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Gambling: a threat to public health?

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As gambling increasingly moves from physical sites As gambling increasingly moves from physical sites such as casinos and betting shops to the internet, the pastime is more accessible than ever

When a nurse is presented with addiction, they may expect to be dealing with alcohol abuse, or a drug dependence. However, problem gambling is being increasingly recognised as a major public health issue, due to its potentially devastating consequences on mental health.

Finally it seems the authorities are taking it seriously. From April 2020, using credit cards to gamble will be banned in the UK. Financial advisor UK Finance estimates that 800,000 consumers use credit cards to gamble, while separate research undertaken by the Gambling Commission shows that 22% of online gamblers using credit cards to gamble are classed as problem gamblers – with even more at some risk of harm. The ban, which will apply to all online and offline gambling products with the exception of non-remote lotteries, will provide a significant layer of additional protection to vulnerable people.

‘Whilst millions gamble responsibly, I have also met people whose lives have been turned upside down by gambling addiction,’ said former Culture Minister Helen Whately. ‘There is clear evidence of harm from consumers betting with money they do not have, so it is absolutely right that we act decisively to protect them.’

‘In the past year we have introduced a wave of tougher measures, including cutting the maximum stake on fixed odds betting terminals, bringing in tighter age and identity checks for online gambling and expanding national specialist support through the NHS Long Term Plan. We have also secured a series of commitments from five leading gambling operators that will include £100 million funding towards treatment for problem gamblers.

Data released by NHS England shows a record number of hospital admissions last year related to gambling addiction, including care for severe mental ill health conditions like psychosis. The number of gambling related hospital admissions has more than doubled in the last six years from 150 to 321.

Cases of pathological gambling, where people turn to crime to fund their addiction has increased by a third in the last 12 months. The NHS estimates that over 400,000 people in England have an addiction to gambling and two million people are at risk of developing the condition. There has also been an increase in the number of young people that are affected by gambling related harm.

Why is gambling addictive?

Rewarding experiences – such as receiving a compliment, having sex, accomplishing a task, or winning a game – cause our brain to send signals via neurotransmitters: chemical messengers that either stimulate or depress neurons in the brain.

The main neurotransmitter in the ‘reward system’ is known as dopamine. When enough dopamine is released due to stimulating, enjoyable activities, humans experience euphoria and pleasure, and feel motivated to do that same activity again. For instance, when drugs are taken, they create a high by increasing the dopamine that’s released in the reward system up to 10 times more than the amount natural rewarding experiences would generate. This also happens when gambling.

Research and studies into gambling’s effect on the brain indicates that it activates the brain’s reward system similarly to how drugs do: by releasing a higher amount of dopamine.

Online gambling

Online gambling has grown exponentially in recent years, with particular concern that young people are increasingly using it as a gateway to problematic behaviour, such as theft, unsustainable borrowing. The amount of money taken from gamblers online increased from £1.2bn in 2007 to £5.6bn in 2018, with almost all of that increase coming from gambling through smart phone apps. Excluding the National Lottery, an estimated 9 million people in the UK gambled last year with more than half doing so by mobile phone or tablet, according to the Gambling Commission.

The Gambling Commission estimated in 2016 that online gambling accounted for 33% of all gambling activity. That number is very likely to have increased significantly since.

‘By its very nature, gambling can be an inherently risky activity, with some people betting with limited resources and the potential for it to become an addiction. It is estimated that there are currently over 300,000 people in the UK with symptoms of gambling disorder, making this an issue of real and growing concern,’ said Shirley Cramer, Chief Executive of the Royal Society for Public Health.

Millennials aged 25-34 accounted for the biggest increase in online gambling of any age group last year, according to the Gambling Commission. They are now the most likely of any age group to hold more than five online gambling accounts, are more likely to have gambled at least once in the past four weeks (disregarding the National Lottery) and the most likely of any age group to gamble via mobile phone. Betting before and during sports matches is now common among younger gamblers with revenue from sports betting now outstripping that from online poker or slot games.

According to recent NHS England Data, 46 people under the age of 25 attended a hospital as a result of their addiction last year, with one person as young as 15 receiving treatment, compared to 37 people under 25 receiving treatment the year before – an increase of a quarter.

‘Gambling harms have been shown to lead to serious consequences for an individual’s health and wellbeing, including a higher risk of debt, mental health issues, substance abuse, physical health disorders, poor educational performance and damage to relationships,’ added Ms Cramer. ‘It is with growing concern that in recent years, we have increasingly seen the impact of gambling harms on the health of children and young people.’

Treatment and referral

Recognising a patient who may be suffering from gambling addiction may be difficult in primary care settings, as there often are not any obvious physical health symptoms.

