Editor’s note: This op-ed was prepared by Dr. Lindsey Mortenson, a faculty physician, college psychiatrist, and college health administrator who advocates for collaborative, pragmatic, and data-driven approaches to improving the lives of young adults. This op-ed is part of our Special Series on Addiction Among Emerging Adults, which was funded by a research and consulting contract with DraftKings.
What comes to mind when you think about gambling? Slot machines? The stock market? Social media? How about blind box toys like Labubus?
Do you think about addiction? You should.
Gambling lines today are blurry. Games and financial transactions are laced with gambling components, and the core elements–a stake, a risk, and a prize–are hard to recognize.
Even the most attentive, person-centered physician or therapist deploying recommended screening tools can miss a gambling problem. I have first-hand experience with this.
During residency I treated a midlife professional for what seemed like a straightforward anxious depression. But a year into treatment, nothing was working. Then one day she mentioned her weekend casino habit. Later in the session she mentioned financial stress. That’s when the penny dropped. I asked a few questions. And then a few more.
She teared up. This happens in treatment when you get close to the source of pain.
She had recently gambled away the savings for her daughter’s wedding. Afterward, in a moment of desperation, she self-excluded from a local casino. A few weeks later she returned there and was arrested for trespassing. I remember the clinical picture suddenly being more clear: little details–the extra shifts at work, marital conflict, the high anxiety–coalesced around a root cause.
These days I work in college health, where we screen for lots of important things: alcohol abuse, anxiety, depression. But we don’t routinely screen for problem gambling.
This is understandable. It can be hard to fit everything in during an already busy appointment; time is a barrier. Many currently available screeners are too long or a bit anachronistic—dinosaurs from a bygone era of land-based gambling. Perhaps this is why the U.S. Preventative Services Taskforce hasn’t recommended a gambling screener for frontline healthcare workers.
To be fair, screening and detection are complicated. Online gambling occurs behind locked phones, passwords, and technology we barely understand. Self-report surveys have limitations, especially when they ask about things that make us feel ashamed or use terms we don’t recognize. In our era of widespread gamblification, is it realistic for prediction market contracts and video game loot box transactions to code as gambling?
The barrier to better detection (and therefore, treatment) is data and research. And we’re strapped for both.
The tiny amount of federal funding for addiction research is earmarked for substance abuse. Gambling disorder, its lesser known cousin, is nowhere on the list of 327 NIH funding priorities. This is in spite of the fact that nearly four in five Americans believe problem gambling is as serious as or more serious than alcohol or drug addiction; and in spite of research demonstrating that digital gaming and gambling change our brains in ways that lower happiness, increase pain, and reduce impulse control. Why is the federal government so uninterested in this enormous drain on our attention, relationships, quality of life, and bank accounts?
The digital gambling shift has also created a seriously uncomfortable paradox. A ton of data are collected by gambling operators about the who, what, where, and how of these transactions. This data bonanza should be a researcher’s dream, right? Except it’s not. Most of the U.S. data is privatized and under lock-and-key corporate or tribal ownership. Also, because gambling platforms are designed for profit and compliance (vs. being human-centered), their data are mined, coded, and structured in ways that are difficult to harmonize with health research. And then there’s the issue of platform hopping, which makes it difficult to measure behavior across multiple gambling modalities.
All of this amounts to a dark data problem.
Worse still, we can’t count the costs. The monetary ones are easy: Americans are on track to lose at least $1 trillion annually to online gambling by 2028. It is financial losses like this that often bring people into treatment. But what about non-monetary losses? In our current data vacuum, these are hard to measure. We know the types of harm: resources, relationships, and health. We know who experiences it: bettors, families, friends, communities. But the full human cost is hard to measure because there are so many negative endpoints: wasted potential, loss of trust, injured relationships, fractured attention, squandered time, suicide (to name a few).
In my clinical work with college students, I think a lot about these kinds of losses. College students are in a transitional phase of life. Younger students are highly resilient, but are equally vulnerable. This vulnerability comes from a trifecta of risk factors: biological, social, and environmental. Social and environmental issues can be changed, tweaked, or optimized. Biological ones? Not so much.
Human brains continue to develop through our mid-late 20s. One of the last areas to develop is the prefrontal cortex, the epicenter of self-control and decision making. This basic biologic fact has informed our historical response to vice industries like tobacco, alcohol, and gambling. These so-called demerit goods (or sin stocks, if they are publicly traded) inflict such a high cost that economists consider them free market failures because of their data asymmetry and how they exploit cognitive biases for short-term gratification.
How can we possibly counteract such powerful commercial forces? In my line of work, we focus on three things: prevention, treatment, and recovery. To do this in an evidence-informed way requires good data: high integrity, no conflicts of interest, and not primarily driven by the vagaries of profit and compliance. Those are the kind of data that produce excellent research, evidence-based clinical practice, responsive services, proactive policy, and better human outcomes. But we don’t have enough of it. And that is holding us back clinically and in research.
We need to reconsider this approach.
Could better days lie ahead? The optimist in me wants to believe so. There are signs of greater data transparency, increased federal research support, better screening tools, new policy approaches, and calls for tighter regulation at the federal level. As more people (unfortunately) experience gambling related harms, governments may face greater pressure to embrace a public health-informed response–like the ones for tobacco, seatbelts, and vaccine preventable diseases that have saved lives and stood the test of time.
I am less bullish about industry self-regulation. Will online gambling operators move toward greater data transparency? More human-centered design? Will shareholders demand it? For my part, I’m skeptical.
Wanna make a bet?
– Lindsey Mortenson, M.D., M.S.
Dr. Mortenson has no commercial conflicts. She can be found on LinkedIn here.