). Interviewers obtained parental consent for minor participants. Among other measures of gambling involvement and frequency, the assessment consisted of the South Oaks Gambling Screen for adolescents (SOGS-RA) (Winters, Stinchfield, & Fulkerson, 1993) at T1 and T2, and the South Oaks Gambling Screen (SOGS) (Lesieur & Blume, 1987) at T3. Mean age of participants at each of the three time periods was 16, 17.6, and 23.8. To allow comparison across waves, the researchers used only the 12 items that they considered equivalent between the SOGS and SOGS-RA to define three gambling severity groups: No problem gambling (N) = a score of 0 or 1; At-risk gambling (A) = a score of 2 or 3; and Problem gambling (P) = a score of 4 or more.

Based on these groupings, researchers assigned labels to four possible courses of gambling problem progression: resistors – those grouped as non-problem gamblers at all of the three time points; persistors – those consistently grouped as either at-risk or problem gamblers; desistors – those who changed from either problem gambling or at-risk gambling to non-problem gambling without a return to their previous state; and new incidence cases – those who were non-problem gamblers at T1 but advanced to at-risk or problem gambling behavior during one or both of the later time periods. Table 1, using the letter designations, N, A, and P, for the groups (defined above) presents the courses of gambling severity over the three time periods.

Table 1. Frequencies of gambling severity group trajectories across the three time periods (N=305).

 
Table adapted from Winters et al., 2005.

Note: N = no problem gambling; A = at-risk gambling; P = problem gambling classifications made using SOGS-RA and SOGS)

As Table 1 shows, most cases (60%) fell into the resistor category, indicating no problem gambling at any point during the study. The next largest group was “new incidence cases” which represented 21% of all cases. Only 3% of participants qualified as persistors, maintaining at-risk or problem gambling throughout all three time periods. Thirteen percent of participants fell into the desistors group, beginning as either at-risk or problem gamblers, but completing the study as non-problem gamblers. Almost 93% of desistors were never classified as problem gamblers during the study; as shown in Table 1, these participants had a code of either ANN or AAN.

If we define adolescence as time periods T1 and T2, and we define adulthood as time period T3, then the data show that researchers classified 25% (77 of 305) of the adolescent sample as either at-risk or problem gamblers, and they classified 25% (76 of 305) of the adult sample as at-risk or problem gamblers. However, the rate of problem gambling (not at-risk) among adults is two-thirds the rate of problem gambling among adolescents (12 adults or 4% compared to 19 adolescents or 6%).

The study suggests that, although the percentage of at-risk or problem gamblers does not change between adolescence and young adulthood (25% for both), the percent of problem gambling does change (6% to 4%). Moreover, given the percentage of desistors (13%) and new incidence cases (21%), many young people dramatically change their gambling behavior between adolescence and adulthood. Also, fewer young adults qualify for problem gambling compared to adolescents. This parallels earlier work investigating prevalence estimates of problem gambling (Shaffer et al., 1999). This research also suggests that a substantial number of young people (8%) qualify as problem gamblers (as defined by the SOGS-RA and the SOGS) at some point between adolescence and young adulthood. It is notable that about 89% of those who reported at-risk level SOGS-RA scores at T1 never escalated to more serious gambling problems at T2 and T3; this implies that those who score as at-risk might either (a) not be at risk in the near future for more serious gambling problems or (b) not be at risk at all.

The design of this study offers important advantages over the cross-section studies commonly used to examine youth gambling. The longitudinal design of this study allows analysis of two important aspects of youth gambling behavior. With this design, researchers can document not only prevalence, but also incidence rates at each assessment period. A limitation of this study is that the researchers evaluated participants with the SOGS-RA at time periods T1 and T2, but used the original SOGS at T3. Though they only used equivalent items, it is possible that slight differences between these items could partially account for the change in problem gambling behavior between T2 and T3. Finally, obtaining parental consent for minors, though necessary, might have influenced participants to under report gambling-related problems.

Gambling problem progression during adolescence appears to be a dynamic phenomenon. This study confirms the shifting natural history of gambling problems, as the few existing longitudinal studies on gambling behavior previously have suggested (Shaffer & Hall, 2002; Slutske et al., 2003; Winters, Stinchfield, Botzet, & Anderson, 2002). Winters et al. remind us once again that future research needs to employ more longitudinal designs, using an individual level of analysis, to consider both the lifetime and past-year measures of gambling severity.

What do you think? Comments on this article can be addressed to Michael Stanton.