Venetia Leondidaki, Consultant Clinical psychologist, at the National Problem Gambling Clinic.recommends that nurses be aware of gambling addiction when patients present with issues linked to financial strains, or other mental health issues.

‘We advise [primary care staff] to use screening tools, such as the problem gambling index, a brief questionnaire. Indicators that someone may have a problems could be issues with debts and financial issues,’ said Dr Leondidaki.

‘People with problem gambling may also have a number of mental health problems, including depression, anxiety family and relationship breakdowns, problems with the law. So the number of ways their lives may have been affected by gambling, and sometimes people are scared to come forward and say the problem is gambling. I would always ask about other addictive behaviours. Sometime people find it easier to talk about alcohol or drugs rather than drugs.’

Additionally, Dr Leonidaki says nurses should be aware that certain conditions, and medications may be linked to an increased risk of problem gambling.

‘We know that certain conditions may be more likely to develop problem gambling. For example those who are prescribed medication for Parkinson’s are more likely to develop problem gambling. The same thing happens for patients who are prescribed common antipsychotics are more likely to develop problem gambling,’ she said. Evidence from the US has suggested that the antipsychotic drug aripiprazole, has been linked to uncontrollable urges to eat, gamble, shop and have sex.

NHS England has announced the opening of 14 specialist gambling clinics in January to tackling this rising problem. The first gambling clinic specialising in younger patients was also opened in June, as fears of a new epidemic in younger generations are raised by the accessibility of gambling on phones and computers

Once referred to one of the new NHS specialist clinics, psychiatrists and clinical psychologists will work with patients who could have a range of complex problems including persistent gambling, compulsive behaviours, development disorders and difficulties earlier in childhood that underlie addiction.

Treatment for compulsive gambling may include both psychological therapy and medication. Cognitive behavioural therapy focuses on identifying unhealthy, irrational and negative beliefs and replacing them with healthy, positive ones. Family therapy also may be helpful. Additionally, some antidepressants and mood stabilizers may help problems that often go along with compulsive gambling — such as depression, OCD or ADHD. Some antidepressants may be effective in reducing gambling behaviour. Medications called narcotic antagonists, such as useful in treating substance abuse, may help treat compulsive gambling.

‘We would start with an assessment in the clinical interview to understand the level of the impact on someone’s life,’ said Dr Leonidaki.

‘Our treatment offers frontline therapy, CBT, which very much focuses on how our cognitive bias, about things like randomness and ability to control things, they roll into gambling. We teach people how there may be some biased beliefs that drive them to continue gambling.

‘Alongside this we will also do something called stimulus control. We help people limit access to gambling and money, this is a really important step in the programme. It Is important they self-exclude from old behaviours for example if they use bank accounts where they have more control of their finances, and how much money they can take out every day. Some software that they can install on their phone and computers that block gambling sites. Having a friend or a relative controlling their money. Not taking cash or cards when they go out with them.’

Gambling, like any addiction, can cause enormous harm to the physical and mental health of patients. With the rise of easy-to-access gaming on smart phones, more and more patients run the risk of falling into the cycle.

Video games have also become a major source of concern, particularly the availability of ‘loot boxes, which some say are gateways to gambling aimed at children as young as ten.

These are virtual collections of in-game purchases and other add-ons. To progress in the game, players can collect extra items and content, but do not know what items they will be given until they’ve paid – which encourages users to keep spending and playing.

Investigations have found numerous cases of children spending money without their parents knowledge, including a 16-year-old paying £2,000 on a basketball game and a 15-year-old losing £1000 in a shooting game. A report by the Royal Society of Public Health in December found that over half of young people believe that playing a video game could lead to gambling and that the link between gaming and gambling is a negative one.

‘Frankly no company should be setting kids up for addiction by teaching them to gamble on the content of these loot boxes. No firm should sell to children loot box games with this element of chance, so yes those sales should end,’ said Claire Murdoch, National Mental Health Director for the NHS.

Despite the daunting scale of the problem, it does look like the NHS is getting ready to respond properly.

‘Our NHS is fighting back against a rising tide of gambling related ill health as more people than ever before are being egged-on by shameless gambling firms not just to take a chance with their money, but with their health too,’ said Claire Murdoch.

‘While the NHS will always be there for people – adapting, improving and increasing different and new treatments as our patients need them as part of our Long-Term Plan – the gambling industry, which takes upward of £14 billion a year from punters, must take the blame for this increase and ensure a fair amount of its profits help its customers who may suffer from addiction.’

For more information on the National Problem Gambling Clinic, visit: https://www.cnwl.nhs.uk/national-problem-gambling-...

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