A gambling addiction is not a sure bet, but there are warning signs to watch for with online sports betting

Host Amber Smith: Upstate Medical University in Syracuse, New York, invites you to be The Informed Patient with the podcast that features experts from Central New York's only academic medical center. I'm your host, Amber Smith. During the first three months that online sports betting has been allowed in New York state, cumulative bets have totaled more than $4 billion.

Mobile sports wagering, it turns out, is very popular, but is there a downside to gambling becoming such an easy recreational activity? I'm talking about this with Dr. Sunny Aslam. He's a psychiatrist at Upstate who specializes in addiction medicine.

Welcome back to "The Informed Patient," Dr. Aslam.

Sunny Aslam, MD: Thanks for having me.

Host Amber Smith: Now sports betting is legal in 30 states and the District of Columbia, and in New York state, there are nine mobile sports betting operators, including FanDuel and DraftKings, that allow New Yorkers to place bets from their mobile phones.

Do those of you who work in addiction medicine expect to see an increase in problem gambling?

Sunny Aslam, MD: We do, of course. I think it's inevitable. The interesting thing that came up most recently for me clinically, was someone talking about cryptocurrency, someone who struggles with alcohol use and was feeling overwhelmed at their work, but didn't quite put the two together and it seemed like the conversation focused more on cryptocurrency then than the drinking.

But it's interesting to see how things are changing rapidly, right? With the betting, with cryptocurrency and our economy as well. You can kind of think of it as a casino in some ways, the way investments work. And, this is, an area that's broad-ranging

Host Amber Smith: Is all gambling "problem" gambling?

Sunny Aslam, MD: No. One of the ways I think about gambling is analogous to alcohol, that many people can have a glass of wine or go out to a bar, and it doesn't cause them any distress at all. They do this in groups or as a couple with friends. It's a social event. They set limits around their drinking, and they do it responsibly, with no harms at all. But there are a small group of people with alcohol, just like with gambling, who will be harmed by their repeated use.

Host Amber Smith: Well, let's talk about the potential harms of gambling, aside from losing a lot of money. Right? What are the other harms?

Sunny Aslam, MD: So it can causes significant distress, in, we would say, in work and love. As, well, the way we look at life in psychiatry. Does it affect your job and does it affect your relationships, particularly to those closest to you?

And so, it's true that 50% of people with gambling use disorder, have a mood disorder such as major depression, 40% can have an anxiety disorder, 32%, attempt suicide or have suicidal thinking, and half of those will actually attempt suicide. So you can see there's a wide range of problems associated with gambling use disorder.

And about half of people with gambling use disorder have an alcohol or a tobaccoaddiction as well, or both.

Host Amber Smith: Lottery tickets and racetracks. Those are older forms of betting that have been around for years. Is there any noticeable difference in terms of the amount of time or money spent or the addictive hold between these in-person forms of gambling and the online gambling?

Sunny Aslam, MD: Our data shows that different groups of people and people with different incomes and socioeconomic status are drawn to different types of gambling. In particular, of course, our concern with online betting is that there's virtual anonymity, and the accessibility is around the clock.

There are other limits with more traditional gambling that are built in, although, casinos do interesting things, like there are no clocks around, there are no windows for sunlight. They fight tooth and nail to keep smoking, inhaling tobacco, in the casinos. All of these things contribute to their profits and have been shown to be very effective in contributing to their profits.So there are many different factors that can play into this.

Host Amber Smith: You mentioned, with the in-person gambling, sort of the side benefit maybe of socializing with people, but if you're doing this mobile stuff, you're not really socializing with people, are you?

Sunny Aslam, MD: You may not be. You might be in a group, but it seems unlikely. It seems like something that people would do more likely alone, and the two different paths that we hear about from patients and that have been studied, particularly around what happens in the brain, is gambling for a rush or gambling for an escape.

And so, online can be both.It taps into both those areas.