Notes

1. A previous article by Winters and colleagues (Winters et al., 2002), reviewed in WAGER 7(17), reports prevalence rates across the three waves of data for this sample.

References

Gupta, R., & Derevensky, J. L. (1998). An empirical examination of Jacobs' General Theory of Addictions: Do adolescent gamblers fit the theory? Journal of Gambling Studies, 14(1), 17-49.

Jacobs, D. F. (2003). Juvenile gambling in North America. In H. J. Shaffer, M. H. Hall, J. Vander Bilt & E. M. George (Eds.), Futures at Stake: Youth, Gambling, and Society (pp. 256-282). Reno, NV: University of Nevada Press.

Lesieur, H. R., & Blume, S. B. (1987). The South Oaks Gambling Screen (SOGS): A new instrument for the identification of pathological gamblers. American Journal of Psychiatry, 144(9), 1184-1188.

Shaffer, H. J., & Hall, M. N. (2002). The natural history of gambling and drinking problems among casino employees. Journal of Social Psychology, 142(4), 405-424.

Shaffer, H. J., Hall, M. N., & Vander Bilt, J. (1999). Estimating the prevalence of disordered gambling behavior in the United States and Canada: A research synthesis. American Journal of Public Health, 89(9), 1369-1376.

Slutske, W. S., Jackson, K. M., & Sher, K. J. (2003). The natural history of problem gambling from age 18 to 29. Journal of Abnormal Psychology, 112(2), 263-274.

Winters, K. C., Stinchfield, R. D., Botzet, A., & Anderson, N. (2002). A prospective study of youth gambling behaviors. Psychology of Addictive Behaviors, 16(1), 3-9.

Winters, K. C., Stinchfield, R. D., Botzet, A., & Slutske, W. S. (2005). Pathways of youth gambling problem severity. Psychology of Addictive Behaviors, 19(1), 104-107.

Winters, K. C., Stinchfield, R. D., & Fulkerson, J. (1993). Toward the development of an adolescent gambling problem severity scale. Journal of Gambling Studies, 9(1), 63-84.

Addiction and the Humanities, Volime 1(8) - Getting Smashed: The Story of One Woman’s Struggle with Alcohol Abuse

A recent study of college drinking behavior reveals that in 2001, 48.2% of students who consumed alcohol, drank to get drunk (Wechsler, et al., 2002). Alcohol, even in small servings, slows reflexes and impairs judgment; binge drinking* or drinking heavily can place people at greater risk for serious consequences, such as car crashes and date rape (NIAAA, 1995). Also disconcerting is a trend among female students: women are trying to drink as much alcohol, and as quickly, as their male counterparts. In April 2002, Time Magazine featured an article titled “Women On a Binge,” which discusses this phenomenon. The opening paragraph of the article quotes one senior woman at Syracuse University who describes two goals for her senior year: to learn how to drive a stick-shift and to “drink a guy under the table” (Morse et al., 2002). Women cannot metabolize alcohol as efficiently as men because they have lower levels of the enzymes that break down alcohol, and their bodies have a relatively higher fat to water ratio (NIAAA, 1999). Further, women are more likely to be victimized when intoxicated, and are more likely to experience long-term health consequences due to heavy drinking (NIAAA, 1999). When all these factors are considered, recent drinking trends among women and the potential consequences are reason for alarm.

These statistics might seem abstract to some; for those who might have difficulties imagining how they translate to real life, a new memoir by another 2002 Syracuse University graduate provides one possible narrative of the lifestyle suggested by the percentages above. In Smashed: Story of a Drunken Girlhood (2005), Koren Zailckas chronicles as much as she can remember of her relationship to alcohol: from her first drink at 14 and her first hangover a few months later, to getting her stomach pumped at 16, and then to her self-destructive binge-drinking and blackouts in college. Her drinking resulted in a sexual assault, caused her to vomit blood, and deleted from memory her late-night journey to an unfamiliar apartment in New York City. Though it is now obvious to the author that drinking resulted in very risky decisions and situations, the “beer goggles” she wore perpetually for a decade allowed her to ignore the risks and their roots.

For Zailckas, alcohol served as an anesthetic to the awkwardness of adolescence and growing up: it allowed her to escape her feelings of shame and self-consciousness (Zailckas, 2005, p. xvi), while accentuating the more outgoing aspects of personality so well guarded when she was sober (Zailckas, 2005, p. 62). Drinking created a bizarre paradox: though Zailckas felt as though she had better control of the negative feelings she had about herself, in reality, these feeling emerged in more destructive ways when she was intoxicated. Alcohol is a mood magnifier. For example, instead of directly dealing with the feelings surrounding her sexual assault, Zailckas and a friend vandalized the fraternity house in which the man who assaulted her lived. Because she was less conscious of the impact of her experiences when drunk, she dealt with them in non-constructive ways. Using alcohol in this way is consistent with Khantzian’s self-medication theory (Khantzian, 1997), which suggests, in part, that individuals engage in behaviors, sometimes excessively and harmfully, to compensate for underlying problems and conflicts.

