"Ask the gambling question," FPs told as "secret" addiction becomes more common
Dee Kramer
CMAJ 1997;157:61-2
[ en bref ]
Dee Kramer is a freelance writer living in Toronto.
© 1997 Dee Kramer
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In brief
Family physicians were recently advised on ways to determine if their patients are addicted to gambling. Jim Milligan of Toronto's Donwood Institute says the problem is becoming more common but is often difficult to detect.
En bref
On a conseillé récemment aux médecins de famille des façons de déterminer si leurs patients sont esclaves du jeu. Jim Milligan, de l'Institut Donwood de Toronto, affirme que le problème se répand mais qu'il est souvent difficile à déceler.
Eighty-five percent of Canadians gamble, says Jim Milligan, director of the program on problem and compulsive gambling run by Toronto's Donwood Institute. The betting ranges from the millions wagered on Superbowl Sunday -- the single largest illegal gambling event in North America -- to slot machines at casinos and lottery tickets. "The desire to yell Bingo," says Milligan, "is irresistible."
He is passionate about his subject -- the human cost of gambling addiction -- and recently shared his knowledge with a large audience of physicians and caregivers during the second annual conference on substance abuse in primary care at St. Joseph's Health Centre in Toronto.
A December 1996 report estimated that 1.2 million Canadians are addicted to gambling. "It's like a feeding frenzy," explained Milligan, who said gambling can be compared with the intermittent-reinforcement experiments done on rats in laboratories. "Gamblers are never sure when the win will take place -- they get hooked on the excitement. Every time is a close call. They hear the coins fall in their neighbour's bucket, or they read that someone has won the lottery. The big win is possible, so they try again.
"The sign of intelligence is being able to learn from your actions, but this doesn't work with gambling. You cannot predict the future because each present act is random. Each time you gamble is a new event. You lose all sense of rationality. They tell me, 'I was up $800 and I should have walked away, but I put all my money back in.' "
The addiction is easy to explain, he said. "It is the one way for people to escape their lives of oppression and despair and to get all that society promises, whether that be 'the trip' or 'the house.' What do you think 'Imagine the Freedom' or 'You can't win without a ticket' means?"
Today, governments are also addicted to gambling, or at least to the revenue it generates. In 199596 the Alberta government took in $588 million, or 3.7% of its revenue, from gambling. In Ontario, Casino Windsor grossed $422 million in 1996, and the province will soon license up to 20 000 video lottery terminals to operate at charity casinos, racetracks, bars and hotels. In essence, politicians have legitimized behaviour that used to be considered unacceptable. "Gambling has become so normal that it is just about impossible to buy a carton of milk without investing in a lottery ticket," said Milligan.
Of course, greater normalization means greater access and more addiction. "The percentage of addicts may stay the same," he said, "but the numbers go up." This is particularly true for teenagers. Even though it is illegal for anyone under age 18 to receive money from the Ontario Lottery Corporation, there is now a thriving industry in which older students moonlight as bookies for younger ones.
However, gambling is still a "secret" addiction. It has no clear physical symptoms, so how can a family physician identify it? "Be aware that people loathe to talk about it," said Milligan, who added that gamblers are too ashamed for self-disclosure.
"Ask the gambling question," he said. "Put it into your repertoire as much as questions about relationship issues and alcohol. Always keep in mind the extensive crossover between addictions. When alcohol or drugs are the primary abuse, about 40% of addicts have a concurrent gambling addiction; when gambling is the primary abuse, about 50% also have alcohol or drug addictions."
Milligan said research into health issues concerning gambling is still at the developmental stage, but physical ailments such as problems with the lower back and abdomen are exacerbated when gamblers sit for too long and ignore biological needs. [In May, the Ottawa Citizen reported that some adults wear diapers when playing slot machines at casinos so that they do not have to give up their chair to answer nature's call. -- Ed.] Milligan noted that withdrawal from gambling addiction can mimic substance withdrawal by causing anxiety, tremors and headaches.
"If you are seeing anything that sends up your antennae such as depression, relationship problems, weight loss or panic attacks, then ask, 'How are you spending your leisure time?' "
Early intervention by physicians can help patients come to terms with their ambivalence about whether they want to stop their behaviour. "One of the most difficult things gamblers have to come to terms with is that if they give up gambling they will never reach the same high again."
Physicians can raise their consciousness about the pros and cons of gambling. What does the patient get out of gambling, what would they lose if they gave it up, and what is its impact on their lives?
Change comes from new learning, said Milligan. Gambling addicts have to learn they have no control over a system that is totally random and that their sense of control is false. They have to realize that the gambling industry is always going to be the winner and anyone who is winning is bound to lose. Once the gambler perceives there is a problem, change becomes possible. "At the Donwood," said Milligan, "we believe that anybody can wind up with a gambling problem and that we can intervene at any point in the process.
"You have a small window of opportunity -- you have to get to them in the short period when they are not in the action, when they are rational. You talk to them about their belief system, their faulty cognition and the emotional payoffs gambling gives them. You work with them around future plans, their responsibilities, other sources of self-esteem and other activities to replace gambling."
Milligan ended on a positive note. "We believe that people can deal with their gambling problem and not go back. They can get on with their lives without having to take on the label of pathological gambler. Full recovery is possible."
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