Host Amber Smith: Can people become physically addicted to gambling the way someone might be addicted to a particular drug, or is gambling a psychological addiction, potentially?

Sunny Aslam, MD: Yeah. So this is where there's been a change in our field, to some extent.

So gambling use disorder, a gambling disorder, was moved into the category from impulsive disorders to be treated with substance use disorders, with other addictions, essentially, because there's increasing recognition of the chemistry in the brain, the wiring in the brain, is virtually identical to what happens with, for example, you inhale a cigarette, it activates the seeking system in the brain, and it seems to be virtually indistinguishable for those with gambling use disorder.

Once you have become addicted to gambling, there's repeated harm. That part of the brain appears to be changed for people, and it is something that will be with them forever.

Host Amber Smith: This is Upstate's "The Informed Patient" podcast. I'm your host, Amber Smith, talking with psychiatrist Sunny Aslam on the subject of gambling addiction.

How does a person, or someone who cares about them, determine whether they're addicted to these mobile sports betting apps?

Sunny Aslam, MD: Can I come back to that point about work and love? If it's affecting your job, if it's affecting your relationship, then there probably is already. If you've noticed your partner's gone for hours, there's money missing, there are those kinds of red flags, and you bring it up, and you don't get adequate answers, that's the sign of a problem.And those are often the screening questions around gambling disorders, If you tried to repeatedly make up for losses and have you lied to loved ones about how often or how much you bet?

So when those relationships are being affected, there's a clear sign of a problem.

Host Amber Smith: Are there strategies to make sure gambling doesn't become a problem?

Sunny Aslam, MD: Yes. Unfortunately the difficulty is, the industry is built against you. The industry knows where its profit centers are, and those are in people with other addiction and mood disorders. But there are ways to have an accountability partner. Don't do this alone, set a limit around how much time and how much money you'd like to spend, and then, if you notice you're going over those limits, maybe it's time to ask for help. And there's a number of ways of getting help.

And that can mean coming to the addiction medicine clinic for a consultation or going to a 12-step group; Gamblers Anonymous is very popular, and there's good evidence that 12-steps work, and psychotherapy, and then the treatment of comorbid disorders can be helpful as well.

Host Amber Smith: So if someone already knows they have a problem with, let's say alcohol, are they more likely to develop a problem if they start with the mobile sports betting?

Sunny Aslam, MD: That's right. So, as I mentioned, half the people with gambling disorder have an alcohol or tobacco addiction already, so we know that those are risk factors. Being young and male is a risk factor as well for gambling disorder. If you already have a mood or anxiety disorder, you're at particular risk as well, so there's a number of these risk factors that people should keep in mind before they enter into online betting or head to the casino.

Host Amber Smith: Now someone who suspects they have a problem: If the person wants help, is the recommended strategy to quit entirely, cold turkey, so to speak, or to just cut back and try to manage?

Sunny Aslam, MD: Of course, each case is different. It's very hard to say, and we have limited amounts of research. This has not been an area that has been a focus of research during an opioid epidemic, and actually tobacco kills more people than all other addictions combined, so there's a big focus on alcohol use disorder, which kills 95,000 people a year.

Gambling's prevalence is about 1%. We just don't know as much. But what we do know, we can draw some conclusions from other areas, such as alcohol use disorder. Actually, most people who recover from alcohol problems, they do it on their own. That's interesting; you know, as a psychiatrist, I'd love to tell you that I cure all kinds of people of alcoholism. It's not true.

So we know there's certain groups of people who are able to work through their problems with gambling or alcohol, etc., but we recommend, if you feel you need the help, ask for it. There tend to be barriers to treatment, but 12-step groups, for example, don't cost a thing. You can't beat the price; they're available. And we're also available, as well as other treatment centers in town, to treat people, and it doesn't hurt to come in for a one-time consultation.

I would think if someone was relatively well adjusted, it wouldn't be a problem to come in. I worry about the ones who don't come in; denial is a significant part of addiction, and often people feel like I'm just going to win big on the next one, but they can do that for hours, and it can be financially disastrous and emotionally disastrous.

