For years, the Lewis & Clark Community Counseling Center in Portland, Oregon, had helped a small group of patients dealing with gambling addiction.
“We could offer someone an appointment the same or next business day,” Frankie DiFerdinando, director of Lewis & Clark’s problem gambling service, told Addiction Treatment Business.
Then came the gambling apps, which made gambling as easy as clicking a button on a mobile device.
“People now can legally wager on how many times Taylor Swift will be shown on TV during a Kansas City Chiefs game, or flight delays, or gas prices,” DiFerdinando said.
In 2018, the Supreme Court shot down a federal law that kept most states from allowing sports betting. Today, sports gambling is legal in 37 states, and most of those states permit digital bets. According to the Legal Sports Report, U.S. sports gambling wagers soared from $24 million a month in 2018 to $6.7 billion in August of 2023 alone.
Sports gambling legalization has produced a “ripple effect” of making gambling, overall, a more mainstream pastime, DiFerdinando said. Now, Lewis & Clark has a waitlist of gambling patients.
Yet despite the definitely growing demand, behavioral health businesses face an uphill climb in knowing what resources to invest into gambling treatment, much less whether it can become a profitable business proposition.
The American Psychiatric Association recognizes gambling as a behavioral health disorder. Yet Medicare, Medicaid and private insurance mostly do not cover a treatment process that has elements different from treating substance use disorder (SUD) or mental health disorders.
“Even with all the attention given to the opioid crisis, there are still treatment centers closing, so I do not see an immense growth coming in gambling treatment,” Marti Paulson, CEO of Project Turnabout, a nonprofit that operates a residential gambling treatment program, told ATB.
Providers know gambling and gambling addiction are on the rise, but they don’t know how many people want help.
According to Lia Nower, director at the center for gambling studies at Rutgers University, the last national study on the prevalence of people with a gambling disorder was completed in 1999. The 24-year-old report said 2% of the adult population is at-risk for a gambling disorder. Unlike SUD or mental health, there is no dedicated federal funding for problem gambling research.
Some states such as New Jersey do their own research, with Nower noting that 6% of New Jersey adults are at risk for a gambling disorder. Other states, however, have spottier reporting.
It is also not known who at-risk is seeking treatment. The peer-reviewed research periodical Addiction Journal published a study last year that 1 in 25 people in the U.S. and United Kingdom with moderate-risk gambling sought help, and 1 in 5 people with a gambling problem pursued treatment.
But the study acknowledged caveats, concluding: “It is highly likely that our study underestimated the prevalence of help-seeking for problem gambling in several ways.”
One way to tap into demand is to more explicitly address patients already seeking treatment for other behavioral health disorders
According to DiFerdinando at Lewis & Clark, about 75% of people who come in for gambling treatment have a co-occurring disorder.
In theory, providers could seek reimbursement for a disorder covered by Medicaid, Medicare or private insurance, while simultaneously treating a gambling problem. But treating for gambling requires its own clinical training – and a unique set of patient approaches.
Project Turnabout is in Granite Falls, Minnesota, a town of less than 3,000 people that is 100 miles west of Minneapolis and surrounded by casinos. According to Paulson, it is one of a handful of residential gambling treatment centers in the country. Williamsville Wellness in Hanover, Virginia, and Algamus in Goodyear, Arizona, are two other residential treatment centers.
Treating gambling is partly like helping someone with a dependency for cocaine or another drug stimulant, Paulson said, since it works on a similar part of the brain, spurring impulsive decision-making. There is also a “real withdrawal with headaches, nausea and vomiting the first days of not being able to get action.”
In some respects, Paulson said, gambling patients are under even stricter guidelines than patients with a chemical dependency. Not only are residents handed a highly regimented schedule from 7 in the morning to 8:30 in the evening, but they must follow rules like not wearing any type of clothing with sports logos or any logo that may hint at gambling. They also cannot share things.
“You cannot share belongings right down to you do not give people a cigarette, because they’ll gamble on cigarettes,” Paulson said. “Patients will gamble on potato chips.”
The approximately 200 residential patients that Project Turnabout sees each year typically spend a month at their facility and then receive 26 weeks of outpatient treatment.
Unlike SUD or mental health disorders, there is no federally approved medication that specifically treats gambling, which means patients must rely on counseling. Project Turnabout patients are recommended nine-hours of weekly counseling at the start of outpatient treatment, with session amounts gradually declining, Paulson said. Project Turnabout also refers patients to local Gamblers Anonymous chapters.
Figuring out financing
Federally, updates to mental health parity laws that effectively require some types of private insurance reimbursements have not applied to gambling.
“Insurers can decide what they are going to cover, and they have decided not to cover gambling,” Paulson said.
The lack of an insurance backstop has made gambling treatment a less promising business model than SUD or mental health disorders, which each saw a venture capital influx amid the pandemic.
Paulson sees her share of “high-end” clients who pay out of pocket, but that can be risky in itself with some patients not forthcoming about gambling debts.
Presently, then, gambling treatment providers rely on state funding. In Minnesota, the first month of gambling treatment is state-funded, using revenues from the Minnesota lottery and local casino fees. Oregon also finances initial gambling treatment, DiFerdinando said.
A National Association of Administrators for Disordered Gambling Services report found that in 2021 that 42 states provided publicly-funded gambling services, totaling $94 million, an increase from $73 million in 2016.
Linda Graves, the association’s outgoing director, said that states have gradually done more to cover the costs of patients who seek treatment from nonprofit and for-profit providers. But state-by-state treatment varies greatly.
“Some states have no treatment of any kind like Wisconsin, but others may have a full range of treatment services including residential treatment in California,” Graves told ATB.
For now, Graves said, funding and services for problem gamblers is “extremely uneven.”