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.
Transcript (edited):
CNS: Welcome, Im 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 states 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 dont 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 dont pay it back until they get into recovery and even then when they go into Gamblers Anonymous- theyre an average 100,000 dollars in debt for men and 60,000 in debt for women and theyve gambled much more than that. Thats 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 theyll 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 havent gotten that far. Theyve 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 its 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. Ive 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 didnt notice it. What they found is gambling is basically an upper. Its 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. Its a stimulatory activity. Its 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 thats a substantial number.
CNS: So, what is the comparison? Do you have the numbers comparing drug addicts and compulsive gamblers?
BILL: Um
CNS: Percentage wise?
BILL: Im not sure. Im 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 theres about 9 to 12% of the US population who are addicted to drugs or alcohol. So thats I guess a comparison. I dont know if thats 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 youre 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 its about 7 or 8% are considered alcoholics. So in terms of gambling, thats 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 theyve 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; youre probably around 85%. There is a high percentage of other drugs involved. Sometimes a person gives up an addiction they havent 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 youre a teenager you generally dont 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 its hard to tell. Ive seen people who arent sure if they are a meth addict who gambles to pass the time, or theyre a gambler who takes meth to stay up 24 or 48 hours. They havent decided that yet and you know, its 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 its catching up? How is the treatment scenario going?
BILL: I think it is extremely difficult because there isnt as much nearly as much research as there should be. Its just starting to really build. People realize that there is a problem there and they realize theres 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 its 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 – its 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 its just unavoidable. But it seems like treatment is growing and one thing Ive 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 Ill never gamble again. And then when thats over – its Oh, sorry. I didnt mean to disturb you. But its, 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, Im 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 doesnt mean its hopeless, but rather that you have to try a number of times. Its just too easy to be triggered by gambling because its 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. Its just a really big part of American history. Weve gone through 3 phases of gambling where well have gambling and then they realize its a problem or theres too much corruption and then theyll cut it out and then theyll start back again. The most recent wave started in the 1960s Nevada and Las Vegas existed before that and so did Atlantic City, but the lotteries started. I think New Hampshire had one in the 60s 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 theres 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, its certainly going to give gambling its due. Its an actual medical illness. You know, what Im 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 thats a sign of compulsive gambling. Its like any other addiction and the treatment is similar. Once people start they cant 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 parents home. They gamble without thinking – the general public says, oh, just dont gamble. I can walk away, why cant you?
CNS: Well, this is a fascinating topic and something that deserves a lot more attention. Thanks for coming in Bill and Darryl. Wed love to hear comments from our readers. If you have something to share or would like to comment, please get in touch.