Zailckas employs poetic language to articulate an insightful analysis of her own behavior, most likely aided by the clarity of hindsight. Her memories and descriptions seem almost too good to be true, given the author’s state of intoxication during most of the experiences of which she writes. Nevertheless, Zailckas touches on issues to which women everywhere might be able to relate. She credits peer pressure, the drinking culture on college campuses and more generally, the advertising industry and their promotion of alcohol, as well as her desire to define, and be, ‘feminine,’ as factors contributing to her destructive drinking. Though the specific factors that influence drinking and the experiences that follow likely will be wholly unique for each individual, the influences and trends described in Smashed might be universal. In the introduction of her book Zailckas notes “Mine are ordinary experiences among girls and young women in both the United States and abroad, and I believe that very commonness makes them noteworthy” (Zailckas, 2005, p. xv). Whether or not every detail is accurate, this book creates a useful link between the statistics that describe drinking behaviors and the people behind those statistics.

What do you think? Comments can be addressed to Siri Odegaard.

Notes

 * Binge drinking is defined as drinking 5 or more drinks in a row for men, and 4 or more drinks in a row for women.

References

Khantzian, E. J., 1997: The self-medication hypothesis of substance use disorders: A reconsideration and recent
applications. Harvard Review of Psychiatry, 4: 231-244.

Morse, J., Bower, A., Healy, R., Barnes, S., Berestein, L., Locke, L. A., et al. (2002, April 1). Women On a Binge. Time Magazine, 159.

National Institute on Alcohol Abuse and Alcoholism (1995). Alcohol Alert No. 29. Retrieved April 17, 2005 from http://www.niaaa.nih.gov/publications/aa29.htm.

National Institute on Alcohol Abuse and Alcoholism. (1999). Alcohol Alert No. 46. Retrieved April 17, 2005 from http://www.niaaa.nih.gov/publications/aa46.htm.

Wechsler, H., Lee, J. E., Kuo, M., Seibring, M., Nelson, T. F., & Lee, H. (2002). Trends in College Binge Drinking During a Period of Increased Prevention Efforts - Findings from 4 Harvard School of Public Health College Alcohol Study Surveys: 1993-2001. Journal of American College Health, 50(5), 203-217.

Zailckas, K. (2005). Smashed: Story of a Drunken Girlhood. New York: Viking.

Op-Ed/Editorials - When Tribes Buy Racinos

The views expressed in the Op-Ed/Editorials page are solely the views of the author(s) and do not necessarily reflect the views of the BASIS, its sponsors, or affiliated organizations.

I. Nelson Rose, Ph.D.
Professor, Whittier Law School Costa Mesa, CA
BASIS, editorial board member

Startling changes are sweeping the world of legal gambling. Gaming tribes that for decades lived in abject poverty now have a new problem: finding ways to diversify their enormous wealth.

Meanwhile, states have the opposite difficulty. The Islamist attacks of 9/11, coming at the time of the burst of the Internet stock market bubble, drove most state budgets so far into the red that there is no easy way for governors and legislatures to dig their way out. As often happens, lawmakers turn to legal gambling as a painless tax.

Naturally, at some point the two trends had to come together.

The Mohegan Sun casino in Connecticut reported revenue of $1.1 billion for the fiscal year ending in September 2004. With that kind of money, it was easy for the Mohegans to buy Pocono Downs in Wilkes-Barre, Pennsylvania, for $280 million. The tribe can finance the purchase out of its cash flow.

There is no market today for racetracks, especially those that have to compete against nearby casinos. New York is having trouble finding any bidders for its last track license, now that it looks like its racino law is unconstitutional.

But Pocono Downs will be one of only 14 locations in the populous state of Pennsylvania to have a share of the newly authorized 61,000 slot machines. Anyone with a calculator can figure out how much that is worth, given that even on the saturated Las Vegas Strip, 25-cent slot machines make more than $100/day. A near-monopoly in a good location can make $500 per slot per day, or more.

