Dr. Daniel Knoepflmacher (Host): Welcome to On the Mind, the official podcast of the Weill Cornell Medicine Department of Psychiatry. I'm your host, Dr. Daniel Knoepflmacher. In each episode, I speak with experts in various aspects of psychiatry, psychotherapy, research, and other important topics on the mind.

Today, we'll be discussing gambling disorder, a condition that affects millions of Americans and yet remains significantly underdiagnosed and undertreated with research showing that fewer than 15% of those with gambling disorder ever receive professional help. Approximately 1% of the US population meets criteria for gambling disorder in any given year. And when we broaden the lens to include problem gambling, that number rises to between 2% and 3% of adults.

Over the past two decades, the landscape of gambling has shifted dramatically since the Supreme Court's 2018 ruling, opening the door to legal sports betting. The number of states offering it has expanded rapidly. And the rise of online gambling platforms and apps has made wagering more accessible than ever. The ability to bet on your phone at any time from the comfort of your home has led to a measurable rise in gambling-related harm, particularly among young men. Despite its serious consequences, including financial ruin, depression, and alarmingly high rates of suicidality, gambling disorder is frequently minimized and misunderstood.

Today, we'll delve into this important and evolving condition and explore the effective treatments that offer a real hope for recovery. We're fortunate to have Dr. Jonathan Avery joining us today to discuss this topic. John is the Vice Chair of Addiction Psychiatry here at Weill Cornell, and also the Program Director of our Addiction Psychiatry Fellowship Program. He's someone who knows a lot about this topic and actually joined me two years ago on this podcast to talk about alcohol use disorder. So John, it's amazing to have you back as a second-time guest on our podcast.

Dr. Jonathan Avery: Thanks for having me. You know, it's an honor to be back to discuss such a important topic.

Dr. Daniel Knoepflmacher: Well, it was just as I said about two years ago that we talked about alcohol use disorder. And for those of you who haven't heard that episode yet, I highly recommend it. And now, you have your own podcast, which is called Thriving with Addiction. And I've listened to it. It's terrific. The last episode on AI was really amazing.

Everyone should check this out to hear about personal stories of recovery and gain useful information helping people who you may have in your life or in your own life struggling with addiction. So, what spurred you to become a podcaster on top of all of those other things that you do?

Dr. Jonathan Avery: Well, of course, you set a good example of what it's like to communicate with the public.

Dr. Daniel Knoepflmacher: I was just setting you up. This was just compliment fishing.

Dr. Jonathan Avery: Well, you know, as I talked about the first time I was here, this is a very stigmatized field addiction. And I think we need to be talking about it as much as we can. There's so many important topics, important stories to hear that often—because of stigma—aren't shared. And so, my podcast, we alternate week by week between having someone in recovery or a family member who's dealt with addiction and tell their story, and then having an expert come and discuss an important topic in substance use disorders. And it's been a lot of fun. It's fun to talk in this way, to communicate science in this way. I learned a lot. I hope people that listen learn a lot. So, it's just a fun thing to do.

Dr. Daniel Knoepflmacher: I certainly learned a lot from it. And you're an easy guy to talk to. So, you're just the perfect person to be doing this. I do want to turn though to our main topic, otherwise we could spend the whole time just complimenting each other, which I know we're both good at. But let's talk about gambling addiction.

One thing that you always stress when you're talking about addiction—I've heard you talk about it a lot over the years—is the role of stigma. And it's really difficult for those who are struggling with addiction to come forward and get the treatment that can really help them. They feel judged, dismissed, or even chastised by clinicians whose job it should be to help them. And I know you and even I work with people who struggle with alcohol use disorder for example. And the fact is you and I aren't abstaining all the time from alcohol use, right? It's part of our lives. It's part of our culture.

And full disclosure, I'm someone who actually really enjoys gambling. I'll never forget the first time that I walked into a Vegas casino. I was 21 years old. I think it's imploded since the time I was there, but the lights, the sounds, the stakes, the jackpots, you know, all sensory overload and all the fun small talk with people at the blackjack table, the other gamblers, the dealer. I was doing some poker tournaments. I was up, I lost it all. It's not something I do as much these days, but it is thrilling. And yet, of course, I know how destructive this can be for many people.

So, I'm just curious if you don't mind disclosing as well your experience with gambling. And given that, like, how is that something that you keep in your mind when you're trying to help people who are struggling with serious gambling problems?

Dr. Jonathan Avery: Yeah. I think you and I are both lucky. There wasn't gambling on our phone when we were young, because I think we both liked it. And then, I imagine if you came back from that casino as a young man and you had that same casino on your phone, it had been hard not to keep using. And that's what I'm telling folks when they present to care to these days, nothing to be stigmatized about. This is so prevalent and so addictive. It's hard not to get hooked. And so, when I was a young man, I was very much into playing sports, competitive sports. All my friends played sports. And because of being a part of that culture, we bet on sports. I loved betting on March Madness, the Super Bowl. We played poker on poker nights. Fantasy sports was just starting to take off, and we would wager a little bit. But there was nowhere we could go with it back then. Like, at most, you'll lose a hundred bucks, you know? But we couldn't go home and continue to bet on our phone through our parents' account like kids are doing these days. And so, it just sort of died out.

