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Addiction medicine physician Safina Adatia discusses her article, “Why gambling addiction is America’s next health crisis.” She warns that following the Supreme Court’s 2018 ruling to overturn sports gambling bans, the U.S. is facing a potential epidemic with tens of millions at risk. Safina explains that unlike substance use disorders, problem gambling lacks sufficient research, effective treatments, and public health infrastructure. The conversation explores how the ease of access through smartphones and ubiquitous, predatory marketing campaigns are fueling what she calls a “runaway train,” with data suggesting a widespread issue, particularly among young people. Safina argues for a multi-layered clinical approach combining therapy and medication, similar to models for opioid use disorder, and calls for urgent legislative action. She advocates for Congress to fund research, for lawmakers to curb advertising like they did for tobacco, and for a surgeon general’s warning on gambling platforms to protect the public from this avoidable crisis.

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Transcript

Kevin Pho: Hi, and welcome to the show. Subscribe at KevinMD.com/podcast. Today we welcome Safina Adatia. She’s an addiction medicine physician. Today’s KevinMD article is “Why gambling addiction is America’s next health crisis.” Safina, welcome to the show.

Safina Adatia: Thank you very much for having me.

Kevin Pho: All right, so let’s briefly share your story and talk about this KevinMD article that you wrote for us today.

Safina Adatia: Yeah, so my name’s Safina. I’m originally from Canada. I trained at McGill University. I did family medicine, and then I came to Boston for an addiction medicine fellowship. It was something that was a passion of mine, and now I work as an addiction doctor. And something that I noticed just being in Boston, which is such a sports-centered city, is sports betting. Ads are literally so pervasive. My partner, my fiance, who is a Boston native, I asked him about it. He’s a big sports fan, and he was like, “Yeah, betting apps and ads and everything is just so pervasive.”

And I was like, “We have to talk about this,” because even in my fellowship, behavioral addictions… we learn a lot about addictions for substances like alcohol, for opioids, for cocaine, stimulants, and things like that. But behavioral addictions like gambling are not something that’s as much covered. And so I think it’s just going to become such a pervasive issue, and I really wanted to look into it, and lo and behold, I was right. This article came to be basically from that standpoint.

Kevin Pho: All right, so let’s start with the Supreme Court’s 2018 ruling that kind of set what you said, this runaway train, in motion. So talk about that decision and what did that start?

Safina Adatia: So that decision basically opened up sports betting as legal. Each individual state has determined its own laws around whether you can bet online, in person, and things like that. So about 39 states, is my understanding, have sports betting as legal. The states vary on who can go in person and who can do it online, but it’s not hard to get around the rules for betting online. And so it’s just become what was a hundred-million-dollar industry or a four-hundred-million-dollar industry has now become a multi-billion-dollar industry. It’s just everywhere, and the ads are everywhere. It’s just really become problematic, especially amongst the youth, I would say.

Kevin Pho: And I definitely second that. I listen to a lot of sports talk radio. I listen to a lot of sports podcasts, and almost every other ad is some type of sports gambling site. It’s just as easy as downloading an app, and it’s very, very frictionless.

Safina Adatia: Totally. They know it’s so addictive that they incentivize you. They’re like, “Bet this, and you’ll get a bonus,” or, “Join and you’ll get $25 to bet.” There are just so many ways to get hooked on it. And there’s no one monitoring at all. If you can put in fake IDs, no one’s really checking. It’s an industry that has just catapulted with very little regulation.

Kevin Pho: So talk to us more about the dangers of gambling addiction and perhaps contrast that with the other forms of addiction that physicians are familiar with.

Safina Adatia: Sure. Addiction in general, the pathways that are lightened up in your brain, the dopamine pathway, it’s all kind of the same mechanism that happens for alcohol addiction or for opioid addiction. The feeling of the high is all very similar. The consequences for gambling addiction, I would say, are just slightly different because it’s money. You’re spending a ton of money that oftentimes people don’t have, so you can get foreclosures on your homes. Again, it affects men right now more than women, just because men tend to be the target demographic for sports betting in general, as they’re the target audience for sports. But we’ve seen an increase in women’s sports bets as well; about a third of the market now is women.

In terms of the consequences of betting money, because it’s so addictive, people obviously have such financial catastrophes that can happen: losing their homes, losing their relationships. Suicide rates are quite high and associated with gambling as well, and we see that with generalized addiction too. However, gambling tends to affect anyone of any financial demographic just because you have the means to spend money. Whereas I find things like opioid use disorder or stimulant use disorder, you have more housing insecurity, environment, genetics—all of these things can play a little bit differently. I find with gambling, it really does not discriminate against your financial background and SES and things like that.

Kevin Pho: And how does gambling addiction present when you see patients in your addiction medicine clinic? What’s a typical picture of someone with a gambling addiction? How would they come to the clinic?