The Mohegans also want to invest hundreds of millions in proposed tribal casinos in Wisconsin and Washington state. In November 2004, voters in Kenosha approved a non-binding referendum for an $800 million casino-resort an hour north of Chicago that technically will be owned by the Menominee Tribe, but financed and run by the Mohegans.

In Oklahoma, two of the state's four racetracks are owned by tribes. In November 2004, that state's voters approved Class III gaming devices for these and one other track. Although "slot machines" are still illegal, these games will be fast-action linked bingo machines and video pull-tabs with video slot machine displays, as well as video poker. Oklahoma's tribe-owned, off-reservation racinos will be very close to true casinos, with non-house-banked table card games, including poker, pai gow poker and blackjack.

There have been other serious efforts by tribes to own off-reservation casinos, not subject to the Indian Gaming Regulatory Act ("IGRA"), in places such as Detroit, Michigan; West Warwick, Rhode Island; and Bridgeport, Connecticut.

What happens when a tribe becomes the financier and operator of an off-reservation casino? No one knows the answer - yet. But we can make some educated guesses.

First, it is important to note that we are not talking about the more common and controversial issue of "reservation shopping," where a tribe obtains new land, nearer a city, and has it put into trust as part of its reservation. The law here is fairly well established. If a tribe can get the necessary federal and state approvals -- a difficult process -- it can open a casino under the terms of the IGRA.

But what if the casino or racetrack is not part of the tribe's reservation? It might be on land never taken into trust, or even on land owned by another tribe. If the Mohegans succeed in financing and operating a casino on the Menominee Tribe's reservation in Kenosha, Wisconsin, the land won't somehow become part of the Mohegans' reservation. A tribe may own, finance or manage legal gambling on privately owned land to the same extent as anyone else.

But tribes are not sole proprietorships, partnerships nor corporations. They are not just business entities: They are not governments, even when they act like privately-owned businesses.

The legal differences are enormous.

The United States Supreme Court has made it clear that a tribe cannot be sued for any reason, including breach of contract, unless the tribe or Congress consents. This tribal sovereign immunity extends not only to the tribe itself but also to its wholly owned business entities. And the tribe has complete immunity even if the business is off-reservation and has nothing to do with the tribe's governmental functions.

The case that made it to the Supreme Court shows how far this doctrine extends. The Kiowa tribe was involved in a business deal having nothing to do with its governmental activities. The tribe defaulted on a promissory note that was executed off-reservation.

The high Court held the tribe did not have to pay if it did not want to.

Suppliers and even state licensing bodies probably do not realize that, with tribes, they are dealing with governmental bodies that must consent to be sued.

Even if a tribe has waived its sovereign immunity, some courts have held that any dispute must first be heard in the tribe's own tribal court, unless the tribe has agreed to another forum.

Tribes have additional legal advantages not shared by their competitors. It is often said that shareholders of public companies are doubly taxed on their dividends. With gaming, they pay triple: The corporation pays gaming taxes on its gross or net gaming revenue, it then pays state and federal income taxes on its earnings, and its taxpayers then pay income taxes when those earnings are distributed as dividends.

A tribe that obtains an operator's license would have to pay the same gaming taxes. But that is where the comparison ends. Tribes are governments, so they do not pay federal or state taxes. Distributions to tribal members are not always subject to taxation. Tribal members who live on the reservation are often exempt. In any case, it is relatively easy for a tribe to pass on benefits, such as houses, cars and college scholarships, without the tribe member having to pay any taxes.

Tribes, as governments, can do things that for-profit corporations cannot. For example, they can issue tax-free bonds, allowing them to borrow at greatly reduced rates. One tribe in California bought a bank and was then in a position to lend itself money, again at most favorable rates.

Tribes are the only sovereign governments that can contribute to federal, state and local political campaigns. Lawmakers and voters are often called upon to decide whether competing gambling should be made legal. Canada and Ontario did not like proposals for casinos in Detroit, but they could not contribute money to defeat them. Congress and the Federal Elections Commission have put no limits on the size of tribal campaign budgets, and tribes do not have to disclose their sources.

It is not even clear if tribes have to report campaign donations: Courts in California have split on whether state election laws apply to tribes.

Tribes do have one distinct disadvantage, which is more psychological than legal. The IGRA makes it clear that, when it comes to Class III gaming on their own reservation, tribes are equal to the states. And with Class II gaming, tribes do not even have to talk to states.

But when a tribe operates a track or casino outside its reservation, it is subjecting itself for the first time to the regulations and whims of state and even local governments. Will tribes willingly turn over confidential financial information?

