The Greens yesterday released the party’s problem gambling discussion paper. The paper advocates, among other things, for general practitioners to play a greater role in screening and treating problem gamblers – at times with naltrexone, the controversial drug used to treat other addictions.
Gambling reform is likely to dominate politics in 2012, with the Coalition slated to release its policy in February and the Independent Andrew Wilkie lobbying to ensure it dominates the legislative agenda.
So it’s important we have clear, evidence-based information about the harms of problem gambling and the options available to address this widespread problem. And, of course, it can’t all be solved with a pill.
More than just a flutter
The Productivity Commission estimates that between 80,000 and 160,000 Australian adults suffer significant problems from their gambling. And it’s not just the individual who is affected – it also impacts on their family and their community. A further quarter of a million Australians are at moderate risk of becoming problem gamblers.
The liberalisation of access to gambling in Australia has created a range of policy dilemmas. Governments extract significant revenue from gaming operators. But on the other hand, governments pay for treatment services for problem gamblers. They also support the families of problem gamblers in a range of ways – welfare services and benefits are often used by problem gamblers whose behaviour creates a cycle of family poverty that spans into future generations.
It’s also true that gaming operators employ many thousands of staff, pay licence fees and taxes, and deliver entertainment to millions who do not suffer from problem gambling. Gaming operators often point to their contributions to, and connections with, the community base of their businesses.
At the same time, however, a highly disproportionate load in losses (or revenue generation, from the industry perspective) is borne by problem gamblers.
It’s a delicate balancing act and yet, despite two comprehensive national reviews conducted by the Australian Productivity Commission (a decade apart) there are still many unknowns about the true economic and social costs and benefits of gambling on the Australian community. There is also a range of opinions about what should happen next.
There are three main opportunities or mechanisms that can be used to address problem gambling.
The first is to educate people about the risks and adverse consequences of problem gambling, preferably before they have heavy exposure to gambling. Public education campaigns are a key tool in preventing problem gambling. Most Australian governments invest in public education campaigns and activities such as Responsible Gambling Awareness Week.
The second method is to regulate access to gambling in an attempt to minimise its harm. As with most products or services, the more outlets and the more opportunities for access, the greater the sales. So, in most jurisdictions, access to gambling is limited through regulation in various ways.
In Victoria, for example, the government only allows a fixed number of pokies to be licensed to operate. In Western Australia, pokies may only operate in the Burswood Casino.
Most jurisdictions regulate opening hours of the venues that offer gambling services and also the characteristics of the games. In the case of the pokies, the rate at which the player can spend money is regulated, although anti-pokies campaigners often argue that the regulations are too lax.
The pre-commitment approaches, where gamblers are asked to specify a loss limit before they gamble, is slightly different to other approaches because it’s the gamblers themselves who set their limits.
The third main way to address problem gambling is through treatment programs for people who have already developed or who are at risk of developing problem gambling. Some argue that this is closing the gate once the horse has bolted, but it’s important to note that this is the approach that is used with most health conditions. And the treatment of problem gambling is no different from other mainstream health problems.
The good news for problem gamblers is that the recent NHMRC-approved guideline for the screening, assessment and treatment of problem gambling – released last month – has identified some relatively effective treatments for problem gambling. The main recommended treatment, cognitive behaviour therapy, is also effective in treating a range of other health issues.
Interestingly, much of the media focus in reporting of the NHMRC guideline has been on the use of naltrexone. But the guideline is clear that naltrexone is not a front line therapy and it doesn’t have the same runs on the board in terms of proven effectiveness as cognitive behaviour therapy.
It may be an alluring idea to take a pill to cure complex problems, but the guideline recommends further research before naltrexone could be considered for routine prescription for problem gambling.
In any event, most pharma-therapeutic regimens include both the talking therapies, such as cognitive behaviour therapy, and the pharmacological agent.
Role of GPs
We already know a great deal about how to work with problem gamblers and change their harmful behaviour. But between 80 and 90% of problem gamblers in Australia do not ever present for treatment. This is one of our most significant obstacles.
The Greens’ paper emphasises that primary care health workers, especially GPs, can and should play a crucial role in screening for problem gambling. GPs are the front line workers for the health problems of most Australians. It makes sense for them to be involved because they have unique access to Australians.
Another issue is whether we have the most effective services, structures and trained practitioners available to care for problem gamblers. These people frequently experience multiple health conditions in addition to their gambling, including much higher rates of other mental health problems (among them anxiety disorders, depression, personality disorders, alcohol dependence and drug dependence).
This may explain why presentation rates of problem gamblers to treatment services are so low: they may well be presenting for treatment of their other condition(s) and are not being diagnosed as problem gamblers and hence are not treated for this. So it’s vital that those with mental health problems are screened for the condition and, if needed, offered treatment.
While gambling has moral and ethical dimensions, an important area of focus is how we are going to ensure that people with problem gambling are encouraged to seek effective help.
So what next?
Training of practitioners is a priority – primary care practitioners need to know how and when to screen for problem gambling and to whom they should refer people who may require treatment.
The community needs to be educated about the importance of seeking help early for problem gambling and how to support people in seeking and undergoing treatment.
And finally – and what would you expect from scientists? – more research into prevention and treatment of problem gambling is required. It’s early days in this field and we need more progress.