In his treatment of gambling addicts, Dr. Timothy Fong has heard the stories of people who crave gambling the moment they wake, who are able to stay up 36 hours straight to place wagers, and even would rather gamble than have sex.
Gambling addicts don't look like junkies, and the depth of their addiction doesn't show on their faces. Instead, it's hidden away in their finances and relationships.
These people will sell their possessions, steal from family members, and rack up debts they'll never cover -- just for the high of pulling the lever or placing a bet. Gambling goes from fun to compulsion.
"Compulsive gambling is all consuming," Dr. Fong said. "It's damaging beyond belief and they continue to gamble. It's no longer about fun. Gambling becomes about escaping life's problems, desperation, the need to feel normal, taking away the urges and the itch to gamble."
Dr. Fong is the co-director of the University of California-Los Angeles Gambling Studies Program, a pioneering effort that examines the causes and course of gambling addiction and develops evidence-based treatment to address it.
The prevalence of what addiction specialists call pathological gambling is low -- probably less than 2 percent of the nationwide population fits the clinical diagnosis. But the costs associated with pathological gambling can be incredibly high.
"It doesn't look like it's that huge an issue if you look at those numbers. [But] it only takes one guy like [former Ohio State quarterback] Art Schlichter to affect 30 to 40 people and squander $10 million. It doesn't take a lot of problem gamblers to create a really, really big financial mess," said Scott Anderson, problem gambling coordinator with the Ohio Department of Drug and Alcohol Addiction Services.
Studies have found compulsive gamblers are more likely than the general population to declare bankruptcy, have higher rates of unemployment, and carry higher loads of debt.
For states though, casino chips are often viewed as magical beans that can sprout millions in new revenue and stabilize shaky budgets.
That was part of the message behind the successful 2009 drive to bring Las Vegas-style gambling to Ohio: We'll bring construction work, tax dollars, and thousands of permanent jobs.
But experts say the casinos are likely to sow a new crop of problem gamblers.
Less than a year before the casinos open, treatment providers aren't sure how to prepare.
Substance Abuse Services Inc. in Toledo might treat 20 to 30 people a year for gambling addictions, which often are paired with other mental disorders or addictions. It's the expectation of Director Al Woods that more people gambling will lead to more people developing gambling problems, and in turn more people seeking help.
"The question is, are those people around here?" he asked.
Penn National Gaming Inc., developer of Toledo's $300 million Hollywood Casino, has said it expects a market radius of 90 miles.
A nationwide study on gambling habits conducted in 1999 by the National Opinion Research Center at the University of Chicago showed the prevalence of pathological gamblers among those who live within 50 miles of a casino are nearly double the rate of those who live farther away.
More recently, researchers have questioned whether the difference remains that large with the proliferation of online gambling. The study, although more than a decade old, is still a gold-standard measure for gambling behavior in America. But no definitive study has been conducted on how many more problem or pathological gamblers might come from the casinos in Toledo, Columbus, Cleveland, and Cincinnati, or where they might be concentrated.
But Rob Walgate, vice president of American Policy Roundtable, an anti-gambling group, argues that damage will be done and much of it will hit closest to home. "What happens when these casinos pop up in markets? You're opening the ability for people who can least afford it to gamble. People who didn't have the ability to travel to another area to go to a casino now have the ability to gamble," he said.
An evolving issue
Gambling has come a long way from the stereotypical smoke-filled seedy saloon and into the mainstream. Twenty-two states allow casino gambling, and, according to the American Gaming Association, a quarter of Americans have gambled at a casino in the last 12 months.
Likewise, the way we look at problem gamblers has evolved. They used to be seen as having a dearth of willpower and weak moral fiber.
The addiction is reaching a medical parity with drugs and alcohol. Pathological gambling has been added to the Diagnostic and Statistical Manual of Mental Disorders, the clinicians' bible for making diagnoses. Gambling is the only recognized nonchemical addiction.
Experts say pathological gambling, like other medical and psychological conditions, shows up only with the right mix of biological, psychological, and social-risk factors. That includes how a person is programed to deal with risk-taking, chance, and wins and losses, how gambling is used to deal with stress or conflict, and how available gambling is.
But some people argue there's more to it than that.
Mr. Anderson of the Ohio Department of Drug and Alcohol Addiction Services said the science that goes into the newest era of slot machines, with lights bright enough to excite but not too bright to fatigue and seats that vibrate to connect the player to the game, is fascinating but scary.
"Their goal is to make you play faster, longer, and more," he said.
Jim Baldacci, deputy chief compliance officer for Penn National, said there's nothing sinister about slot-machine design. "The machines are designed to appeal to people, just like any product you buy. … [They're] designed to give people what they want," he said.
If machines are popular, they stay on the floor. If they're not popular, the firm replaces them with something that is. He said there's nothing about casinos that cause stronger gambling urges than a day at the horse track. That isn't the goal, anyway.
"We don't want to break people," Mr. Baldacci said. "We want to get a fair share of people's recreation dollars. That's what we're after."
He does acknowledge that a casino opening in a market may bring a brief blip of more reported gaming problems that later retreats to normal prevalence levels. Experts agree but say the blip can vary greatly.