Licensing will be probably be the most difficult area. What will happen when a tribal official, used to issuing gaming licenses, is himself denied a license?

© Copyright 2004, all rights reserved worldwide Gambling and the Law® is a registered trademark of Professor I Nelson Rose, Whittier Law School, Costa Mesa, CA

ASHES Vol. 1(4) - Where There’s Smoke There’s Fire: Personality and Metabolic Responses to Nicotine

Many smokers claim that smoking relieves anxiety and helps promote relaxation. Such claims are consistent with a self-medication motive for lighting up (Khantzian, 1997). Khantzian’s self-medication theory suggests, in part, that individuals engage in behaviors, sometimes excessively and harmfully, to compensate for problems like depression or anxiety. This week ASHES reviews a study of hostility, a problem that is often associated with an increased susceptibility to nicotine dependence. If Khantzian’s self-medication theory applies, nicotine is a way for people with hostile tendencies to diminish these feelings. In a recent study by Fallon, Keator, Mbogori, Turner, and Potkin (2004), the authors examined whether an individual’s tendencies toward hostility relate to their neurological reactions to nicotine.

The researchers recruited 86 participants: 55 non-smokers (i.e., smoked less than 10 cigarettes in their life and none in the past two years) and 31 smokers (i.e., more that 10 cigarettes per day for the past two years). Results from clinical interviews using the Cook-Medley items from the MMPI (Hathaway and McKinley, 1942, 1943; Butcher et al., 1989) determined whether participants were high-hostility (i.e. a score of at least 25 on the Cook-Medley items for men and 18 for women) or low-hostility: 24 non-smokers and 19 smokers were high-hostility. Participants then performed a hostility task (i.e., the Bushman Competitive Reaction Task (BCRT1) (Bushman, 1995). For this task participants compete with a supposed “opponent” to complete a particular task first. At the conclusion of each task the winner blasts the slower “opponent” with noise; in this study aggression is measured both by the length of the noise blast and its intensity, which is set by the winner. Non-smokers performed the hostility task under each of two, randomly ordered, experimental conditions, a placebo patch or a 3.5mg nicotine patch. Smokers had an added condition of a 21mg nicotine patch. The researchers (2004) monitored neurological activity during the task using Positron Emission Tomography (PET).

High- and low-hostility non-smokers did not differ on the BCRT under any experimental condition; smokers showed mixed results. In the placebo condition, high-hostility smokers blasted mock opponents for longer time periods than did low hostility smokers (251 ms vs. 180 ms); however, in the 21 mg nicotine condition, low-hostility smokers applied shock at a higher decibel level (7.1 dB vs. 5.4 dB) than high-hostility smokers.

Neither low-hostility smokers nor low-hostility non-smokers showed a change in brain metabolic activity between the placebo and nicotine conditions (see Figure 1, Rows A, C, and D). Among high-hostility people, smokers showed  greater metabolic activity on placebo than high-hostility non-smokers (Row G), which suggests that nicotine might be used as a form of self-medication. There was virtually no difference in metabolic activity between smokers and non­smokers on the low-nicotine dose (Row H). The lack of difference results from nicotine increasing activity among high-hostility non-smokers (Row B) but not among high-hostility smokers (Row E). Because the low nicotine dose did not change the metabolic activity for smokers, this does not necessarily support the idea that nicotine is used as a way of self-medicating. The low-dose nicotine did not change metabolic activity among low-hostility smokers (Row C) or high-hostility smokers (Row E), but the high dose did dampen activity for high-hostility smokers (F).

Figure 1: Metabolic differences induced by nicotine patch (2)

Red indicates significantly increased metabolic rate following nicotine compared to placebo.
Blue indicates significantly decreased metabolic rate following nicotine compared to placebo.

Thus, the authors suggest, smoking history modifies the brain’s reaction to nicotine in high-hostility participants, though further research is necessary to determine whether this is the case. These results could be interpreted to suggest that self-medication of hostile tendencies might not be a valid explanation for smoking initiation because, in this experiment, nicotine caused hostile non-smokers to become more aggressive, though it might aid high-hostility smokers in controlling hostile tendencies. This research does show that certain traits may contribute to a person’s susceptibility to addictive behaviors, such as smoking. However, the harm caused by most means of nicotine ingestion is serious and sometimes irreversible. Thus, even if hostile tendencies are minimized in response to nicotine, there may be more healthy and direct ways of coping with hostility.

What do you think? Comments can be addressed to Siri Odegaard.

