Gambling Addiction as a Public Health Crisis: Harms, Stigma, and Paths Forward

The global gambling industry is expanding due to increased legislation and an influx of online gambling opportunities accessible through mobile phones. Horrifyingly, it is predicted that net losses by consumers could reach up to $700 billion by 2028 [1]. While gambling is often framed as a form of entertainment, a substantial minority of individuals develop problematic or disordered patterns of behavior. Similar to disordered thinking surrounding alcoholic substances and drugs in which the user feels the need to overuse in order to maintain the emotional effect they feel from the substance, a gambling addict will persuade themselves to continue the self-destructive activity to achieve an acute, emotional high [5]. Thus, gambling addiction is increasingly recognized as a significant public health issue – extending well beyond financial loss – and global estimates suggest that around 80 million people experience gambling disorder [2]. According to the National Council on Problem Gambling, 2.5 million people in the US have a “severe gambling problem” and another 5 million to 8 million have “mild or moderate” problems [3]. The way in which the compelling gambling industry is structured only promotes the increase of gambling disorders, so the question is: how do we mitigate widespread harm to population wellbeing while addressing the stigma that prevents those from seeking treatment against this clinical addiction?

Financial harm is typically the most visible consequence of gambling addiction, which is one, more surface level incentive to treat it. Individuals frequently accumulate substantial debt, depleted savings, experiencing bankruptcy or housing insecurity. A study found that 22.8% of pathological gamblers had declared bankruptcy with an average debt of $53,103, with debts ranging from $5,000 to $250,000 [4]. These financial pressures in turn enforce a cyclical pattern of individuals continuing to gamble in an attempt to recover losses, thereby exacerbating their situation. On a broader scale, the annual social cost of gambling addiction in the U.S. has been estimated at $14 billion, expenses adding up in healthcare, lost productivity, and criminal justice expenses [5].

Yet, beyond financial consequences, gambling addiction is strongly correlated and interrelated with a range of other mental health issues. A large meta-analysis found that 30.9% of individuals with gambling disorder have mood disorders (such as depression) and 29.9% have anxiety disorders, while 34.2% experience substance abuse disorders [6]. In clinical populations and in treatment services for problem gambling, between 22 and 81 percent of individuals have been found to have suicidal ideations, while between 7 and 30 percent of individuals have had suicide attempts [7]. These findings underscore that gambling addiction is a life-threatening condition, highlighting the need for effective intervention not only to improve their financial condition but to augment the physical safety and wellbeing of the individual. Despite the evident severity of these harms, stigma remains a major barrier to recognition and treatment. Individuals experiencing gambling harms are often perceived as irresponsible or lacking in self-control, which reinforces shame and discourages help-seeking. As many as 90% or more of people with gambling problems never seek help [8]. Fear of judgment, wishing to conceal the extent of their indebtedness from others, and internalized shame all contribute to underdiagnosis and undertreatment.

Addressing gambling addiction requires intervention on clinical, social, and policy levels. Evidence-based treatments such as cognitive behavioral therapy (CBT) and peer-support programs have shown effectiveness in helping individuals reduce or stop gambling behaviors [9]. Peer-support programs, including mutual aid groups, can also provide important social support and reduce isolation. If we can work to decrease isolating sentiments, more people will gradually seek help, and it will become more of a social norm. Additionally, policies such as self-exclusion programs, which allow individuals to voluntarily ban themselves from gambling venues or platforms, spending limits, and digital monitoring tools should be implemented to help individuals manage their gambling behavior. Critically, these resources should be done in a manner that enhances the gamblers autonomy in aiding their own situation, rather than invoking

a sentiment of taking over their lives unwillingly.

Furthermore, preventative public health measures are essential. Efforts to reduce stigma through education and awareness can encourage help-seeking and improve early detection, and regulating online gambling environments may help reduce exposure to high-risk products. Addressing gambling addiction requires both support on an individual basis but also on a public basis, modifying and being aware of environments that can contribute to harmful behaviors. We must reconstruct the narrative that gambling addiction is not a personal failing and showing the world how it is in fact a complex public health issue associated with a wide spectrum of harms, including financial strain, mental illness, and significantly elevated suicide risk. These harms affect more than directly to individual subjects, affecting families, communities, and healthcare systems – both directly and indirectly – involved with the individual. Persistent stigma continues to hinder recognition and treatment, so comprehensive solutions such as combining clinical care, public health interventions, and structural reforms are necessary to effectively address the problem.

Reviewed By: Sydney Berger

Designed By: Devin Mulcrone

References

[1] Wardle, H., Degenhardt, L., Virve Marionneau, Reith, G., Livingstone, C., Sparrow, M., Tran, L. T., Biggar, B., Bunn, C., Farrell, M., Viktorija Kesaite, Vladimir Poznyak, Quan, J., Rehm, J., Rintoul, A., Sharma, M., Shiffman, J., Kristiana Siste, Ukhova, D., & Volberg, R. (2024). The Lancet Public Health Commission on gambling. The Lancet Public Health, 9(11). https://doi.org/10.1016/s2468-2667(24)00167-1.

