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Super Bowl Casts Spotlight on Gambling Disorder

By Shelly Reese, January 30, 2014 – Medscape Business of Medicine

Huge Amounts Bet on the Super Bowl

Last year, football fans in Nevada bet a whopping $99 million on the Super Bowl. Gambling is legal there, but those bets are only the tip of the iceberg.

The Super Bowl, which this year will be held in New Jersey on February 2, is arguably the biggest 1-day betting event in the world, with fans wagering on everything from the winner and point spread to the length of the National Anthem. All told, industry watchers estimate that some 200 million people will bet more than $10 billion on this year’s event in legal and illegal venues.

For most of those bettors, the wagering amounts to added excitement and a few dollars one way or another. But the big day is far from benign for the estimated 6 million Americans with gambling disorder. For people addicted to gambling, the Super Bowl is a siren’s song: a desperate chance to get ahead or dig out of a hole they’ve already dug. It’s a tantalizing opportunity to feed a habit that can lead to financial ruin, criminal activity, destroyed relationships, and health problems.

Although gambling addiction is a chronic condition that can contribute to myriad health problems, including depression, substance abuse, ulcers, angina, and hypertension, it generally doesn’t attract a lot of attention from the healthcare community. But physicians who are concerned with treating the whole patient may want to reconsider that oversight.

“The biggest misconception about gambling addiction is that it’s not an addiction at all, that it’s not a disease but a financial or a moral problem and not a condition for the medical community,” says Keith Whyte, Executive Director of the National Council on Problem Gambling (NCPG). “Those were the same attitudes people had about substance abuse 30 years ago.”

What Is Gambling Disorder?
Gambling disorder — also called “problem gambling,” “pathological gambling,” “compulsive gambling,” and “gambling addiction” — has been recognized as a health condition only since 1980, when it was first included in the Diagnostic and Statistical Manual of Mental Disorders (DSM). In recent years, the condition was classified as an impulse control disorder (ICD) not elsewhere categorized, along with such conditions as pyromania and kleptomania.

However, recent research, including imaging studies and neurochemical tests, strongly suggest that gambling triggers a reward stimulus in the brains of problem gamblers not unlike that experienced by individuals addicted to substances. In addition, problem gamblers often contend with substance abuse issues. Consequently, the DSM-5 last year reclassified gambling disorder as a behavioral addiction.

Patients are diagnosed with gambling disorder if they exhibit at least 4 of 9 behaviors in the previous 12 months. Behaviors include a need to gamble with increasing amounts of money to achieve the desired excitement; restlessness or irritability when attempting to cut down or stop gambling; and repeated, unsuccessful attempts to control or stop gambling.

The Hidden Addiction
Whereas advocates such as Whyte hope the “addiction” label will help the public and physicians better understand the condition, others, such as Tom Broffman, a social work professor and researcher at Eastern Connecticut State University, are less optimistic. “The DSM is a book that sits on people’s shelves,” Broffman says. “I don’t see that much is going to change unless we get a chance to train people to screen for gambling disorder. For me, it starts with screening and asking the right questions.”

Whether or not the new classification raises awareness, experts say, the point that should draw clinicians’ attention is the growing number of patients struggling with gambling problems. Last year, people placed 313,000 calls to the NCPG hotline (1-800-522-4700), a number that has been steadily increasing at a rate of 10% per year for the past decade, Whyte says.

The ubiquitous nature of gambling is a major force driving the increase. Once associated with weekly poker games and casino hot spots, gambling is now pervasive. Forty-three states, the District of Columbia, Puerto Rico, and the US Virgin Islands have lotteries, and 39 states allow some form of legalized electronic gaming — including traditional slot machines, video poker, and bingo — at Indian casinos, commercial casinos, racetracks, or other establishments.

And the omnipresent Internet has made electronic gambling, which is illegal in most places, available on demand. The NCPG estimates that by 2018, 100 million people will have a gambling account on their mobile phones.