Notes

1. Subjects watched a violent videotape and then competed against a mock opponent in a reaction-time task. The slower participant received a blast of noise from the opponent. Researchers measured the level of aggression as the decibel level and frequency of shocks administered by subjects to mock opponents.

2. Image reprinted from Cognitive Brain Research, Vol. 18, Fallon, J. H., Keator, D. B., Mbogori, J., Turner, J., and Potkin, S., Hostility differentiates the brain metabolic effects of nicotine, p. 142-148, 2004, with permission from Elsevier

References

Bushman, B. J., 1995: Moderating role of trait aggressiveness in the effects of violent media on aggression. Journal of Personality and Social Psychology, 69: 950-960

Butcher, J. N., Dahlstrom, W. G., Graham, J. R., Tellegen, A., and Kaemmer, B., 1989: Minnesota Minnesota Multiphasic Personality Inventory-2 (MMPI-2): Manual for Administration and Scoring. Minneapolis: University of Minnesota Press.

Fallon, J. H., Keator, D. B., Mbogori, J., Turner, J., and Potkin, S., 2004: Hostility differentiates the brain metabolic effects of nicotine. Cognitive Brain Research, 18: 142-148.

Hathaway, S. R. and McKinley, J. C., 1942: The Minnesota Multiphasic Personality Schedule. Minneapolis, MN.

Hathaway, S. R. and McKinley, J. C., 1943: The Minnesota Multiphasic Personality Inventory (Rev. ed., 2nd printing.). Minneapolis, MN.

Khantzian, E. J., 1997: The self-medication hypothesis of substance use disorders: A reconsideration and recent applications. Harvard Review of Psychiatry, 4: 231-244.

Op-Ed/Editorials - Strength Through Balance: The Importance of Councils on Problem Gambling

The views expressed in the Op-Ed/Editorials page are solely the views of the author(s) and do not necessarily reflect the views of the BASIS, its sponsors, or affiliated organizations.

Kathleen M. Scanlan
Director, the Massachusetts Council on Compulsive Gambling
Editorial Board Member, BASIS

The Massachusetts Council on Compulsive Gambling’s founder and long-time executive director, Thomas N. Cummings, worked with great energy in the early 80’s to advocate for services to address problem gambling. In his appeals to Massachusetts Legislators and other public officials, he would often describe the services he was seeking as analogous to a three-legged stool. In order for problem gamblers to be helped, he would say, a three pronged approach was needed: (1) treatment for those looking for help in breaking the hold that gambling had on them, (2) research to learn more about this disorder, and (3) an advocacy group such as the Council to provide information and connections between problem gamblers and the resources for help. These three “legs” would provide the structure and stability to the “stool” that would make it effective and strong enough to achieve the purpose for which it was created. Providing one or two of the legs only would not be sufficient.

In my eighteen years at the Massachusetts Council on Compulsive Gambling, I have come to recognize the wisdom in Tom’s vision of how to help people with gambling problems. It is the importance of that vision that I would like to address here.

While councils on problem gambling may vary from state to state and country to country in structure, governance, and funding, there are some common elements that most include in their mission. In some form, advocacy, education, public awareness, and referral are part of the continuum of services most councils offer.

The advocacy role is primary in some ways since without advocacy for comprehensive services for those affected by gambling problems there would be no opportunity to meet other needs. In addition, advocating for responsible public policy related to gambling in states, provinces, and countries often results in greater commitment of jurisdictions to providing resources to address the unintended negative consequences of state-sponsored gambling.

The educational role of councils is varied. The benefits of training the community and professionals - all those who meet up with the effects of problem gambling in their daily work - cannot be underestimated. The worlds of medicine and mental health, corrections, domestic violence, suicide prevention, other human services, K – 12 education, higher education, finance are all enabled to deliver their services more effectively by understanding problem gambling’s impact on their work.

Public awareness activities of councils serve to alert the general public that problem gambling is an identifiable disorder, that there is hope for getting better, and that there are resources for help. The goal of public awareness is to provide information in order to empower those facing desperation because of their or their family member’s disordered gambling to make some changes to reverse the situation. Public awareness campaigns that reduce the stigma associated with gambling problems and with seeking help have the potential to change attitudes and behaviors as well as public policy.

The most direct contact that people suffering from gambling disorders have with councils is through their helplines. These information and referral services are crucial in providing the understanding and the resources callers seek. Helpline specialists’ empathic listening, as they offer information and referral, aims to empower callers to take the next step to change their situations for the better.
Because of the work of the councils, some significant improvements have resulted for those facing gambling problems. Yet challenges exist. In addition to coming up with some solutions to the perennial search for stable funding mechanisms, councils could achieve their goals more effectively by shifting some focus from training to systems change and committing to creating and implementing means of measuring whether programs achieve what they intend to accomplish.