And I was thinking recently about my friend group, I mean, we had a lot of risk factors for addiction, for mental health, and what ended up capturing us was stuff that was available. So, part of the reason I became an addiction psychiatrist is because when I was young, the opiate epidemic was taking off, and I saw some friends get caught up in that. And I just think if, well, if online betting and gambling was there when we were young, I'm sure some of us would've gotten into trouble. But luckily, that wasn't part of the scene quite yet.

Dr. Daniel Knoepflmacher: Yeah, I mean, it's something which is very timely for us to be talking about. We're going to get more into this, which what has happened with the technology, with these industries that are behind this. But at the heart of it all, this is something that's fundamentally human, right? I mean, these games of risk, there's excitement and the uncertainty. I mean, we face uncertainty all the time in our lives, and that can be very stressful and anxiety-producing. But when you put it in a game of chance, it's really thrilling.

And I've read about how there's archeological evidence of like clay dice that were used for gambling games that are dating back to 3000 BC and ancient Mesopotamia. I think in Ancient Egyptian tombs, you can see that people are betting on chariot races. This goes way back. So, I'm wondering if you could speak about the history of this human pastime that clearly crosses cultures across the world. How was it that at some point it became seen as an addiction in our medical context, which people needed help with to recover from it?

Dr. Jonathan Avery: Right. No, it's been around forever. It is in our DNA to sort of gamble as you were saying. And so, yeah, it was in ancient Mesopotamia 4,500 years ago that these were found. The ancient Greeks and Romans would bet on gladiators as anyone who saw the gladiator movies will know. But, you know, the recent history—so, it's been around every different civilization throughout time but the recent history in the US sort of started about a hundred years ago with Las Vegas and the legalization of gambling there. Then, it sort of stayed there a long time, but then slowly other casinos were able to pop up in New Jersey, of course, the Native American lands.

Poker started to become more popular and played by people on the weekends and more popular among kids. The World Series of Poker took off in the '90s. And as those a hundred years progressed, it became less of a moral failing and became more acceptable in culture to gamble. Just like when I was growing up in the '90s, we bet on those games and we didn't blink twice. Lotteries became a part of a lot of what people spend their spare change on. And it's generally become accepted, but it was constrained. Because you didn't have it on your phone. It wasn't available all the time. And so, most people that got into trouble were like middle aged folks and or people living close to casinos.

Then in 2018, as you said in the intro, we suddenly got access to sports betting and online casinos on our phone, and it's just skyrocketed in the last eight years, where now you can bet 24/7 on your phone about anything you want, play any game of chance you want. And suddenly, there's a whole new risk profile of who's using and how much people can use.

Dr. Daniel Knoepflmacher: It's everywhere And we can't escape it. But at the core, we're talking about something where many people do it. But then, there's those who are at a level of gambling that is truly problematic. And it is a diagnosis. There's gambling disorder in the DSM-5. I believe that's the only behavioral addiction that has a formal diagnosis in that section of DSM-5. So, can you tell us the parameters of diagnosing someone with a gambling disorder, and at what point is this a problem?

Dr. Jonathan Avery: Right. So now, because of its availability, about half of Americans will gamble in a given year. Some reports up to three quarters, it seems like, will make wagers. But only a very small percentage end up with a gambling addiction or gambling disorder as you might call it. Maybe 1%, I believe, as you said in the intro.

But right below the gambling disorder are people that have problematic gambling. So, maybe they're spending more than they want. And even there's people without problem gambling or without a gambling disorder who, because of the availability and access, make some bad bets here and there and get into financial trouble even though they don't have a gambling disorder. You see that with drinking. Like, someone rarely drinks, they drink once and they end up with a DUI. That doesn't mean they have an alcohol use disorder, they just had some harms from drinking. And so, we're seeing a lot of people with more casual harms these days because of the access that don't meet the criteria for a gambling disorder.

So, what a gambling disorder means when you're really in trouble is you're gambling to the extent where it's starting to interfere with your function, getting in the way of things you'd rather be doing with your life. And strikingly, because of how it works in the brain, this gambling disorder behaves like other addictions. So, you build a tolerance to gambling, you have to bet more and more. People actually have physical withdrawal symptoms when they're not gambling. They try to chase their losses. They spend more and more. Their relationships suffer, the develop mental health and other substance use disorders.

And so, when you're in that most severe category where it's starting to impair your function, that's when you say you have a gambling disorder. But again, because of the prevalence, a lot of people are getting into trouble without meeting those sort of formal criteria.

