The National Council on Problem Gambling held its 24th National Conference this summer in Oregon. Compulsive gambling is another form of addiction, not unlike drug abuse. Compounding the problem for the addict is the fact that it is legal, in fact a source of significant revenue for 48 states in the US. Bill Cohen joins Darryl Inaba in a discussion of compulsive gambling, comparisons with drug abuse, and the status of treatment for this particular form of addiction.
CNS: Welcome, I’m Howard LaMere here with Dr. Darryl Inaba and special guest, William Cohen, Bill Cohen, who is the co-author, along with Darryl, of “Uppers, Downers, All-arounders” and an expert on compulsive gambling. Welcome Bill!
BILL: Thank you! Glad to be here!
CNS: You recently attended a conference here in Oregon focusing on the strategies for treatment of gambling. Is that correct?
BILL: Correct. It was the 24th National Conference of the National Council on problem gambling. The strategies for treatment are way behind the curve compared to those for drug and alcohol treatment.
CNS: And where it was…
BILL: where drug treatment was 20, 30 years ago. There are not quite enough treatment facilities. There are not enough counselors and not enough states willing to put up the money for it and not enough insurance companies willing to cover treatment.
CNS: And of course, almost every state, I think, has legalized gambling, which is different than in times past where gambling was a clandestine affair for the most part other than the horse track. Now there are casinos everywhere. Not just on Indian land, but everywhere.
BILL: Well right now 48 states have legalized gambling. The biggest addicts are the state legislators who are addicted to the money gambling brings in. In Oregon, for example, about 9% of the state’s total budget comes from gambling and that works out to about 400 dollars for every man, woman and child in the state. Compare that to a state like Massachusetts where the average is almost 700 dollars even though they don’t have the poker machines like Oregon does.
CNS: But still no serious commitment to treatment when people go overboard.
BILL: Well, Oregon is…interestingly enough, at the forefront of treatment. Very few states spend any money on gambling treatment, they do spend on treatment for drugs and alcohol. Oregon must -by law, spend 1% of its total gambling revenue for gambling treatments, which I think works out to about 4 million a year. They treat about 15 – 16 hundred people a year and because there are between 80,000 to 120,000 compulsive pathological gamblers in the state, that money is handling a fraction of the problem.
CNS: Similar to the story with drugs.
BILL: Right, but even less so because people are less willing to recognize that gambling is an addiction and just as cruel as any full blown addiction. I am a certified gambling counselor and over the years I have seen people just devastate themselves and their families, even more so than because of drugs and alcohol. They say that the average alcoholic will affect, seriously affect, 7 other people and the average gambler will affect 17 other people because they borrow (money) from everybody and often don’t pay it back until they get into recovery and even then…when they go into Gamblers Anonymous- they’re an average 100,000 dollars in debt for men and 60,000 in debt for women and they’ve gambled much more than that. That’s just their debt.
CNS: Right, because that money circulates back and forth several times.
BILL: And compulsive gamblers are great “forgetters.” You know, you ask somebody, well how much did you lose? And they’ll go, “Well I went to the ATM 3 times and I think - 900 dollars”. And then when they get the overdrafts the next day, they went to the ATM 5 or 6 times, they are 2 or 3 thousand dollars in debt and they just willfully forget it.
CNS: Are drugs used in treatment the way medication is used for drug addiction?
BILL: No, in terms of treatment, they really haven’t gotten that far. They’ve found there are certain drugs that can help trigger gambling. Drugs that work on…dopamine…if they boost the level of dopamine, it seems to…for some people…increase their chances of becoming a compulsive gambler. But in terms of treatment, I would imagine some of the standard treatments might work. Antidepressants and a lot of other drugs.