“In 1970, only about 60% of Americans reported placing a bet in the past year, and those who did so were overwhelmingly male,” says Whyte. “Today, about 75% of people report that they’ve placed a bet, and it’s roughly 55% male/45% female. The population is growing, so you have more people gambling, more gambling going on, and more women gambling. It’s a very significant cultural and demographic shift.”

Only a fraction of those individuals are likely to have gambling problems: In any given year, the NCPG estimates that 2%-3% of the adult population experience a gambling problem. However, those with gambling disorder often also have a variety of physical and psychological problems, says Christopher Welsh, MD, Medical Director for the Center of Excellence on Problem Gambling at the University of Maryland School of Medicine.

Compulsive gamblers suffer a higher rate of ulcers, hypertension, and other stress-related medical conditions than the general population, he says, and are more likely to have disrupted sleep patterns. They are more likely to smoke and abuse alcohol and have a much higher rate of depression and anxiety. Between 17% and 24% of gambling addicts have attempted suicide. Unfortunately, gambling disorder is hard to detect. You can’t smell it on someone’s breath, and the physical symptoms associated with it are easily attributed to other causes and conditions. Screening for it can be difficult.

“It’s a much harder behavior to screen for than smoking or drinking,” Dr. Welsh says. “A lot of people who play the lottery don’t even think of it as gambling,” he says, even if they play routinely with money they can’t afford to lose.

Finally, although many gambling addicts — like substance abusers — are able to curb their addiction without professional help, those seeking support may have a harder time finding programs to meet their needs. Gamblers Anonymous meetings aren’t nearly as ubiquitous as Alcoholics Anonymous meetings, and states provide far less treatment money for gambling addiction than they do for substance abuse. A 2010 survey conducted by the Association of Problem Gambling Service Administrators found that substance abuse treatment programs received 674 times more funding than gambling treatment programs.

What’s the Primary Care Physician’s Role?
Given their regular and long-term contact with patients, primary care physicians can be instrumental in helping patients with gambling problems access treatment, experts say. But they’re up against a challenging adversary: time.

In a world where doctors are being asked to screen for an ever-expanding array of conditions, most simply don’t have time to delve into detailed questions relating to gambling. But advocates say even small steps can help.
Hanging an educational poster about problem gambling in the waiting area or the examination room may prompt a conversation and can provide a patient with a hotline they can call for help, says Nancy M. Petry, PhD, a psychologist at the University of Connecticut School of Medicine, who helped update the DSM.

“Gambling affects a relatively small percentage of the population,” she notes. “It may not make sense to screen everybody who walks through the door, but if a doctor is treating a high-risk population, asking just 1 or 2 questions about gambling can help.” Vulnerable groups include adolescents and young adults, Asian Americans, and recent immigrants, says Marc N. Potenza, MD, PhD, director of the Yale Center of Excellence in Gambling Research.

Whyte recommends doctors ask adult patients 3 simple questions:
• Do you gamble?
• If so, have you ever lied about how much you gamble?
• If so, have you ever felt the need to bet more and more money?

If a patient answers “yes” to either of the last 2 questions, Whyte suggests that the doctor refer the patient to a therapist experienced in treating gambling problems or provide them with the number for the NCPG hotline (1-800-522-4700), where they can find self-help resources and counselors in their area.

Gambling treatment helps people develop coping and refusal skills and address the underlying issues that lead them to gamble, and often includes cognitive-behavioral therapy and participation in a 12-step program. Although the US Food and Drug Administration hasn’t indicated any pharmacologic treatments for gambling addiction, Dr. Potenza notes that selective serotonin reuptake inhibitors and opioid receptor antagonists, which target reward pathways in the brain, may benefit some patients with gambling addiction.

Whyte acknowledges that asking even a few questions eats up precious time but notes that gambling, like diabetes, is a chronic condition. “If you don’t want these patients to keep coming back, you’ve got to ask the initial questions.”