On a recent Sunday morning in Los Angeles, 10 members of Gamblers Anonymous gathered in a park for their regular meeting. After, they shared advice for how physicians can best help patients with problem gambling.
"If a patient talks about financial distress, spouse issues, physical issues, or has blood pressure issues, suspect gambling," one woman said. Another said, if a physician asks about gambling and the patient says, "Just a little," chances are that person is an active gambler.
The bottom line: None of the people -- who spoke for themselves and not on behalf of Gamblers Anonymous -- said they had been asked by their doctors about gambling issues. All said they would welcome such questions.
Gambling is on the rise, and gambling disorder is now recognized in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5). The condition is viewed as similar to substance-related disorders in its clinical expression, brain origin, comorbidity, physiology, and treatment.
Primary care physicians (PCPs), more than any of their colleagues, are likely to encounter a patient with an undetected gambling disorder, according to experts, as it often intertwines with physical and mental health concerns. Those conditions bring the patient to their clinicians, although the patients may not link those issues with their gambling. The physicians may not either.
Few PCPs broach the topic. "I would say the majority of physicians do not screen for it," said Brian K. Unwin, MD, FAAFP, AGSF, a family medicine physician and geriatrician at the Carilion Center for Healthy Aging and professor at the Virginia Tech Carilion School of Medicine, in Roanoke, Virginia.
The clinician who does take steps to screen for the problem is "exceptionally rare," said Timothy W. Fong, MD, clinical professor of psychiatry at the University of California, Los Angeles (UCLA) and co-director of the UCLA Gambling Studies Program. Launched in 2005, the program conducts research, provides prevention and treatment services, and offers training to healthcare providers and the community.
A Las Vegas physician said colleagues in her area are likewise largely unaware, despite the strong connection with the city and gaming. "I do not think most primary care physicians are routinely asking about gambling," said Maureen Strohm, MD, president of the Nevada Society of Addiction Medicine. Strohm also directs the addiction medicine fellowship at HCA Sunrise Health GME Consortium at Southern Hills Hospital & Medical Center in Las Vegas and cares for patients with substance abuse issues.
But physicians should look for gambling issues, she said, especially in those with known substance abuse disorders. "We encourage incorporation of gambling as another question in comprehensive assessment of patients, since it's rarely an isolated issue in our treatment settings," Strohm said.
Why a rise in gambling? Its reputation, for one thing. "It used to be, if you enjoyed gambling, you were viewed as, what -- a person of vice, a person of sin," Fong said. "That's completely changed. Engaging in gambling is more accepted -- and not just accepted but normalized and even glamorized. In some circles, if you don't gamble, it's like, 'What is wrong with you?'"
Opportunities to gamble have increased, including a boom in mobile sports betting. Sports betting online, in person, or both now is legal in 39 states and the District of Columbia. The rate of gambling problems among sports bettors is at least twice as high as that for other gamblers, the National Council on Problem Gambling found. As Fong puts it: "The casino comes to you."
With the rise in opportunities to bet has come an increase in gambling-related disorders. Statistics vary greatly, but Unwin cites a meta-analysis published in 2023 that found moderate-risk or at-risk gambling affects 2.4% of the adult population and pathologic or problem gambling affects 1.29%. He first noticed problem gambling in young soldiers when he was a military doctor and published on it in 2000.
However, the percentage of people with gambling issues seeking care in PCPs' offices is much higher, probably from 5% to 16%, research has found. "When you survey people who go to the primary care physicians, the number [with a gambling issue] could be as high as 10%-15% of those going for any medical reason," Fong said. "Many times, their stories are hidden."
In November, The Lancet Public Health Commission said it views problem gambling as an expanding public health threat.
"In a perfect world, it would be great to ask all patients" about gambling issues, Unwin said. A more realistic approach, given clinical workloads, is to be alert to the possibility, especially in patients with depression or substance abuse, which often accompany gambling issues.
Learn to look at patterns, Unwin said. "If a patient has had impulsivity issues, is a young male, has had depression and alcohol issues, let's look and see what else is going on," he said. Other red flags include anyone with an active mental health problem or with a family history of known gambling problems, Fong said.
Some personality traits are linked with a higher likelihood of gambling issues, Fong said, including highly impulsive behavior and risk-taking behavior. Many problem gamblers are "not very good with loss aversion. They lose a bunch and shrug it off and go back the next day," he noted.
Often, however, the clues are not obvious. Unwin remembers caring for an older couple, and the wife set up an appointment with him -- not to talk about her health but to discuss his gambling. "My husband has spent us into debt," she said. Unwin recalled being completely surprised.
The situation illustrates the flaw in the stereotypical profile of a problem. "In our mind's eye, it's often an older White male who talks loudly, is perhaps counterculture," Fong said. But he often sees young and older people from all cultures and all economic levels struggling with gambling: "Like other forms of addiction, it cuts across all demographics."
Many physicians struggle to understand the attraction of gambling, Fong said. They ask: "How can you be addicted to a behavior? Why can't you just stop?" He tells them: "If people could do that, they would not have a biological psychiatric disorder," which is what gambling disorder is.
The urge to gamble can be so strong, "You can't think of anything else," Fong said. "It screws up your day." Gamblers say they're after the "action," the euphoric state similar to the highs produced from some drugs. Compared with recreational gamblers, problem gamblers rely more on long-term learning than short-term reward?, and so are less able to learn from their losses in the immediate past, research by Fong and others found.
One in five problem gamblers seeks help, and 1 in 25 with a moderate-risk habit do so, Unwin said, citing a 2022 study.
To identify concerning behaviors, physicians can turn to two brief screeners that take just minutes:
"People tend to be pretty honest with their doctor when asked about gambling," Fong said. "Even the act of asking is enough to get people to start thinking."
To meet the DSM-5 criteria for gambling disorder, patients must exhibit at least four or more concerning behaviors in the previous 12 months.
For available treatments, "our toolbox is growing," Fong said. "Psychotherapy probably works best," including cognitive behavioral therapy and relapse prevention approaches. "Twelve-step programs work very well," Fong added.
Medications used for alcohol use disorder, such as naltrexone, an opioid antagonist, are prescribed for gambling disorder, with some success, he said. Often, developing a positive therapeutic relationship with a person who does not judge them is enough to change behavior, Fong said.
To provide treatment and other services, the UCLA program collaborates with the state Office of Problem Gambling. "We know that at least 70% of our patients who stay in treatment and participate in treatment make really meaningful gains and improvement in some part of their lives," Fong said. "They do gamble less; they do gamble with less money.
Fong tells gamblers seeking help: "My goal is to reduce the harm related to your gambling." In working with patients, he identifies forms that are most problematic and those less likely to cause problems. For some, sports betting may be an issue, but going to Las Vegas a few times a year to play the slots may not generate harm for them. Many patients still gamble, he said, but have a better quality of life if they focus on health and wellness.
"Abstinence is just one domain," Fong said. The others -- home, health, self-care, a sense of purpose, community -- are important, too. He helps patients to focus on those."
Of all the addictions, gambling is one physicians are largely unaware of, Fong said. "And the patients have something that can be treated."
Unwin, Strohm, and Fong reported no relevant financial disclosures. Physicians can attend open meetings of Gamblers Anonymous to find out more. Members of the group are available to speak to clinicians.