Chasing the High: Why Gambling Disorder Belongs in the Addiction Conversation

The clamor of the casino floor has given way to something quieter, harder to see: the silent glow of the smartphone screen. For centuries, gambling carried a recognizable cultural image: it lived in casinos, racetracks and back rooms; it was episodic and spatially bounded. In many cases, it was visible enough that concern would flare before its harms became entrenched, and before gambling could evolve into a gambling disorder. That is no longer the world clinicians face.

New digital platforms have made gambling constant, private and frictionless. The ever-expanding perimeter of wagering now includes sports betting apps, online poker, loot boxes and skins betting — prediction markets like Kalshi now let people bet on anything from who will be the next Fed Chair nominee to which musical artist will top the charts. This growing network of options has recast wagering as a routine form of entertainment, folded seamlessly into the daily rhythms and pockets of more and more Americans. What once required travel, cash and social exposure now requires only a smartphone, a stored payment method, and a moment of agitation, boredom or hope.

For most people, gambling remains occasional and contained. But that fact can obscure the more important one: Online betting is accelerating the path from casual play to clinically significant harm for a meaningful minority of users, and it is doing so with unprecedented speed.

The transition from initial experimentation to clinical compulsion can occur without ever crossing a recognizable social or behavioral threshold. Because the digital ecosystem is allowing gambling to happen in isolation, the escalation of time spent wagering, financial loss and internal preoccupation typically unfolds without the public scenes or obvious red flags that historically alerted families or clinicians to a developing crisis.

This is why gambling disorder can no longer sit at the margins of the addiction conversation, and why its relationship to substance use disorder (SUD) deserves far more clinical attention than it currently receives. To keep treating their intersection as peripheral is to miss one of the most rapidly expanding and clinically consequential patterns of co-occurring addiction in contemporary life.

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Gambling disorder is the only behavioral addiction recognized in the DSM-5 alongside substance use disorders. It is characterized by persistent, problematic gambling behavior that leads to clinically significant distress and impairment in personal, social or occupational functioning.

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Gambling Disorder and Substance Use Disorder: Two Sides of the Same Coin

As the only behavioral addiction included in DSM-5’s addiction category, gambling disorder occupies a singular position in modern psychiatry. This distinction reflects a growing recognition that addiction is not defined solely by the presence of an external chemical. It is also defined by what repeated behavior does to the brain’s reward systems, decision-making and emotional regulation. This is where the conversation becomes clinically important, and the overlap between co-occurring substance use disorder (SUD) and gambling disorder becomes undeniable.

Key Facts About Gambling Disorder:

• Alcohol and other drug challenges are roughly four to seven times more prevalent among people with gambling problems than in the general population.
• No medications have been approved for the treatment of gambling disorder.
• Despite comorbidity rates of 20%-50% with SUDs, the condition remains largely invisible within standard addiction frameworks.
• Roughly 6%-16% of adolescents reported online gambling in the past year.

Alcohol and other drug challenges are roughly four to seven times more prevalent among people with gambling problems than in the general population. Emerging research points to shared underlying genetic vulnerabilities, biological markers, cognitive deficits and shared risk factors like trauma history and age.

In both gambling and substance use, behavior becomes organized around anticipation, pursuit and temporary relief. A winning bet reinforces behavior in ways that closely parallel drug-related incentive learning and engages similar reward and control circuits in the brain such as the ventral striatum, amygdala and prefrontal cortex (the brain regions responsible for reward, emotion and decision-making). These overlapping mechanisms help explain shared presentations, like compulsive pursuit despite consequences that would seem, from the outside, intolerable, or reward reinforcement strong enough to override longer-term interests and values, including maintaining important relationships or meeting basic needs like housing.