Dr. Daniel Knoepflmacher: That piece about withdrawal and the physical symptoms, that's something that I think a lot of people don't know, and I want to get more into the biological side of this in a minute. But you mentioned 1% of the population may meet criteria in a given year. Can you get a bit more granular and touch on other factors like age, gender, demographics? How is this breakdown?

Dr. Jonathan Avery: So historically, while we would say substance use disorders, we say typically they're disorders of adolescents. So, something like 70% of addiction emerges by the time you're 18. But for gambling, we always said something different. Like, this primarily affects men who are older, in their 30s and 40s and beyond. And similar for women, much less women were gambling, maybe more on slot machines or about 50/50 on slot machines. But historically, we saw sort of middle-aged men. Those were our typical people with gambling disorder.

Now with the phones, which we worry about our kids, looking at social media or other problematic content, but now they're gambling. And what we see is the age of people who present increasingly being younger and more male who are in the sports world just like I was when I was growing up. And so, the risk factors are to be male, to be a younger male, to be a male that has a history of mental health struggles, of substance use struggles, especially those who have ADHD and those who drink alcohol or smoke nicotine products. And so, those might be the most vulnerable of individuals. But again, because of the prevalence, we see also for the first time people without those risk factors who just get access to it and it sort of goes out of control as well. But those are the classic risk factors we think of.

Dr. Daniel Knoepflmacher: And this cuts across all different cultural backgrounds and socioeconomically, et cetera?

Dr. Jonathan Avery: It does. There are certain cultures that, historically, were less likely to gamble, you know, was once considered a sin, as I mentioned before. And different cultures have more strict attitudes towards gambling. But what really happened with the progression over time is that it was decreasingly viewed as problematic and thought of almost as fun. And then, the way it's sort of married with sports culture, these days is really pronounced. Like, if you like sports, you've got to like gambling. Because they talk about sports in terms of odds, and they update betting odds as the game progresses. And part of the pre-game show is talking about what bets to make these days. And so, the access and the availability and the acceptability is really there with a lot of people these days.

Dr. Daniel Knoepflmacher: Well, with the potential for catastrophic financial impacts for those who are affected. I mean, this is an emotional rollercoaster. People have impulsive behaviors. I think it is probably associated with this kind of gambling disorder. It doesn't surprise me that there's a higher risk for suicide in this population. Can you speak a little bit about how that's true in gambling disorder and how even compared to other addictions?

Dr. Jonathan Avery: Yeah. The toll it takes on you when you're losing everything that you have to this gambling disorder can be very pronounced. And so, while those are all the risk factors we mentioned, once a gambling disorder develops, it increases your odds of depression, anxiety, increases your odds of developing a substance use disorder. And then, concerningly, it increases the odds of suicide. People feel they have no way to get out of tremendous debt, people coming to collect the debt.

And then, one other characteristic of a gambling disorder that I didn't mention earlier is lying about it or hiding those losses. You know, I sometimes see people, and the shame and the secrets that are built up just feel overwhelming for folks. And they're just not sure how to navigate that. And so, yeah, at times, suicidality becomes a prominent factor in more severe gambling disorders and something we're always on the lookout for when people present with gambling.

Dr. Daniel Knoepflmacher: So as an addiction psychiatrist, how do you screen for problem gambling? Like, what are the specific things, for instance, that you'd recommend to people like me who are more general practitioners who really want to make sure that we don't miss this?

Dr. Jonathan Avery: The general teaching is that psychiatrists or clinicians commonly don't ask about substance use disorders. Then, they especially don't ask about behavioral addictions. And we are talking about gambling here, but the other prominent ones include phone use, sex addiction, gaming. And we're often just not asking the questions at all to our patients. And we have no idea how much money they're spending each week on the lottery or what apps they're using and how much money they're spending.

And so, part of it is just asking the questions like, "Do you gamble? Tell me about sports betting. Do you play the lottery? How much money do you spend on it?" And then, once you get a sense of their pattern, you want to know sort of those diagnostic questions I was talking about in terms of do they continue using despite harm? Are they hiding the gambling behavior? Are they looking to borrow money to continue the gambling? And then some of those tolerance and withdrawal symptoms that we talked about as well.

Dr. Daniel Knoepflmacher: What's fascinating about behavioral addictions is that they're addictions without being a substance that actually hits a receptor directly in your brain that you imbibe or smoke or whatever. So, I wanted to talk to you about this, because I think of the addiction within psychiatry as one area where we actually know a good deal about the neurobiology. And you just described that there's actual physical symptoms of withdrawal that could come with this. So, what do we know about what's going on biologically in the brain during gambling, and specifically for those individuals who are struggling with gambling disorder?

Dr. Jonathan Avery: It is pretty striking and you're not alone. I mean, people didn't really believe these behavioral addictions could be addictive or cause addiction in the brain way, the same way the substances do. And in fact, gambling really wasn't added to the addiction chapter of our diagnostic manuals until the latest version that was previously characterized as an impulse control disorder, more than an addiction.

