Thursday, November 7, 2013

Gambling, you in?

The big news this week in Sonoma County was the grand opening of the long-anticipated Graton Resort & Casino, located in Rohnert Park, six miles south of my home in Santa Rosa. To quote The Press Democrat, our local paper, "Thousands of people from around the Bay Area descended on the Graton Resort & Casino for its debut Tuesday, clogging surrounding roads and forcing the casino to temporarily close its doors to long lines of gamblers waiting outside."
Graton Resort & Casino in Rohnert Park. (CBS)
Graton Resort and Casino (CBS)

Per the same PD report, people were crazy excited: some arrived to the casino before 4:30am to be the first ones in, almost all 5,700 parking spaces were full of cars, Highway 101 was backed up for miles, 3,000 slot machines were occupied by 11am, and people were so anxious to see the new digs that they even parked on nearby streets and walked to the casino. Imagine that, walking to the casino?! Hooray for outdoor exercise!

Reading the article literally made me want to vomit, and I had to pause a moment to evaluate why something that drew thousands of people in wonderment was so automatically distasteful to me. After a little bit of research (yes, I am a geek) and some reflection, my nausea is not any better: it may even be worse.

Warning, this is a self-righteous post. Both my doctor self and my public health self are threatened by this place and what it represents to individual patients and to my community at large.

Doctor me: Gambling may be bad for your health.

The act of gambling--"placing something of value at risk for the opportunity to get something of even higher value"-- is not, in and of itself, a bad thing. Let's face it, lots of people gamble. Eighty-six percent of US adults report having gambled at least once in their life, 60% in the last year.  And, similar to other enjoyable aspects of human existence, for most people, gambling is fun and not at all dangerous. In fact, research shows that less than 10% of adults gamblers develop a gambling disorder. That means that more than 90% don't.

But it also means that somewhere between 15 and 20 million adults in this country have a gambling problem. That's a lot of people. To put the number in perspective, in the US, the equivalent of half of all Californians (there are 38 million of us) have a gambling disorder. And that doesn't include the rest of the world!

To be honest, until I delved into my research on gambling and casinos this week, I didn't remember from medical school that "pathological gambling" was actually  a psychiatric diagnosis. It's not a diagnosis I have ever made--though I've certainly worried about a friend or two.


According to the bible of psychiatric medicine, the Diagnostic and Statistical Manual of Mental Disorders (DSMIV), in order to be diagnosed with "pathological gambling" a person has to meet five or more of the following criteria. "Problematic gamblers" meet thee or four criteria.
  • Preoccupied with gambling (e.g. preoccupied with reliving past gambling experiences, handicapping or planning the next venture, or thinking of ways to get money with which to gamble)
  • Needs to gamble with increasing amounts of money in order to achieve the desired excitement
  • Has repeated unsuccessful efforts to control, cut back, or stop gambling
  • Is restless or irritable when attempting to cut down or stop gambling
  • Gambles as a way of escaping from problems or of relieving a dysphoric mood (e.g, feelings of helplessness, guilt, anxiety, depression)
  • After losing money gambling, often returns another day to get even ("chasing" after one's losses)
  • Lies to family members, therapist, or others to conceal the extent of involvement with gambling
  • Has jeopardized or lost a significant relationship, job, or educational or career opportunity because of gambling
  • Relies on others to provide money to relieve a desperate financial situation caused by gambling


Pathological gambling used to be found right alongside trillotrichomania (compulsive hair-pulling), kleptomania (recurrent urge to steal), and pyromania (obsessive desire to set fire to things). However, interestingly, in the newest version of the bible (aka DSMV), gambling disorder has been moved to the section on Addiction.