DARRYL: I was very interested in the conference that Bill went to because first of all, the draft of the Diagnostic Standard Manual, DSM 5 is out – it will be released in 2013 - and the draft includes, for the first time, gambling – compulsive gambling, pathological gambling, as an addiction related disorder. They are moving it into the same classification as drugs and it is the first behavioral type of addiction that is going to be included in the section covering addictions and related disorders. It is the only one right now, although we believe that several other behavior addictions will be added by the time of publication. The reason it’s included is because the altered brain chemistry that occurs in drug addiction, seems to occur in gambling addiction. And because of that, they are looking at treatments, as Bill was talking about, that included medication. I’ve seen several reports now that…Naltrexone, the narcotic antagonist, seems to be effective in suppressing the craving that occurs in gambling as it does for other drugs and other drug addictions. So I was wondering if at this conference…because part of it was supposed to be about treatment – if they talked about any new research that warranted bringing on these drugs.
BILL: Uh, no. There were a lot of parts to the conference so it might have been addressed but I didn’t notice it. What they found is gambling is basically an upper. It’s a stimulatory thing. And when they did brain scans of gamblers, compared to cocaine and methamphetamine users, they found the same parts of the brain were affected in much the same way. It’s a stimulatory activity. It’s a binge activity, like cocaine use. Gamblers gamble until their last dollar is gone and they have no more access to money. So the guess is, in terms of treating it with drugs, that medications would be similar to those used to treat stimulant addiction – meth or cocaine addiction.
CNS: And we know there are not a whole lot of those at this point.
BILL: No, not a whole lot of drugs and not a whole lot of breaking through the denial. I gave the statistics for the number of people just in Oregon. Nationwide there are probably about 4 million addicted gamblers and that’s a substantial number.
CNS: So, what is the comparison? Do you have the numbers comparing drug addicts and compulsive gamblers?
CNS: Percentage wise?
BILL: I’m not sure. I’m not sure percentage wise. 1½ percent for pathological gamblers – again depending on who you ask. I mean, the problem with gambling is that gamblers themselves are loathe to admit that they have a problem.
DARRYL: Right now there’s about 9 to 12% of the US population who are addicted to drugs or alcohol. So that’s I guess a comparison. I don’t know if that’s what you are asking for, but both are significant numbers of people affected by the same type of changes in the brain, I think. Whether you’re a gambler or a cocaine addict.
BILL: In terms of percentages, the figure is about a percent and a half nationally, but if you add in problem gamblers, then all of a sudden that figure jumps up to 3 to 4%. In terms of alcoholism, I think it’s about 7 or 8% are considered alcoholics. So in terms of gambling, that’s a substantial number.
CNS: Now what about the crossover between drug takers and gambling?
BILL: Addiction is addiction is addiction. In Gamblers Anonymous and in various surveys they’ve found that over 50% are alcoholics too. Probably if you added other drugs in there, you would be talking 70, 75%. You throw in cigarettes; you’re probably around 85%. There is a high percentage of other drugs involved. Sometimes a person gives up an addiction – they haven’t had a drink in 10 years and then they start gambling and say “oh well this is benign, no problem here” and then they get hooked. There is a high percentage of people who stopped drinking, but say, “oh gambling is okay! It is safe”!
DARRYL: Question, Bill…did they talk about what came first? Was somebody an alcoholic and became a gambler, or was somebody a gambler and became an alcoholic or a drug addict or did it simultaneously happen at the same time?
BILL: No…to gamble you have to have money and when you’re a teenager you generally don’t have that much money. Although nowadays, more and more kids are playing cards, but most often smoking, drinking, all of those most often came first. But sometimes later on it’s hard to tell. I’ve seen people who aren’t sure if they are a meth addict who gambles to pass the time, or they’re a gambler who takes meth to stay up 24 or 48 hours. They haven’t decided that yet and you know, it’s simultaneous for a lot of them.
CNS: Well, so what are the prospects for treatment? You mentioned that it was way behind. Does it look like it’s catching up? How is the treatment scenario going?
BILL: I think it is extremely difficult because there isn’t as much…nearly as much research as there should be. It’s just starting to really build. People realize that there is a problem there and they realize…there’s a book on gambling in America that talks about the finances of gambling and that a state loses about as much money as it receives from gambling revenue, states lose in the cost of jail time, in embezzlement, in work time loss …but it’s a hidden cost. But politicians love the idea that they can raise 9% of the budget without calling it a tax.