But the reason we have incorporated it into the world of addiction, including gaming and sex as well, is that it does hit the same reward pathways in the brain—so response to naltrexone and 12-step work, some of the treatments as well. So, it sort of made it ours, and it's crazy to think about, but even though it's not a substance, gambling can be neurotoxic. It causes changes in the brain, just the way substances do.

And in fact, if you looked at someone's brain with a gambling disorder and someone's brain with a cocaine use disorder, you'd have to be really trained to identify the differences, because they light up dopamine in the same way, they impact the frontal cortex in the same way. And then, some of that cortisol, stress, the disrupted sleep, the anxiety, depression, that results changes the brains in very similar ways to what we see with people with substance use disorders.

And then, when you don't get that dopamine reward. You feel the withdrawal symptoms, your brain starts firing things that make you feel almost flu-Like. It's sort of hard to believe when you can not gamble and feel sick just because your body is rebelling on not getting that reward.

Not only that, because gambling, the way it works is with this variable ratio reinforcement, that might be the most powerful learning schedule in behavioral psychology and one of the most powerfully reinforcing things in the brain. And so, what that means, I think everyone's sort of seen those operant conditioning experiments before where the animal, if they get their food every time they click on the lever, they know what they're getting and they don't click on the lever so much. If you give them their food or any other substance intermittently, they keep pressing that lever, pressing that lever, and they just will keep doing it until something really bad happens to them. And that's what happens with gambling. Because you don't get the reward every time, you keep playing and keep playing, and your brain is shooting up these huge dopamine spikes. So, you keep playing and keep playing until you win. And so, that reinforcement schedule makes it especially addictive and toxic for the brain.

And then, also there's this phenomenon of near-misses that happens in gambling. And we see this a lot now that they have these parlays where you have to hit multiple bets in a row to win. These near-misses light up the brain almost as much as if you win. So then you want to gamble more because, "Oh, you almost just won." And you can almost feel that sort of viscerally and you want to just keep playing. And it feels like it's something you're doing on your own, but it's really the brain that's sort of egging you on because of how you're rewarding it.

Dr. Daniel Knoepflmacher: I've seen that watching people play slots. It's like, "Cherry, cherry, cherry. Oh, bar," you know? Ah, it's hard not to get sucked in. Now, of course, with gambling disorder like, most things in psychiatry and certainly, with addiction, it doesn't in occur in a vacuum. And I know just from my own practice, I've never encountered a patient where gambling disorder, if that's something that they're struggling with, was the only diagnosis at play. So, you alluded to ADHD and a few other things earlier. Can you talk about the common co-occurring diagnoses?

Dr. Jonathan Avery: Yeah, there are many, as you said. And that's true for all substance use disorders, it's rare to have any addiction without having co-occurring mental health or having multiple substance use disorders. Really, the common pathway often trauma. I mean, we see a lot of people that have had trauma that end up with gambling disorder or with substance use disorders.

And then, those early life experiences and trauma and the gambling often lead to—well, it's often common in people with ADHD, as I mentioned, and then very co-occurring with major depressive disorder, anxiety disorders. Those with more severe mental illness like bipolar disorder, often have increased rates of gambling as well just related to the impulsivity.

And then, where there's one substance use disorder, there's many. And so with gambling, we often see both behavioral addictions and substance use disorders, from sex addiction to alcohol, nicotine, stimulants. And so if gambling's there, you're looking for other stuff as well for sure.

Dr. Daniel Knoepflmacher: What about bipolar? Touching on that, I mean, it's something when we're teaching residents about the spectrum of bipolar illness, gambling is something that we can sometimes identify as a hallmark of potential hypomania or something else going.

Dr. Jonathan Avery: Exactly. And that's true for all substance use disorders. I mean, there's some thought that they should have even teased out as a separate diagnosis people with bipolar disorder and substance use disorder and addiction, just because there is a subset that it's just so prevalent. And among those former axis 1 conditions, bipolar disorder has the highest odds ratio of developing substance use disorders and gambling. And that's because in the hypomanic or manic phase, as you were mentioning, you're more impulsive. You're chasing things that really get the dopamine system going. And I've had seen some of the most difficult gambling and financial losses in people with bipolar disorder that really hurts too, because it doesn't happen gradually at times. A lot of gambling disorders develop gradually over time. But sometimes you see people in a manic phase who do something they've never done before and suddenly are facing incredible financial losses. And it just feels like it came out of the blue and it can really hurt.

Dr. Daniel Knoepflmacher: And this might be a rarer thing, but just something that comes to mind, as a side effect of certain medications. you know, I'm thinking in terms of Parkinson's disease, for instance, where we have a medication like pramipexole, but that's something that I've sometimes used in psychiatric treatment. So, any thing you could add about those associated risks?