Dr. Fong said when casino gambling first came to Biloxi, Miss., and Detroit, problem-gambling prevalence rates for those living within 50 miles of the casinos went as high as 10 to 15 percent in the first three to five years but then fell back to the more standard 2 to 4 percent range.
Some older studies show that problems are more likely to spike when casinos are introduced to a gambling-naive area, but gambling isn't new to Ohio. It has horse tracks, the Ohio Lottery, weekly poker games, church bingo, and Internet cafes. Even casinos aren't the novelties they once were; most Ohioans live within a couple hours of a gambling house.
Still, Dr. Fong said the rates of problem gambling ultimately will have some correlation with the ease of gambling.
"Just like if we were to have cocaine available in every 7-Eleven, we'd have more cocaine problems. It's just availability and access. If you have more brick-and-mortar casinos, more online casinos, more access to credit, you're going to have a recipe of more people engaging in the behavior and we're probably going to have more people developing these problems," he said.
Cost of treatment
"To treat those people, it's going to take thousands of dollars. It's not going to take hundreds of dollars per addict. It's going to take thousands per addict. It's going to be a big number," Mr. Walgate, the gambling opponent, said.
And that's a point upon which there seems to be a consensus: Treatment has been badly underfunded.
The Ohio Lottery Commission gives $335,000 a year to the Ohio Department of Drug and Alcohol Addiction Services for problem-gambling services. That pays for six treatment programs statewide, including Substance Abuse Services Inc., and covers six gambling counselor training sessions by the Problem Gambling Network of Ohio.
According to researchers from Cleveland State University, that's not nearly enough. In a 2005 study, they concluded that mitigating gambling issues would require nearly $22.9 million. If casino gambling were allowed, the study's authors said several million dollars more would be necessary. There's more money coming, but not that much.
Included in the constitutional amendment Ohio voters passed in 2009 is a provision that 2 percent of the tax collected from the casino operators will go to a state problem gambling and addictions fund managed by the Ohio Department of Drug and Alcohol Addiction Services. Casino officials estimate that will amount to between $10 million and $12 million a year once all four sites are up and running.
State health officials say that will bolster the treatment programs, but with no solid data to fall back on, they're not sure how much they'll need.
"We don't know what enough is," Mr. Anderson said.
The Department of Drug and Alcohol Addiction Services hopes to increase the budgets and services at the state's treatment centers. But until the money starts rolling in, officials are hesitant to budget any of it. Compounding the questions is the amendment's official language. It says the money will be used for "treatment of problem gambling and substance abuse and related research," not just gambling specifically.
"That's really, really broad," said Jenny Campbell-Roux, a Dayton-area addictions counselor and director of the Problem Gambling Network of Ohio. "We're going to have to work hard to make sure a good portion of it is dedicated just to problem gambling."
It'll be up to the state Casino Control Commission to decide how that pot of money gets divided.
The commission is still working through all sorts of issues -- from casino security to card counting -- and Chairman Jo Ann Davidson said problem gambling remains a top concern. It also will be a top concern when splitting the money, but she wouldn't be more specific.
"I don't want to get into percentages, but I think this will be the key factor when we negotiate with ODADS [Ohio Department of Alcohol and Drug Addiction Services]."
Also yet to be written are the problem-gambling regulations that apply to the casinos themselves.
The two casino operators -- Penn National in Toledo and Columbus and Rock Ohio Caesars in Cleveland and Cincinnati -- will be required to post a gambling help-line number throughout their four casinos and on advertising materials. Ms. Davidson said the commission is likely to require them to use the Cleveland-based hot line the Ohio Lottery Commission already contracts with, spending about $34,000 annually. The chairman said she and her colleagues believe having more familiarity with available resources will better serve callers.
"We want to make this very state specific," she said.
Penn National also has self-exclusion lists, which allow individuals effectively to bar themselves from gambling in a Penn National casino. If the person is recognized, the casino must turn him or her away. The laws vary from state to state, though most require the confiscation of jackpots and some allow the arrests of violators. Mr. Baldacci and Ms. Davidson said those rules in Ohio are still evolving. Aside from state law, Mr. Baldacci said Penn National also follows the American Gaming Association's code of conduct for responsible gaming.
Among the requirements: Everyone who works at a Penn National casino is trained to look for overt signs of problem gambling and report up the chain if they see someone they suspect is playing irresponsibly.
"If they suspect someone's got a problem, they have to report up the chain and someone will approach them [and] ask them if they're all right. But we've got to be careful because our folks are not mental health counselors," Mr. Baldacci said.
Much of what the company does must start with the gamblers themselves. People can opt out of receiving promotional material from the casino and can place financial restrictions on themselves, for example, being unable to to cash checks or get casino credit.
Each casino's general manager does have the authority to bar individuals from the property for issues such as cheating, unbecoming behavior, and a suspected gambling problem.
Mr. Baldacci said most who are approached end up in a state gambling program, though exclusions do happen. He did not know how many people have been excluded because of suspected gambling problems.
"We're not ashamed of our product," Mr. Baldacci said. "We want them to play, but we want them to play responsibly."
Contact Tyrel Linkhorn at: firstname.lastname@example.org or 419-724-6134.