While recognizing the important work that councils do, the need for the other legs of the stool is clear. Without research there would be limited scientific knowledge about gambling disorders to inform treatment and advocacy efforts. Without problem gambling treatment, those suffering most acutely from disordered gambling would not have access to the care they seek. And without advocacy groups, it is possible that the situation would look much like it did prior to the 1980’s…with a paucity of awareness of this disorder and resources for help - with only a handful of human services and other professionals confident of their ability to recognize and refer or treat problem gambling, with minimal attention paid to public policy related to gambling, and no easily accessible way for someone seeking help to find it.

What do you think? You can address comments to Kathleen Scanlan.

Op-Ed/Editorials - Come Bet with Me

The views expressed in the Op-Ed/Editorials page are solely the views of the author(s) and do not necessarily reflect the views of the BASIS, its sponsors, or affiliated organizations.

Ken Winters, Ph.D.
Professor, Dept. of Psychiatry
Director, Center for Adolescent Substance Abuse Research
University of Minnesota

For those who monitor the gambling industry, you will want to follow the recent proposal to expand gambling to the airways. Richard Branson, the entrepreneurial British owner of Virgin Atlantic Airlines, announced a couple of months ago that he intends to include blackjack and roulette on his new international fleet of double-decker planes.

A report about flying casinos gets my attention a lot quicker than the usual type of gambling news I have been reading lately in the press, such as how the Gov­inator plans to ply more gambling dollars from the tribes in California. The press release by Branson will have more legs to it than most gambling media stories. Guys like Branson do not just announce news, he makes news. He’s a lot like Dan Rather in that way.

But there is a nagging ambivalence about Branson’s idea. Is this a sign of gambling expansion gone amok? What’s next? Gambling on the Space Shuttle? Or perhaps Branson has devised nothing more than a clever marketing scheme with minimal, if any, health consequences.

To get some clarity on this issue, I asked my campus club lunch group about Branson’s flying casinos. My colleagues are legitimate culture vultures. They are particularly astute at clarifying the meaning of cultural happenings. For example, they astutely comforted me that the rapid popularity of youth soccer is not a sign that this game will soon replace baseball as America’s number one sport. The reason so many kids play soccer is “to avoid having to watch it.” And they predict that Michael Jackson will be found innocent by the jury. “He will (moon) walk.” They also told me that it’s a lot easier to go free if you are a pop star than if you are a fertilizer salesman, which is Scott Peterson’s profession.

So how did my culture vultures respond to Branson’s gambling plan? With more superficiality than alarm. Instead of public health warnings, they toyed with the idea. At one point they engaged in a silly game of inventing new slogans that Virgin Atlantic flight attendants will need to learn. A sampling:

“You are now free to move about the gambling area.”

“Please fasten your money belt.”

“Please return your betting table to a full and upright position. We will be cashing in your poker ships soon.”

“It has been a pleasure serving your gambling needs and we hope you will gamble with us again.”

So my culture vultures are nonplussed. Maybe I should follow their lead. After all, research tells us that the overwhelming majority of people who gamble apparently do so in a safe and fiscally-responsible manner. How much harm could result from a few Branson casinos flying around in international airspace?
Note to Branson’s marketing department. You have a great opportunity here to spice the games a bit. Brits like Branson love to place odds on all sorts of events. Why not invent innovative airline games that we can all enjoy? I offer this one suggestion: An airline racing game, with a real-time radar screen, where bets are placed on which flights will arrive at their destination on time. It could be called p-air-mutuel betting.

This is not to say that we should drop our guard when it comes to the dangers of gambling expansion. I for one will sound the public health alarm when gambling shows real expansion, such as if it were to expand beyond Las Vegas and Atlantic City. And I rue the day if gambling were to show up in that other space - cyberspace. Now these expansions seem worthy of our attention.

And if I am ambivalent about such trends, I will seek the input from my culture vultures.

What do you think? You can address comments to Dr. Ken Winters.

The Dram, Volume 1(4) - Treating Co-occurring Alcoholism and Depression

National studies show that alcoholism and depression frequently co-occur (Kessler, Crum, Warner, Nelson, Schulenberg, Anthony, 1997). Each problem poses significant emotional, financial, and social costs to families and society. Though there are effective treatments for either health crisis alone, treating co-occurring depression and alcoholism might require more than simply combining effective individual approaches to each disorder. This week The DRAM focuses on a study by Moak, Anton, Latham, Voronin, Waid, and Durazo-Arvizu (2003) that assessed the effectiveness of sertraline, a selective serotonin reuptake inhibitor (SSRI), for treating drinking and depression, when added to Cognitive Behavioral Therapy (CBT).