Dr. Jonathan Avery: Yeah, exactly. I mean, it's uncommon, but a well-known side effect of people on dopaminergic agents for Parkinson's disease or for other medications that hit the same pathway in the brain that's responsible for addiction, they sometimes engage in in problematic gambling. And that's also really good evidence that this is not a moral failing. This is something that goes on in the brain. I think those cases, when I see those, are the most striking. This is someone with no history of addiction, no history of substance use disorders or mental health issues. They're given a medication for Parkinson's disease, and then they can't stop gambling. They've never even thought about gambling in their life. it's one of those moments that sort of reinforces, "Ah, this is something that's really biological that's going on here."

Dr. Daniel Knoepflmacher: And we're bio-psychosocial thinkers. And certainly, the biological is really important to emphasize there. I want to also turn to the cultural though. And this is me just sort of pontificating a bit, but I think about certain subcultures where anecdotally it seems like this kind of gambling can be more prevalent.

I've talked to young men, college age men who've talked about being in the dorms and this culture of like, "Oh, the guy down the hall just hit a jackpot," you know, or "His parlayed bets all came through," and there's this kind of herd mentality betting on things.

Similarly, I think living in New York City, there's a lot of people who are on career paths here that are built on making high stakes financial decisions that come with tremendous amounts uncertainty and some risk. So, I'm just curious. I don't know if there's any studies on this, and you can just say, "Nah, let's move on." But is there anything about how these kind of subgroups might be at higher risk for problem gambling?

Dr. Jonathan Avery: For sure. I mean, we've talked sort of today about how the young men that are at risk, I was just doing a talk at a school on Narcan and opiates. I was sitting in front of these guys and that's all they were talking about, like what they're going to bet, who their bets are. It has really become a part of young male culture. Instead of talking about the movie you watched or whatever else, sports themselves, to talk about the gambling and gaming on them. It's so a part of culture.

But as people get older, we also see them in increased rates, in certain jobs that have, you know, a couple common characteristics like easy access to money, regular hours, high stress. And so, here in New York, we see people that are in finance or trading, and they can gamble in ways that feel different. They can do it with other people's money or their own money. There's certainly these apps that play like gambling for managing your own money, you know, like Robinhood and other apps like that. And so yeah, stock traders, day traders, financial brokers.

And then people with the regular hours and the high stress jobs like ER doctors or people in the military, for example, are at increased risk. And then, with sports betting, people in sports, and it's sort of the most unfair to our athletes and our young athletes or people that work in sports. I mean, we make it such a part of the culture. And then, we expect them not to bet on it. It's really sort of, I feel like, the most unfair for them almost.

Dr. Daniel Knoepflmacher: Well, that really gets into, I think, the risk that can come with having access to this technology too. Because as you pointed out, the technology makes this incredibly accessible at all hours of the day. And now, we even have further commodification of this with these prediction market apps like Kalshi or Polymarket, and these have created a world where people can bet on countless areas of uncertainty beyond sports.

I mean, maybe still the Olympics, but it could be the Oscars or it could be elections, even war and sometimes the death of people, which gets into really gray areas. I think it opens up all kinds of questions about, let's say, you've mentioned athletes—well, pressures for insider information. We had a scandal within the NBA or, even worse, potentially financially incentivizing people to create negative outcomes. I mean, you could think about some scary things.

So, I know you're just an addiction psychiatrist, you're not president of the United States. But first of all, do you think that we are gravitating towards some cultural level of problem gambling? And is there anything we should be doing as a society to really try to reduce this potential harm?

Dr. Jonathan Avery: Yeah, I mean I think we sometimes justify it because of the taxes saved, and the money that goes into education from gambling and things like that. But I think that dwarves the potential harm with all of this. We're creating a new generation that are, as you say, betting on everything and getting into trouble with gambling and increasingly pushing them to their rooms and their phones. And we should step up as a society.

I mean, right now, those gambling markets are not regulated very well. I asked these kids that I saw in the school, like, "How are you betting? You're all 16, 17 years old?" And they're like, "Oh, my dad's account," "My brother's account," VPNs, and the dark web. It's so easy to get access to these things.

And just when you try to worry about betting on sports, you shut those apps down. And then, you've got these other markets like you described, where you can suddenly find yourself betting on the outcome of the Iran war and when certain political leaders are going to pass and really crazy stuff. And that's not good for anyone. So, we've got to not just treat it at an individual level to your point, but treat it as a societal issue that's sort of overtaking a lot of folks. And we need to protect them especially protect the young kids and the adults.

Dr. Daniel Knoepflmacher: Is there work among addiction psychiatrists that their national associations, et cetera, to maybe do some advocacy to help legislators understand these threats?

Dr. Jonathan Avery: There is, I think, the American Academy of Addiction Psychiatry, American Society of Addiction Medicine are doing good work in trying to promote these things at the level of the state and the national government, and the federal government, just because it is so important. And it impacts the kids, as I said. So, we've got to put these restrictions on them, just like we're doing with social media or AI or exposure to pornography, which is at 11 to 12 years old these days, we're allowing. We would never let our adolescent kids have a bottle of vodka in their room. We're giving them access to this incredible addictive technology. And I think we sometimes overlook that gambling is one of those things that is part of the menu of things that they're getting exposed to.