Safina Adatia: To be honest, we don’t see a lot of people presenting with gambling addiction. That’s the main thing. A lot of people don’t recognize that they have a problem, whereas with substance use addiction, it’s just so much more pervasive where it’s recognized as a problem because the Supreme Court ruling is quite recent. Whereas alcohol and cigarettes, that was in the sixties, and now we have finally recognized that those substances are not healthy. Even then with alcohol, for example, it’s quite slow. It’s only just starting to be recognized as a dangerous substance. But if you think about the ads for smoking back in the sixties and how it was encouraged to smoke at Fenway Park—my partner was saying the ads for smoking were everywhere. And now, 60 years later, we’re able to say we finally cut down on cigarette smoking.

Gambling is so new. I mean, gambling’s been around forever, but the online gambling component is just so new that I don’t think people realize that they have problems with gambling as of yet. I don’t actually have a lot of patients who present in the clinic. In my mind, it’s someone between the age of 25 to 34; that’s the most common age group we see. It’s a young male who’s into sports, and people don’t necessarily think they have a problem because they’re sometimes betting small amounts, and they don’t realize how bad it can get, to be honest. I don’t think we’re going to see people presenting in hospitals or clinics for some time.

Kevin Pho: Now, whenever I listen to those sports betting ads, at the end, there’s always a 1-800 number, some type of hotline: “If you have a gambling problem, call this number.” Do people actually call those numbers? What happens when you do call those numbers? How effective are they?

Safina Adatia: To be honest, I haven’t actually ever tried, so I’m not 100 percent sure, but I don’t think it’s enough. A 1-800 number… I mean, there are crisis lines. It’s mandatory for them to provide some type of help and assistance, and I’m sure the lines can direct them to services that are in person. But there hasn’t been a ton out there in terms of treatment for gambling use disorder.

We have some medications, but it’s really cognitive behavioral therapy: a multimodal avenue of medication, therapy, and counseling, trying to break this pattern and cycle that takes months. It’s not going to be just calling a helpline one time that’s going to help someone out of their addiction. It’s going to take time, and we actually need significantly more research because it’s just become such a widespread issue now.

Kevin Pho: So how does one screen for a gambling disorder, say in the primary care setting that I’m familiar with? What kind of questions should I be thinking of, or what kind of history should I be on the lookout for if someone potentially has a gambling issue?

Safina Adatia: That’s a great question. There are some questionnaires that exist. Oftentimes it’s about how much are you gambling in terms of the day-to-day. Are you doing this every day? Are you doing this a few times a week? Are you hiding it? Hiding is a big component of screening for gambling use disorder. Are you hiding this from someone? Similar to other substances, you can even use the DSM criteria, to be honest, and just replace the alcohol with gambling. Like, how much money are you spending on this? Is this affecting your relationships with people? Are people thinking that you have a problem with this?

So, I would say the combination… It’s not a normal question to ask, “Is gambling a problem for you?” It’s going to be something that probably comes up in the context of that person initiating it. But once they do initiate it, I would say asking similar questions to other substances, replacing it with gambling. And then there are gambling-specific questionnaires that you can access.

Kevin Pho: So let’s say I ask some of these questions and I have a suspicion that the patient in front of me has a gambling issue. In terms of next steps, what are some resources? You mentioned things like cognitive behavioral therapy and potentially some medications. So from a primary care setting, where would I direct that patient?

Safina Adatia: You can always direct them to an addiction medicine physician or psychiatrist. I think that’s a really good resource to start off with. In terms of the other types of treatments, SSRIs, so things like sertraline, have been somewhat studied with a little bit of effect. Naltrexone is another one. And then brand new GLP-1s, kind of like Ozempic and Wegovy, are really coming up in front in terms of treating all kinds of addiction. So, I think experimenting and trialing something is probably better than nothing to help someone. If the benefits outweigh the risks, then trying some of those medications to start and then referring them to an addiction specialist would probably be the next steps.

Kevin Pho: And first line, let’s say, in the contrast between naltrexone, which I know is used for alcohol use disorder, and SSRIs in a primary care setting, is there a particular one that you would lean towards first?

Safina Adatia: I would say naltrexone, probably just because it’s been demonstrated to have efficacy in alcohol use disorder. What it does is it blocks the endogenous opioid pathway when it’s activated, when you have a euphoria, which essentially targets the dopamine pathway. Whether it’s going to be effective or not, we don’t really know. But again, these are such new issues and concerns that the studies are just not 100 percent there yet. We just don’t have the research to say whether this will work or not.

But I would probably start with naltrexone. You could do a combination of naltrexone and an antidepressant, especially if the person also has comorbid depression and anxiety, which again, with gambling, you often have comorbid mental health issues. So there’s nothing to say that you couldn’t try both together, to be honest, while you’re waiting to refer to therapy or things like that.