Moak et al. (2003) recruited through newspaper advertisement or clinical referral 240 treatment seekers meeting Diagnostic and Statistical Manual of Mental Disorders (American Psychiatric Association, 1987) criteria for major depressive episode or dysthymia and alcohol dependence or abuse. The authors employed extensive exclusion criteria, including psychoactive substance dependence. Of 240 potential participants, 185 were seen for an initial assessment; 78 were excluded from the study, and 107 agreed to participate. Moak et al. (2003) asked these individuals to remain alcohol abstinent for the 3 days prior to initiation of a single-blind placebo condition. All subjects had an individual CBT session during the placebo lead-in week. Individuals who remained abstinent or only drank minimally for an additional 7 days and scored at least a 17 on the Hamilton Rating Scale for Depression (HAM-D, 21 items -- Hamilton, 1960) were randomized into SSRI or placebo groups in a double-blind design. All participants received 4 tablets of study medication: either sertraline or matched placebo. The SSRI group started at 50 mg daily and gradually increased to 200 mg daily over two weeks. Dosage decreased back to 50 mg over 7 days and stopped before the end of the 12 week study. Researchers recorded alcohol and depression-related data during the 12 weeks. Evaluations were conducted at the end of the study, week 12, and at follow-up, weeks 16 and 26 (post-treatment); Moak, et al, will present follow-up data in another article that is yet to be published. Any participants who dropped out of the study during the 12 week treatment period, were encouraged by researchers to return for follow-up evaluations at weeks 12, 16, and 26. Approximately 70% of the participants completed the study, with participants on SSRI more likely (p = .08) to complete the study (84%) than those on placebo (67%).

Table 1: Drinking and depression outcome measures (adapted from Moak et al., 2003)

Note: BDI-Beck Depression Inventory
* Significant difference, p<0.05 between SSRI and placebo groups; § significant difference for females only
** Score given at last available treatment.

The results indicate that CBT supplemented with administration of sertraline reduces drinks per drinking day to a greater extent than CBT supplemented placebo; participants in both groups had fewer drinks per drinking day and more percent days abstinent during the study than in the 90 days prior. Further, there was no difference between the sertraline and placebo groups with regard to heavy drinking days per week, or percent days abstinent. The authors note that the SSRI used in this study might be more beneficial for women than men, as significantly greater changes in depression for the sertraline group were observed only for women. Depression and drinking generally decreased for both SSRI and placebo groups over the course of the study.

It is important to note that the CBT used for this study is a truncated version designed by Project MATCH (Kadden, Carroll, Donovan, et al., 1992). The results of the Project MATCH study show that condensed CBT is effective in treating people who are alcohol dependent and depressed. Overall, though sertraline resulted in participants drinking fewer drinks per day, other drinking outcomes did not differ greatly between the two groups. It will be interesting to see the results of the data collected during follow-up visits at 16 and 26 weeks. This will hopefully help determine the long-term efficacy of these treatments.

What do you think? Comments can be addressed to Siri Odegaard.

References

American Psychiatric Association. (1987). Diagnostic and statistical manual of mental disorders, third edition (revised) (Third (revised) ed.). Washington, D.C.: American Psychiatric Association.

Hamilton, M. A. (1960). A rating scale for depression. Journal of Neurology, Neurosurgery and Psychiatry, 23, 56-62.

Kadden, R., Carroll, K., Donovan, D., et al. (1992). Cognitive-behavioral coping skills therapy manual: A clinical research guide for therapists treating individuals with alcohol abuse and dependence (Vol. 3). Washington, DC.

Kessler, R. C., Crum, R. M., Warner, L. A., Nelson, C. B., Schulenberg, J., & Anthony, J. C. (1997). Lifetime co­occurrence of DSM-III-R alcohol abuse and dependence with other psychiatric disorders in the National Comorbidity Survey. Archives of General Psychiatry, 54, 313-321.

Moak, D. H., Anton, R. F., Latham, P. K., Voronin, K. E., Waid, R. L., & Durazo-Arvizu, R. (2003). Sertraline and cognitive behavioral therapy for depressed alcoholics: Results of a placebo-controlled trial. Journal of Clinical Psychopharmacology, 23(6), 553-563.