But even as you get older, I mean, people are throwing away their 401(k) and hurting themselves. We need to get some protection around this so that there are limits on what a person can lose and how they can be sort of tricked almost by these really addictive technologies.

Dr. Daniel Knoepflmacher: Well, you just said it right there. I can see you talking to a senator and them being compelled by what you have to say.

Dr. Jonathan Avery: We'll send this out to the politicians after we're done.

Dr. Daniel Knoepflmacher: Well, now, that you've helped solve problems at the societal level, I want to return to individual people. And the treatments that really work for a gambling disorder, what's the first thing you do when you're working with someone, let's say, who's come to you struggling with gambling?

Dr. Jonathan Avery: Well, they've already done the big first step in that they raised their hand and they came to me. I think that's step number one. Addiction, as we talked about at the beginning, it hides in the secrets and the shadows. And if you're out there and you're struggling, the first step is just to raise your hand and tell anyone, tell your significant other, tell your parents, tell your clinician that you're working with. Because until you do that, there's no way forward.

And then, if you're unsure of who to connect to get help, there are wonderful helplines; 1-800-GAMBLER is a good one. There's 1-800-MY-RESET as well. And those will provide hotline assistance in addition to connecting with resources, because there are good resources, there are good therapies, good meds, and good self-help groups.

And I think you were starting off by talking about therapies. And so yeah, if someone comes to see you therapy, you can use cognitive behavioral therapy or psychodynamic therapy to understand why they're using. A lot of it is just doing harm reduction and relapse prevention stuff too, like setting protections on their money, involving family, having themself exclude from different apps and casinos if that's an issue. And so, that's a lot of what I work on if people present to me.

Dr. Daniel Knoepflmacher: And those resources like 1-800-GAMBLER, I mean, they even have those in the casinos, and I'm assuming online.

Dr. Jonathan Avery: If you squint at the bottom of the commercials, in the bottom of the apps, you take something out, you can maybe see that they're obligated to say that exactly.

Dr. Daniel Knoepflmacher: Maybe that's some legislation like with the cigarettes and when you go to certain countries or even here where they have this huge thing emblazoned across, like they need to do that more. I like what you said about the person just walking through the door, and I guess that highlights so much of the work you've done, that being the person on the other side of that person coming from the door, that's the moment you want to make sure to be as empathic and accepting as possible, because they've just taken a huge step to get to you.

Dr. Jonathan Avery: Yeah. What's so humbling about being an addiction psychiatrist—and that's true for psychiatry in general around a lot of things—it's often the first time they've said the thing they're so shameful about out loud. And you see both the suffering and the relief in having someone else to share it with and to go through it with. And then, you know, you can work with it and find a way forward. And so, it can be very hopeful. And people do get better. And it's not just therapy by the way. There are interesting meds, like naltrexone, which is sort of like the med for all addictions these days. It's an opiate antagonist that helps with impulsive behavior that's been shown to be good for gambling.

And then, of course, we're psychiatrists so we can help with all the other co-occurring conditions we mentioned before: the ADHD, the depression, the anxiety, certainly bipolar disorder, if there are other substances. And so, seeing a psychiatrist is often important to get those co-occurring conditions, and then potentially meds to help with some of the impulsivity around gambling as well.

Dr. Daniel Knoepflmacher: And what about 12-step groups? I mean, that something that plays a big role in addictions in general. What about Gamblers Anonymous or other organizations like that?

Dr. Jonathan Avery: Yeah. I think actually that Gamblers Anonymous or Sex and Love Addicts Anonymous, these groups that exist for behavioral addiction sometimes are almost more powerful than the 12-step groups for alcohol use disorder or alcohol, just because people are often so alone with their behavioral addictions that to enter a room with other people who are going through the same thing and to talk about it with them and to know you're not alone, it really does relieve a burden for folks as well, even beyond seeing a psychiatrist or therapist.

And these groups are so accessible. They're available nationwide. They're available on Zoom, in-person. And so, suddenly, you can go from being all alone in your room with this to having a group of people that are in it with you that can support you. You can get a sponsor, you can work the steps in the same way you do for 12-step groups for substance use disorders or alcohol. And that is an essential part of treatment often. People are often a little nervous about going to groups. My New Yorkers are very nervous about group processes. But once they're there, I've never sent someone there for gambling who sort of then regrets it. They often feel really welcome, and that it's a welcome resource for them.

Dr. Daniel Knoepflmacher: And you mentioned the individual psychotherapies, CBT using psychodynamics psychotherapy to kind of understand what the meaning of this gambling pattern is for the person. And then, also, motivational interviewing, I imagine, is in the mix as well.