There are pretty obvious similarities between gambling and substance abuse; these similarities go beyond the financial problems and destruction of relationships that are so often untoward consequences of addictive behaviors. Just like in alcohol and drug addiction, brain imaging studies done while people are gambling actually show activation of the reward areas of the brain (aha, so the reward is more than just the money).  Problematic gamblers report cravings and highs-- just like substance abusers. And, like alcoholism, gambling issues tend to run in families.
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Dopamine (our brain's happy juice-- levels go up during sex, drug use, exercise, and chocolate chip cookie eating) and imbalance in the regulation of dopamine probably also play into gambling disorders.  There have actually been case reports of patients with Parkinson disease developing pathological gambling after being started on medicine that messed with their dopamine; and there are similar reports about patients with restless leg syndrome taking dopamine-related medications developing new problematic gambling habits.

Gambling is also associated with other mental health problems. In one study,  people with pathological or problem gambling were compared with  non-gamblers and were 3 times as likely to report ever having experienced major depression, 2 times more likely to report phobias, 6 times more likely to report antisocial personality, 3 times more likely to report current or past alcohol abuse or dependence, and 2 times more likely to report current or past nicotine dependence.

Problematic gambling disproportionately affects young people--people over 65 are much less likely to have a problem (so it's probably okay to let grandma gamble when she wants)--and men, who are three times more likely to have issues than women. Pathological and problem gamblers are more likely than other gamblers or non gamblers to have been on welfare, declared bankruptcy, and to have been arrested or incarcerated.

If you are worried you or someone you know may have a gambling disorder, check out this link , it can help you decide if your worry is warranted.


Public health advocate me: Gambling is bad for our community's health.
Gambling has increased markedly over the last fifty years. In 1960, 61% of Americans reported gambling, in 1999 the number was up to 86%.  In 1978, there were only two states with legalized gambling, and today only two states have not legalized gambling (those prudish holdouts are Utah and Hawaii). Thirteen states allow casinos on non-Indian land.

Casino advocates argue that casinos do good for the wealth and health of communities: casinos create much appreciated new jobs (the new RP casino is expected to generate 2,000 jobs), tax revenue, and local retail income. In doing all this, they increase a community's per capita income, increase individuals' buying power, and directly lead to more people having health insurance. These are all potentially good things. Casinos also draw tourists and other outside visitors, which also increase the income of the community. The wealthier the community, the healthier, right? And don't forget, casinos provide entertainment, which is. . .well. . .fun.

But the negative impact of casinos on the health of communities is not to be minimized. For individuals employed in casinos, the shift work and sleep disturbances are substantial. Casinos also increase second-hand smoke exposure. Casinos  have been shown to increase traffic volume as well as property and violent crimes in a community. And increased gambling has been associated with increased child abuse and domestic violence, unsafe sex practices, alcohol abuse, alcohol related MVAs, and increased suicides.

And the closer the casino, the more likely we will become problematic gamblers. In fact, the availability of a casino within fifty miles is associated with double the prevalence of problem and pathological gamblers, compared to a casino located 50-250 miles away.

If we had a choice, would we really want more problematic gamblers in Sonoma County? Would we want more lung cancer? More road rage? More pollution? More violence toward our children? More alcoholism? More violence?  Is it worth the fun? Or even the jobs?

I will be awaiting the PD reporting of the opening of the next Sonoma County Regional Park or new Santa Rosa City school, which I am sure will draw a similarly eager crowd at 4:30am on opening day, anxious to be the first ones to be let in "the doors". In the meantime, head on down to the new Graton Resort & Casino, not exactly what the doctor ordered. Please take note, the least you can do is park your car across town and walk there-- at least then you will be getting some exercise.
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Additional References:
http://blog.ncrg.org/blog/2013/05/evolving-definition-pathological-gambling-dsm-5
http://www.ncpgambling.org/i4a/pages/Index.cfm?pageID=3314#widespreadgambling
http://www.healthimpactproject.org/resources/body/KHI-HIA-issue-brief.pdf
http://www.aafp.org/afp/2000/0201/p741.html
http://www.stlouisfed.org/publications/br/articles/?id=638
http://www.northbaybusinessjournal.com/67388/rp-casino-project-proceeds-despite-opposition/
Uptodate.com: pathologic gambling

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