Host Amber Smith: Now, some people see mobile sports betting as a way purely to make money. So I wonder if there's research that shows yet whether the person who studies and pores over statistics before placing bets is any more or less likely to become addicted than the person who approaches betting like it's a game, and they're just going to bet on their team?

Sunny Aslam, MD: I certainly worry more about someone who thinks they're going to crack the code of a multibillion-dollar industry. That level of grandiosity is going to tend to lead to a large loss and a large fall. So I do worry more about those than someone who's more humble, just thinking, "I'm going to go in, I'm going to spend my 500 today, and that's it. I'm probably going to lose it." That's much healthier thinking, being humble, as in most areas of life, right? If we're more humble, we tend to have a more reasonable outcome.

Host Amber Smith: Do you see similarities between mobile sports betting and online gaming?

Sunny Aslam, MD: There are similarities. Harm from repeated use is how we define addiction in our clinic. And people can get lost or dissociate off into a world where they have little face-to-face contact. And this of course was worsened through the pandemic, where there was this phenomenon where people may have only been seeing other people through online means, through Zoom meetings or their gaming, so in some ways that might've been healthy, but for others, it enabled and helped them avoid the contact with other human beings that they may have already tended towards. And so for those people, that can plunge them deeper into anxiety and worsen their mood and make it harder for when they do have face-to-face contact with people, to overcome the intense feelings of anxiety, shyness or struggles with connecting with people face to face.

Host Amber Smith: There are some positive connections through these gaming communities,so how do you maintain that but also minimize the threat of getting sucked into it too far and spending too much time at it?

Sunny Aslam, MD: I see that as similar to strategies for gambling as well: setting limits, having an accountability partner, doing it with a friend or a relative, and just keeping an eye on the number of hours.

A lot of the psychotherapy we do is focused around people's self-care. And so when someone comes in and explains their seven, eight, 10 to 12 hours a day staring at a screen, they're going to tend to not have the best physical health. Maybe their jobs or their other relationships are causing them to feel anxious and they haven't put it together, but these are the kinds of connections we try to help people make in psychotherapy, is, you're feeling hopelessly, anxious, and depressed, you haven't had contact with humans much in the past few months, what's your thinking about that? And try to help people put some of those ideas together and then see what they want to do about it, if anything.

Host Amber Smith: Do the online games for kids, because a lot of them appeal to young kids, do you think it prepares them or grooms them to grow up into online sports bettors?

Sunny Aslam, MD: I think, unfortunately, in a lot of for-profit businesses, they're there to make a profit. And we know this through deep study of particularly the alcohol and tobacco industry, as they, in their documents, they talk about profit centers and they know that capturing young brains gives you a profit center for life.It's not as interesting to them to focus on the elderly because then you're getting a customer for 10, 20, 30 years. If you get teenagers, you're getting a customer for 60, 70 years. And so alcohol, tobacco, those industries have learned from that.

And then you see other industries doing very similar things, cannabis and gambling. If you can make something sexy to teenagers and get their attention with bubblegum vaping flavors and sexy-looking devices, it's good for business.

And unfortunately for our patients, for people who are more vulnerable, people who already have an addiction, who already have a, psychiatric disorder, they're particularly vulnerable, and they're targeted by these companies.

Host Amber Smith: Well, Dr. Aslam, you've given us some good information and lots to think about with mobile sports betting, so I appreciate you making time for this interview.

Sunny Aslam, MD: Thank you.

Host Amber Smith: My guest has been Dr. Sunny Aslam, a psychiatrist who specializes in addiction medicine at Upstate. "The Informed Patient" is a podcast covering health, science and medicine brought to you by Upstate Medical University in Syracuse, New York, and produced by Jim Howe. Find our archive of previous episodes at upstate.edu/informed.

This is your host, Amber Smith, thanking you for listening.