Dr. Jonathan Avery: Yeah. MI is sort of the mainstay of a lot of addiction care and getting the motivation to come from them. Because there's some folks that we do see with gambling, especially the way it's so promoted by society these days who are getting themselves into trouble but aren't ready to change the behavior yet.

And for those people, motivational interviewing is important. It helps sort of tease out for the person what the pros and cons of their behavior are. And it works on getting their change talk to come from them. Because one of the big principles as an addiction provider is not to be a finger wagger or an information dumper, but you're really in it to help that person change on their own, more or less, and to guide them there. And so, motivational interviewing is a good approach to the patient, especially the person who is not completely sold yet that they should change a behavior.

Dr. Daniel Knoepflmacher: And, thinking about behavioral interventions, especially when we're talking about technology playing such an important part of this. I know just for cell phone use, there's these things like Brick, which you can put on your phone to kind of limit the amount of social media use or other apps that you use. I imagine there should be good technologies out there that could be really helpful that assuming somebody wanted to support their own recovery with this could really make a big difference.

Dr. Jonathan Avery: Yeah. There's good stuff out there. There's self-exclusion programs, there's software blockers. There's also a bunch of recovery apps, that are available online as well. The problem has emerged though, that there's just so many ways to gamble and bet these days that, even the most sophisticated technology, you can still be betting on the war. Like we mentioned, there's so many platforms these days that these software blockers can't block all of them. And it's very hard at times for patients with gambling disorder.

The real big change often comes when you give up sort of all your money to a family member or to a financial advisor or someone where you just don't have access to put it in anywhere and really keep close tabs on your credit cards and your credit lines. And really, I mean, one of the big principles in addiction is you want as many steps between the desire to use and actually using. And so, you need not just these blockers, but you need eyeballs on your money. You need people helping you manage it. And that can feel powerless. People don't like giving up control of anything, but especially their hard-earned money, and especially if they've had a problematic relationship with money, it can be hard. But often, that's the critical step is, once get give up access for just the time, just so your brain can reset, that's often a game-changer.

Dr. Daniel Knoepflmacher: Back to medications, you named a few earlier. Naltrexone, we're very familiar with when it comes to alcohol. In this case, I imagine it's working on the same pathways. I mean, because we're talking about dopaminergic effects. Can you just speak a little bit about naltrexone, how it's working here, and then also what you've seen anecdotally from patients using naltrexone?

Dr. Jonathan Avery: Naltrexone is an opiate blocker that downstream then cools off sort of the reward pathway. And in that way, it helps people with craving, especially towards the alcohol and opiates, it's been well demonstrated, but also to a host of other behaviors and including gambling. And so, ii helps with craving for it, it helps with impulsivity around doing it. It also causes a little weight loss, which if people don't mind. So, it's also well-tolerated. It's pretty an easy med to start and to take.

There are a couple other meds though, I guess, worth mentioning as well, including topiramate, which is sort of a mood-stabilizing med that helps with impulsivity. Sometimes we even use meds for bipolar disorder when people don't have bipolar disorder, like lithium to help with some of the compulsivity and impulsivity around some of the gambling behavior, but a lot of the other meds ends up being treating the co-occurring disorders as I mentioned previously.

Dr. Daniel Knoepflmacher: Well, you talked about weight loss. This reminds me of something. If you go back and listen, talked about two years ago, it was a little bit over two years ago when you were on last time, which is the GLP-1 agonist medication, popularly known as Wegovy, which is semaglutide, or let's say Zepbound, which is tirzepatide. These have been shown with some recent increased studies to be effective for certain addictions. Can you comment on all about their application for gambling?

Dr. Jonathan Avery: Including for gambling, it seems. Yeah, of course. The GLPs are good for every condition that can ail a human being these days, to be honest. And part of that is as it relates to addiction, is that we do have those same receptors in our reward pathway. There's pretty good evidence that it does help with substance use disorders and these behavioral addictions now.

And there's a lot of promise, especially as we get these newer generation, more targeted, better tolerated GLP drugs, that it could be a game-changer the field of addiction, including these behavioral addictions. And anyway, gambling disorder often results in overeating and other impulsive behavior and alcohol use disorder. And so, sometimes the GLPs can cool off a lot of some of the complementary behaviors and conditions as well.

Dr. Daniel Knoepflmacher: Any other new things out there being studied or things that you're looking at?

Dr. Jonathan Avery: Everyone's trying TMS and ketamine and hallucinogen treatment for the behavioral addictions for gambling as well. And there's some promise there. But still, despite all of that and the GLPs, it does come down to a lot of just the behavioral changes in the end, to be honest, the Gamblers Anonymous, getting a good therapist. And these meds sort of help around the edges, but it often requires a real systemic change in your life to really get on the other side of these.