Despite numerous commonalities, society often downplays the severity of gambling — similar to its treatment of culturally celebrated substances like alcohol. It frequently characterizes the behavior as an impulse control problem or a habit unique to the individual, rather than a systemic, population-level concern. Viewed through a clinical lens, gambling and SUDs appear less like separate problems and more like overlapping expressions of the same underlying vulnerabilities.

What Makes Gambling Disorder Unique: Financial Trauma, Shame and Suicide Risk

Even as we acknowledge these shared biological roots, gambling disorder introduces specific clinical challenges that are absent in traditional substance use profiles. One of the most overlooked is financial trauma.

Unlike SUDs, where financial harm is often secondary to the illness, economic devastation is a definitive and distinct clinical driver in gambling. The disorder directly produces debt, depleted savings and legal risks that sustain cycles of harm. While clinicians are trained to treat the psychological and behavioral dimensions of addiction, they cannot resolve the material aftermath of a gambling disorder. The financial damage may take years to repair and serves as a continued source of distress and psychic entrapment even after the acute symptoms of the disorder, such as the cravings and impulses, have subsided.

The damage is intensified within the digital gambling landscape, where losses remain hidden and accumulate extensively without the physical decline or public disruption that typically signals an SUD. This absence of visible indicators reduces the opportunities for family, colleagues, or clinicians to intervene early. Consequently, by the time an individual seeks support, the crisis may encompass not only the addiction itself, but foreclosure, relational breakdown and profound despair.

Gambling disorder also puts people at a uniquely heightened risk for suicide. Debt, and the shame surrounding it, are often experienced not simply as hardship but as total personal collapse. Unlike in SUDs, where despair often arises diffusely from intoxication, declining health or chronic psychosocial instability, shame in gambling disorder centers on seemingly deliberate financial acts that are visible, countable and hard to rationalize away. This can lead to a pervasive sense of self-engineered ruin and despair rooted not in what an outside substance did, but in what the person believes they did to themselves. This leads many to believe that they have not simply made mistakes but have become irredeemable — a powerful perception that does not reflect the neurobiological reality of the disorder.

The distinction is clinically meaningful. Gambling behaviors appear highly volitional and self-sabotaging, amplifying perceptions of personal agency in one’s downfall, unlike the more externalized or physiological attributions common in SUDs. Patients with gambling disorder report elevated guilt and shame tied specifically to personal betrayals and financial devastation, distinct from the broader withdrawal-driven dysphoria seen in SUDs.

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You’re not alone. If you or someone you know is in crisis, contact the 988 Suicide & Crisis Lifeline. Call or text 988, or use the 988Lifeline.org chat. If it’s an emergency, call 911.

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Gambling Disorder Treatment: Bridging the Gap in Screening and Care

These features make gambling disorder clinically distinct and mismatched to the way behavioral health still screens for, detects and delivers gambling disorder treatment. Gambling disorder often emerges later, in more concealed and financially catastrophic forms, yet most clinical workflows remain oriented toward substance-based models of visibility, assessment and intervention. When screening does occur, many intake forms still ask about gambling in dated, narrow ways that reference traditional casinos, lotteries or horse racing, failing to capture the reality of modern digital formats. In behavioral health settings, this means gambling disorder goes largely undetected.

This has far-reaching implications for both gambling and substance use, as there exists a bidirectional relationship between the two disorders. Sometimes gambling appears first and substance use follows; in other cases, SUD comes first and gambling emerges later as another expression of the same underlying vulnerability. A clinician who treats only the substance use, without assessing for gambling, fails to address the underlying reward dysregulation and leaves an active pathway for addiction to transfer from one harmful behavior to another.

When gambling disorder is identified, a number of treatment options exist. Borrowing from traditional 12-step models, Gamblers Anonymous remains one of the most widespread supports, offering peer mentorship and recovery accountability. Cognitive behavioral therapy (CBT) and motivational interviewing (MI) are both well-supported psychosocial treatments, with most CBT models being adapted from SUD frameworks targeting maladaptive thought patterns, cognitive distortions, cravings and behavioral triggers.

