Addiction Goes Untreated

According to a National Survey on Drug Use and Health by the Substance Abuse and Mental Health Services Administration, 23.2 million people, or 9.4 percent of the United States population, aged 12 or older needed treatment for an illicit drug or alcohol use problem in 2007. Of these individuals, 2.4 million people totaling 10.4 percent of those who needed treatment, received treatment at a specialty facility such as a hospital, drug or alcohol rehabilitation or mental health center. Thus, 20.8 million people, or 8.4 percent of the population aged 12 or older, needed treatment for an illicit drug or alcohol use problem but did not receive it. These estimates are similar to those in previous years.

Buprenorphine

Buprenorphine is a partial agonist of opioid receptors that carries a low risk of overdose. Buprenorphine reduces or eliminates withdrawal symptoms associated with opioid dependence but does not produce the euphoria and sedation caused by heroin or other opioids. In 2000, Congress passed the Drug Addiction Treatment Act, allowing qualified physicians to prescribe Schedule III, IV and V medications for the treatment of opioid addiction. This bill created a major paradigm shift that allowed access to opioid treatment in general medical settings, such as primary care offices, rather than limiting it to specialized treatment clinics. Buprenorphine was the first medication approved under the Drug Addiction Treatment Act and is available in two formulations: Subutex®, which is a pure form of buprenorphine and the more commonly prescribed Suboxone®, which is a combination of buprenorphine and the opioid antagonist naloxone. Suboxone is a unique formulation with naloxone that causes severe withdrawal symptoms when addicted individuals inject it to get high. Physicians who provide buprenorphine treatment for detoxification and or maintenance treatment in office must have special accreditation. The government requires these physicians to have the capacity to provide counseling to patients when indicated or to refer patients to those who do. Treatment of opioid addiction in an office can be cost-effective approach that increases the reach of treatment and the options available to patients. Many patients have life circumstances that make treatment in the office of a physician a better option for than specialty clinics. For example, a recovering addict may live far away from a treatment center or have working hours incompatible with the clinic hours. Addiction treatment is available in the office of a primary care physician, psychiatrist and other specialists, such as internists and pediatricians. Patients stabilized on adequate, sustained dosages of methadone or buprenorphine can function normally. Recovering addicts can hold jobs, avoid the crime and violence of the street culture and reduce exposure to HIV by stopping or decreasing injection drug use and other risky sexual behavior. Patients stabilized on medications can also engage more readily in counseling and other behavioral interventions essential to recovery and rehabilitation.

Pathological Gambling

Pathological gambling is being unable to resist impulses to gamble, which can lead to severe personal or social consequences.
Causes

Pathological gambling usually begins in early adolescence in men, and between ages 20 and 40 in women.

Pathological gambling often involves repetitive behaviors. People with this problem have a hard time resisting or controlling the impulse to gamble. Although it shares features of obsessive compulsive disorder, pathological gambling is likely a different condition.

In people who develop pathological gambling, occasional gambling leads to a gambling habit. Stressful situations can worsen gambling problems.
Symptoms

People with pathological gambling often feel ashamed and try to avoid letting others know of their problem. The American Psychiatric Association defines pathological gambling as having five or more of the following symptoms:

Committing crimes to get money to gamble
Feeling restless or irritable when trying to cut back or quit gambling
Gambling to escape problems or feelings of sadness or anxiety
Gambling larger amounts of money to try to make back previous losses
Having had many unsuccessful attempts to cut back or quit gambling
Losing a job, relationship, or educational or career opportunity due to gambling
Lying about the amount of time or money spent gambling
Needing to borrow money due to gambling losses
Needing to gamble larger amounts of money in order to feel excitement
Spending a lot of time thinking about gambling, such as remembering past experiences or ways to get more money with which to gamble

A psychiatric evaluation and history can be used to diagnose pathological gambling. Screening tools such as the Gamblers Anonymous 20 Questions can help with the diagnosis.

Treatment

Treatment for people with pathological gambling begins with recognizing the problem. Pathological gambling is often associated with denial. People with the illness often refuse to accept that they have a problem or need treatment.

Most people with pathological gambling enter treatment under pressure from others, rather than voluntarily accepting the need for treatment.

Treatment options include:

    Cognitive behavioral therapy CBT has been found to be effective.
Self-help support groups, such as Gamblers Anonymous. Gamblers Anonymous is a 12-step program similar to Alcoholics Anonymous. Principles related to stopping the habit abstinence for other types of addiction, such as substance abuse and alcohol dependence, can also be helpful in the treatment of pathological gambling.
A few studies have been done on medications for the treatment of pathological gambling. Early results suggest that antidepressants and opioid antagonists naltrexone may help treat the symptoms of pathological gambling. However, it is not yet clear which people will respond to medications.

Like alcohol or drug addiction, pathological gambling is a chronic disorder that tends to get worse without treatment. Even with treatment, it's common to start gambling again relapse. However, people with pathological gambling can do very well with the right treatment.

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Pachinko

Pachinko is a Japanese gaming device. A pachinko machine resembles a vertical pinball machine, but has no flippers and uses a large number of small balls. The player fires balls into the machine, which then cascade down through a dense forest of pins. If the balls go into certain locations, sequences of events are triggered that result in more balls being released; these balls can then be exchanged for prizes. Pachinko machines were originally strictly mechanical, but modern ones have incorporated extensive electronics, becoming similar to video slot machines.

The machines are widespread in establishments called parlors, which feature a number of slot machines; hence, they operate and look similar to casinos. Modern pachinko machines are highly customizable, keeping enthusiasts continuously entertained. Because gambling for cash is illegal in Japan, balls won cannot be exchanged directly for cash in the parlor; instead the balls are exchanged for tokens, which are then taken outside and exchanged for cash at a place nominally separate from the parlor and possibly run by organized crime.

As an indicator of the popularity of pachinko in Japan, Japanese government estimates of the annual turnover of the pachinko industry are in the region of 29 trillion yen. To put this in perspective, this is about twice the annual turnover of Japan's automobile industry, and approximately equivalent to the estimated annual turnover of the global narcotics trade.

Pachinko parlors are known for tweaking their machines to maximize their profits without intimidating customers, which means that most machines have different payout settings than what their manufacturers claim. The Japanese police can tolerate such manipulation as long as it happens outside of business hours; generally, those that cause a loss to the player are found in greater numbers.

Resetting of machines every day before opening hours is a feature of all parlors, because of the strict enforcement of closing times implying some players having to give up their machines when they hit a string of jackpots. Those whose machines are in payout mode at this time are allowed to collect their balls for the duration of the payout. Some parlors allow members to hold a particular machine across operating sessions. Timing is another factor in determining how parlors set their machines: holidays, when many people play pachinko, are favorable because many play it for leisure and the parlors are keen to attract them to come back for more. Weekends are unfavorable because the majority of players have only this time to play.

The layout of the different setting machines is a psychological method of attracting players; machines near the entrance are usually set at a high payout rate. When people walk by the parlor and see players at those machines with a large number of balls, they are more inclined to go inside and play the other machines even though they are at lower settings. For this purpose, many parlors employ "sakuras" to sit at these machines and emulate players winning a large number of balls; they are required to return these balls to the parlor free of charge minus their wages.