Kevin Pho: Have you seen or heard a success story where someone may have been diagnosed with a gambling addiction or gambling use disorder and there’s a successful treatment in turning that around? Have you seen or heard a success story that you could share with us?

Safina Adatia: Personally, no. Not yet. Because as I said, we just don’t have the data or the numbers yet of people who I think are presenting in clinics with gambling use disorder. I think if you were to have more psychiatry-focused—just because again, there’s more of an abstinence-based therapy that comes with psychiatry versus in the primary care setting or addiction medicine physicians versus addiction psychiatry—I think that would be a different outcome. But for me personally, I haven’t treated very many people with gambling disorder just because it’s still so new.

I also think the demographic who has a gambling use disorder, like the young male clientele, they’re not going to the doctor in general. They’re not accessing services in general. And so I think it’s going to be another five to ten years before we see this as a serious, serious problem.

Kevin Pho: How about from a policy standpoint? In your piece, you draw parallels to tobacco companies and the regulations that have been placed around them. So from a policy standpoint, do you see any movement or what would you like to see done?

Safina Adatia: Oh my gosh, the marketing. There needs to be more restrictions on the ads. There was a study that I just read about that. When the ads are there, it really promotes the person to want to take action. We know that from anything, from buying beauty products to TikTok. Anything where you’re advertising something is going to have an effect on the person. So if they have control on the ads like they do with the pharma industry, if there’s control on what is advertised, that can really change the trajectory of these things because it’s being promoted so heavily. You walk through North Station at the TD Garden and it’s just billboard, billboard, billboard, billboard. The advertising is insane.

Again, like you said, every other advertisement that you hear on the radio and now that we have AI and on social media, you can see that the ads are going to start targeting certain demographics who are more susceptible, more prone, who are watching, and it’s just going to become this cycle.

So there needs to be control on the ads. I also think there needs to be more diligence with checking ages and IDs, especially with online sports betting, because it’s very easy to skirt around the rules. There just needs to be more restrictions on who can sports gamble, how people are able to apply for an account, and just ensuring that the youth and the adolescents who are just so much more impressionable do not have access.

Kevin Pho: And as far as you know, are you seeing any movement on the federal or state level regarding any of these types of regulations you’re talking about?

Safina Adatia: I think there’s talk; I don’t think it’s happening yet just because the sports betting lobby is so big. It’s an $11 billion industry now as of 2024. It’s huge. So I think it’s going to take a little bit of time before we see actual progress. I think things might have to get more dire before rules are reversed.

Kevin Pho: All right, let’s take a step back and maybe talk outside of sports gambling. You did mention things like GLP-1 agonists in the treatment of potential addiction, and I’m seeing that in the news as well. So where are we with that? What kind of potential are we talking about, and what kind of data do we have so far regarding that?

Safina Adatia: It’s still very early stage, so it’s still very much experimental. I think it still needs to be for a very target clientele because it does result in weight loss, whether we like it or not in a candidate. So you need to pick someone who may have weight loss as a goal as well as a substance use disorder.

I think that it’s probably one of the most promising things we have in addiction because it really does quiet the noise in the brain. That’s what everyone says when it comes to food, and it’s what’s happening with addiction as well. We have heard from patients in these studies that when they started cutting down on the food, they didn’t have the desire to drink alcohol as much, or they didn’t have the desire to smoke cigarettes. I think that targeted therapy could have some serious widespread potential to treat substance use disorder, and I’m so excited to see what happens.

Kevin Pho: We’re talking to Safina Adatia. She’s an addiction medicine physician. Today’s KevinMD article is “Why gambling addiction is America’s next health crisis.” Safina, let’s end with some take-home messages you want to leave with the KevinMD audience.

Safina Adatia: First of all, I want people to know that addiction can affect anyone. This is not something that is specific to people who are unhoused or who don’t have financial means. I think anyone is susceptible to addiction. If you have an issue with an addiction, with addiction in general, please, please go see a physician. Physicians are trained in this; they can get you resources and help. There are lots of resources available within your state, within your country, and online.

The main thing to note, especially for health care providers, is that this is something that is pervasive. Addiction affects so many people across the country, and almost one in five people use substances in general. More than that, people are getting addicted. I think that it’s really important to try to intervene when things are fresh and just starting out, as opposed to waiting until things have become very dire.

Screening is obviously very important as a health care provider. Asking about substance use and addiction and adding gambling to that is so important, just because it’s become so pervasive in the last five to seven years and it’s just everywhere. Gambling really is affecting a lot of people now, and we need to be more mindful of that.

Kevin Pho: Safina, thank you so much for sharing your perspective and insight. Thanks again for coming on the show.

Safina Adatia: Thank you for having me.