Dr. Daniel Knoepflmacher: We'd all love to just have that magic pill or the injection that then we don't have to do all the hard work in behavior and therapy, and relationships, which of course is really crucial and central to all of this. And along those lines, families are a huge part of this. And you've done a lot of work with your programs here in educating families, who have members that are struggling with addiction. So, I'm wondering if you can talk about the work with families when it comes to gambling disorder.

Dr. Jonathan Avery: Yeah. Nobody recovers alone. And I think the temptation when someone comes to see me is to try to recover on their own, but it's almost impossible. You need that community of people that have been through it too. But you need your family. You need your partners and your parents and your friends, and you need to be open and honest with them. I think that's the way through. And increasingly, we're recognizing that addiction is a family disease and it impacts everyone. And so, we got to bring the family in.

And family, for gambling, as I mentioned, is especially important because these financial decisions that you make when you're gambling impact everyone in the family. And financial infidelity is something that when you're hiding your gambling losses from your significant other, that's some of the biggest hurt I see in my clinical practice when someone comes forward and announces to their significant, "Hey, I've lost all of our retirement savings from gambling." And so, family needs to be involved not only in their treatment, but you often need couples therapy or family therapy to repair some of the hurt and rebuild some of the trust that's been lost through gambling.

Dr. Daniel Knoepflmacher: Well, John, we've covered so much. And I have one last question, thought that has come to mind as we're talking about all of this. So, we think about addiction often as a model of abstinence versus harm reduction. And I know, when it comes to AA, often with alcohol, there's a culture of complete abstinence. And that's difficult, but you can stop yourself from drinking alcohol. There's mocktails. You can take Antabuse or something along those lines.

When it comes to addictions, I'm curious about that same concept of abstinence. If somebody really is not allowed to gamble, we've talked about how this is just suffused through our lives everywhere. I know that people do March Madness brackets. We're in March now, and this is the time when people are doing this. Is that something that somebody who is recovering from addiction should not put $20 into that, because you have to have this complete sense of abstinence? Or is there a different way to maybe think of it more from harm reduction standpoint? I'm just curious how you handle that as an addiction psychiatrist.

Dr. Jonathan Avery: Yeah. One of the biggest changes in the addiction field over the last 10 to 15 years has been this idea that people can recover without being abstinent. And we've talked a lot about that, especially with alcohol use, where people have had a severe alcohol use problem and they can reach a point of moderating and consider that to be in recovery actually.

It's a little murkier with gambling at times in that, often, and especially 12-step recommends this, a lot of therapists do, often you do need a period of real abstinence, even from watching sports sometimes in that initial period just to reset. And then, if you're going to moderate, and some people come to me and they do want to moderate gambling, you just have to do it very intentionally, often because sometimes the stakes get really high in terms of financial losses and family systems. So, you just initially often are taking this abstinence approach. But then, as time goes on, if the March Madness comes around or the Super Bowl comes around and you do want to bet. You just have to be very intentional about it. And that's generally the rule for moderation in general, is that once people are in recovery, if they're going to moderate, it shouldn't be an impulsive thing. It should be something that's really thought out, discussed with your family, discussed with your therapist. If you're hiding it, that's trouble. And so if you're going to moderate, it's got to be out there in the open. And everyone's got to be on the same page.

But yet to your point, I mean, it's been such a part of culture these days. Like, my family has a family like March Madness poll, and if one of us struggled from gambling, are we not going to do it? It feels wrong and that feels off for a lot of folks too. And so, you just got to be intentional and thoughtful. And ideally, everyone in your family knows and you're talking about it and that's sort of the best way to go.

Dr. Daniel Knoepflmacher: Well, John, I could keep asking you questions, but I don't want to make this podcast too long. I just enjoy talking to you. And fortunately, for all of you out there who are listening, you can have a lot more of John on his podcast, which is called thriving with addiction. I love that title because that's the point. That's the kind of humanistic, empathic approach that you have, that this is not something that should be judged or stigmatized. It's something which you can thrive as you struggle to recover from addiction.

Dr. Jonathan Avery: It is something that's in all of us and in all our families. And I get suspicious when we sort of talk about overcoming or ignoring it. This stuff that's addictive is everywhere in us, around us. And we just have to be talking about it and be mindful about it. And I think that's the best way through.

Dr. Daniel Knoepflmacher: It's very true with what we talked about today clearly. I mean, this is everywhere. And so, please check out John's podcast so you can learn more from all of the amazing people that he has on his show. But thank you, John, for taking the time to come with me today and talk about this, because I think it's on a lot of people's minds and it's certainly a growing issue in our society.

Dr. Jonathan Avery: No. Thanks for having me. And thanks for all you do with your podcast and everything here at Weill Cornell.

Dr. Daniel Knoepflmacher: Well, thank you again, John. And thank you to all who listen to this episode of On The Mind. We are the official podcast of the Weill Cornell Medicine Department of Psychiatry. As you probably know, our podcast is available on all major audio streaming platforms. I'm not going to name them all because you know them, but they include things like YouTube and Apple Podcasts.

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