Additionally, several pharmacological agents across dopaminergic, opioid, and serotonergic systems have been evaluated for gambling disorder, including antidepressants, lithium and opioid-receptor antagonists. While open-label studies have shown promise, double-blind placebo-controlled trials have demonstrated mixed efficacy, so to date, no medications have been approved for the treatment of gambling disorder.

The absence of approved pharmacological treatments positions psychosocial and behavioral interventions as the primary clinical approach for managing gambling disorder. Despite available modalities, implementation remains absent or inconsistent, often because behavioral health providers receive little to no formal training in treating gambling disorder.

This diagnostic silence is particularly harmful given that gambling disorder rarely occurs in isolation: Despite comorbidity rates of 20%-50% with SUDs, it remains largely invisible within standard addiction frameworks. This systematic omission leaves the complex and intertwining needs of these individuals unexamined and unaddressed.

Youth Gambling Addiction: How Online Betting Exploits Adolescent Vulnerability

Adolescents and young adults warrant special concern, particularly in the growing context of youth gambling addiction. Young people are already at elevated risk because adolescence is a neurodevelopmental period associated with heightened impulsivity, increased reward sensitivity and greater propensity for risk-taking behavior. Online delivery channels reduce barriers to wagering at a time when reward systems, impulse control and identity structures are still maturing, which creates a heightened susceptibility to the addictive mechanisms of gambling. A culture of saturation exploits these vulnerabilities and normalizes accessibility through personalized promotions and mainstream advertising, creating an environment that invites and encourages the behavior, teaching youth to experience risk as recreation from an early age.

Data coming out of Tennessee Redline in 2025, after the state legalized gambling, found that out of those who identified age, more than 20% of gambling-related hotline traffic came from callers younger than 24. These numbers are telling not simply because they are high, but because they suggest that users as young as 12 are encountering harm quickly, successfully circumventing weak age verification controls and developing gambling challenges — often before the adults around them fully understand the threat.

The industry’s ability to camouflage its mechanics within common digital interactions obscures its inherent risks and exploits age-related vulnerabilities. Wagering no longer arrives in young people’s lives as a clearly demarcated vice, but within the familiar subcultures of sports fandom, gaming, competition and entertainment.

A large 2021 systematic review of adolescent online gambling found that roughly 6%-16% of adolescents reported online gambling in the past year, with higher rates among boys. Youth who engage in online gambling show higher rates of impulsivity, lower school performance and more frequent use of alcohol, tobacco and other drugs than their non-gambling counterparts. For behavioral health providers, the implication is clear:  We should assess gambling risk with substance use risk, because the two often emerge together, reinforce one another and lead to negative consequences.

The Future of Integrated Addiction Treatment: Gambling and Substance Use Together

The current paradigm often treats SUD and gambling disorder as separate conditions, even though they’re parallel expressions of the same dysregulated reward-learning processes. They emerge from overlapping vulnerabilities, recruit identical neurobiological processes and frequently intensify one another. This co-occurrence finds a catalyst in the digital wagering ecosystem, which removes the friction of time and space to make reward-driven risk immediate, private and omnipresent. Consequently, clinicians are increasingly encountering individuals whose substance use and gambling behaviors evolve in tandem, shaping risk patterns older treatment models were not designed to address.

The clinical field is currently in a position where it must adapt to these shifting realities. Prioritizing alignment across addiction types supports a movement toward integrated care, acknowledging that gambling and substance use act as bidirectional gateways to one another. Accelerating workforce training, updating screening tools and continuing to expand evidence-based treatment options will prevent care systems from building for simplified populations while treating far more complex ones.

Recognizing behavior patterns earlier is about seeing the full constellation of vulnerabilities, exposures and experiences shaping a person’s choices and risks. From that vantage point, gambling disorder becomes an integral part of the broader architecture of addiction rather than a peripheral issue.

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