DARRYL: You know although it is in its infancy, it seems to me that there is a growing movement in the treatment of gambling - like food addiction in this society - it’s hard to not be tempted by gambling. The stock market is gambling. There is gambling on television, gambling sites, Texas Hold ‘Em TV and office pools and whatnot - it seems like it’s just unavoidable. But it seems like treatment is growing and one thing I’ve been sort of stimulated by, is Gamblers Anonymous. Is that working out in this state or other places around the country? Are there a growing number of meetings? Are there a growing number of people participating and that does that have the same hope and benefits it has for alcoholism and narcotic addictions and other addictions?
BILL: Well, Gamblers Anonymous uses the basic Alcoholic Anonymous 12-step program – but gamblers are somewhat less religious. The only time they invoke God, is “God, just let me win this one time and I’ll never gamble again”. And then when that’s over - its “Oh, sorry. I didn’t mean to disturb you”. But it’s, still basically the same idea, but I think denial is easier for gamblers. You ask a gambler if they have a problem and they say, “Oh, I’m not a compulsive gambler. I just have a cash flow problem.” For them to just admit that they have a problem and are a compulsive gambler is really difficult…really difficult for that to happen. And so Gamblers Anonymous is sort of growing, but boy, meetings come and go, a lot more so than with Narcotics or Alcoholics Anonymous. Some people say that about 1 out of 10 or 1 out of 20 people come back to a second or third meeting.
CNS: Pretty small percentage.
BILL: Pretty small percentage, but that doesn’t mean it’s hopeless, but rather that you have to try a number of times. It’s just too easy to be triggered by gambling because it’s everywhere – in all 48 states – so you either have to move to Hawaii or Utah.
CNS: And I just read in the news that Congress is re-thinking its ban on internet gambling. So that could become legalized and become yet another revenue source for the federal government.
BILL: Yes…a lot of it is about revenue. If you look back historically at gambling, a lot of the Ivy League colleges were financed by lotteries. Part of the American Revolution was financed by lotteries. It’s just a really big part of American history. We’ve gone through 3 phases of gambling where we’ll have gambling and then they realize it’s a problem…or there’s too much corruption and then they’ll cut it out and then they’ll start back again. The most recent wave started in the 1960’s… Nevada and Las Vegas existed before that and so did Atlantic City, but the lotteries started. I think New Hampshire had one in the 60’s and now all but 2 states have them.
CNS: Do you see where the inclusion in the DSM will impact the awareness?
DARRYL: I think it has to. I think the DSM is regarded as a research evidence based diagnostic tool that when they include something, it means that there’s a huge body of scientific evidence including research on the brain, research on brain imaging, research on brain chemistry that solidly places it as a disease or as an illness…as a form of mental illness. So, at least in the medical field, it’s certainly going to give gambling its due. It’s an actual medical illness. You know, what I’m wondering about Bill, though is that since few in the general population are problem or pathological gamblers, how difficult is it for the non-pathological gambler to understand that drive or the pathology associated with gambling. I mean, what makes a person a pathological gambler versus a normal gambler, a “normie”?
BILL: Well a lot can be explained in terms of drugs. If a person starts and they cannot stop, then that’s a sign of compulsive gambling. It’s like any other addiction and the treatment is similar. Once people start they can’t stop. They think about it or are obsessed with it all the time. Whenever they think of something to do to change their mood, they think about the gambling. They do damage… the continued use, in spite of adverse consequences, and the consequences are dire. I mean people lose their homes, lose their parent’s home. They gamble without thinking - the general public says, “oh, just don’t gamble”. I can walk away, why can’t you?”
CNS: Well, this is a fascinating topic and something that deserves a lot more attention. Thanks for coming in Bill and Darryl. We’d love to hear comments from our readers. If you have something to share or would like to comment, please get in touch.