LAS VEGAS — Downstairs was a sensory overload: Roulette wheels spun, slot-machine chimes rang, and dealers hurried to scoop up stacks of casino chips resting in front of busted blackjack hands. Many gamblers held a drink in one hand and a cigarette in the other.
It was perhaps a strange setting for a conference about substance use treatment. But there may have been no better venue than the Planet Hollywood Resort & Casino for the stark warning being offered in a ballroom upstairs: America’s addiction professionals are ignoring gambling.
The session on gambling constituted a sharp pivot from the rest of the conference, put on by the American Association for the Treatment of Opioid Dependence, an advocacy group representing the nation’s more than 2,000 methadone clinics. But it underscored the growing unease across the public health world about harmful gambling behavior, which some surveys show has increased by 30% in the last six years.
“Why don’t we consider gambling when we’re talking about opioids?” asked Andrew Schreier, a director of clinical services for Community Medical Services, a chain of opioid treatment programs. “There’s actually a lot of information out there about gambling in relation to opioid use. We often don’t talk about it.”
While Schreier’s appeal to addiction professionals came steps from a casino floor, perhaps more importantly, it came amid a surge in access to gambling — or “gaming,” as the industry refers to itself — and, as a result, gambling addiction. Since a 2018 Supreme Court ruling struck down a de facto ban on sports betting, roughly three dozen states have legalized wagering on sports. Twenty-nine states allow gamblers to place bets online, effectively allowing users to risk the balance of their bank accounts from their smartphone.
Schreier’s presentation reflected a growing unease among addiction-treatment providers that many of their patients, even as they seek treatment for a substance use disorder, are also engaging in potentially dangerous gambling behavior.
Also concerning, experts say, are gambling’s lightning-fast spread throughout the country and the immense harms it can cause. Americans bet nearly $120 billion on sports in 2023, according to the American Gaming Association.
It is also a known contributor to suicide or suicidal ideation. Many people seeking help from gambling hotlines report suicidal ideation, and studies from multiple countries show that people who exhibit harmful gambling behavior consider or die of suicide at many times the rate of the general population. In 2017, a World Health Organization document classified gambling-related harms as “substantially higher” than those associated with drug use.
“It certainly is something that is worthy of a national alarm,” said Petros Levounis, the immediate past president of the American Psychiatric Association. “Access is just so easy: Everything is just a click or a swipe away, and you can lose a lot of money so fast and so easily.”
Psychiatry, addiction medicine, and public health more broadly are finally becoming more attuned to the problem, Levounis added, but “there’s a lot of distance to be traveled still.”
As gambling continues to become more common, and as the long-running U.S. drug crisis continues, it’s likely that addiction treatment providers will be increasingly called upon to help treat both conditions at once. Even before the post-2018 explosion in digital sports betting, links between gambling and substance use were well documented: Those with a history of substance use are known to be at higher risk for gambling disorder, and vice versa.
Now, nearly 1 in 5 American adults have an online sports-betting account, and according to the Substance Abuse and Mental Health Services Administration, a roughly equivalent number met the criteria for a substance use disorder.
The parallels between gambling and other public health crises related to addiction, like tobacco and the current drug overdose crisis, are clear — both in terms of largely unregulated companies aggressively marketing known harmful products, and in terms of neurobiology.
“The more we study gambling, and the more we study substance use disorders, the more we appreciate that they go through very similar paths in the brain,” Levounis said. “The way one gets addicted to tobacco, heroin, alcohol, cocaine, is quite similar to the way that one gets addicted to gambling or sex or the internet.”
Despite the gambling industry’s immense reach, no federal agency is tasked with regulating it, and no federal funds are specifically earmarked for gambling research.
“The public health concern here is that you have a wild west environment with no safety net and no guardrails,” Rep. Paul Tonko (D-N.Y.), said in an interview. “You have an extremely vulnerable audience that’s getting bombarded with this advertising that is largely predatory in nature, with big gambling companies offering hundreds of thousands of dollars’ worth of free or bonus bets.”
Tonko, who has long advocated for high-quality treatment for substance use disorders, is one of few voices in Washington who has sought to warn the public about what he views as a “dangerous situation” with regard to digital sports betting.
In 2023, he introduced legislation that would have largely banned advertising for online sportsbooks. Earlier this year, he announced a framework for a more targeted proposal that would prohibit advertising during sporting events and common tactics like sign-up bonuses, as well as ban the use of artificial intelligence to track user behavior and offer individualized promotions meant to keep them gambling.
“We really looked at the advertising component and mimicked what was done in the ’60s to address a substance like tobacco,” Tonko said. “We need to address this with a high order of science and public health concern.”
Despite the problem’s immense scope, some addiction treatment professionals may not be equipped to add gambling to their repertoire: In one survey Schreier cited, 82% of addiction treatment professionals said they lacked resources to share with a patient whose gambling was cause for concern.
At one point, he appealed to the audience for examples of how other clinicians respond when patients present with signs of gambling addiction. He was met largely with head shakes.
“That’s OK — that happens a lot,” he said. “I hear that all the time: That we’re not really doing anything.”