[2] Wardle, H., Degenhardt, L., Virve Marionneau, Reith, G., Livingstone, C., Sparrow, M., Tran, L. T., Biggar, B., Bunn, C., Farrell, M., Viktorija Kesaite, Vladimir Poznyak, Quan, J., Rehm, J., Rintoul, A., Sharma, M., Shiffman, J., Kristiana Siste, Ukhova, D., & Volberg, R. (2024). The Lancet Public Health Commission on gambling. The Lancet Public Health, 9(11). https://doi.org/10.1016/s2468-2667(24)00167-1.

[3] National Council on Problem Gambling. (2024). FAQs: What is Problem Gambling? National Council on Problem Gambling. https://www.ncpgambling.org/help-treatment/faqs-what-is-problem-gambling/.

[4] Grant, J. E., Schreiber, L., Odlaug, B. L., & Kim, S. W. (2010). Pathologic gambling and bankruptcy. Comprehensive Psychiatry, 51(2), 115–120. https://doi.org/10.1016/j.comppsych.2009.04.002.

[5] National Council on Problem Gambling. (2024). FAQs: What is Problem Gambling? National

Council on Problem Gambling. https://www.ncpgambling.org/help-treatment/faqs-what-is-problem-gambling/.

[6] Galeazzi, G. M., Marchi, M., & Castagnini, A. C. (2025). Psychiatric morbidity and gambling disorder: A systematic review and meta-analysis of population-based surveys. European Psychiatry, 68(1), e161–e161. https://doi.org/10.1192/j.eurpsy.2025.10122.

[7] Marionneau, V., & Nikkinen, J. (2022). Gambling-related suicides and suicidality: A systematic review of qualitative evidence. Frontiers in Psychiatry, 13(13), 980303. https://doi.org/10.3389/fpsyt.2022.980303.

[8] Bijker, R., Booth, N., Merkouris, S. S., Dowling, N. A., & Rodda, S. N. (2022). Global prevalence of help‐seeking for problem gambling: A systematic review and meta‐analysis. Addiction, 117(12). https://doi.org/10.1111/add.15952.

[9] Tran, L. T., Wardle, H., Colledge-Frisby, S., Taylor, S., Lynch, M., Rehm, J., Volberg, R., Virve Marionneau, Saxena, S., Bunn, C., Farrell, M., & Degenhardt, L. (2024). The Prevalence of Gambling and Problematic gambling: a Systematic Review and meta-analysis. The Lancet Public Health, 9(8). https://doi.org/10.1016/s2468-2667(24)00126-9.

Rewiring the Will: The Ethics of Deep Brain Stimulation for Treatment-Resistant Addiction

Sometimes individuals will reach a point in their ailments where typical medicine and interventions have no effect. For patients with severe, treatment-resistant substance use disorder (SUD), that can happen after years of failed rehabilitation and medication trials. There are over 75,000 drug overdose deaths in the United States every year, and despite advances in behavioral and pharmacological treatments, over 50% of those receiving treatment for opioid use disorder experience relapse [1]. Considering this issue, deep brain stimulation (DBS) is now a part of the conversation as an intervention for the most critical cases. The procedure has been used to treat Parkinson's disease, but its application to addiction is an entirely other matter. 

What DBS Can Do

DBS is an adjustable, reversible, and non-destructive neurosurgical intervention using implanted electrodes to deliver electrical pulses to areas in the brain [2]. In treating addiction, the primary target of DBS has been the nucleus accumbens (NAc), a subcortical structure involved in reward processing. DBS has shown promising treatment effects in regards to the plastic changes in the NAc that are common characteristics of addiction [3]. The rationale behind performing this procedure is that if drug-seeking is a result of disrupted reward circuitry, then modulating that circuitry could interrupt the cycle of craving and relapse.

Early clinical results have shown some promise. A review of 26 human DBS studies between 2007 and 2023 found that DBS primarily targeting the NAc presented encouraging levels of efficacy in reducing cravings and consumption [2]. While some DBS trials were followed by remission in subjects, 73.2% of patients still reported drug relapses [2]. A 2023 trial found that DBS of the NAc and ventral capsule was safe, feasible, and had the potential to reduce substance use, craving, and emotional symptoms in those with opioid use disorder [1]. While results are not definitive, DBS has demonstrated some favorable outcomes. However, before we continue to move forward with it, this technology deserves a closer look at its ethics. 

The Autonomy Paradox

The central tension in applying DBS to addiction treatment involves autonomy. In general, the definition of autonomy is twofold: it involves the willingness to consent to medical procedures and the ability to lead an independent life without a sense of alienation of self [4]. These two aspects can go in opposite directions, as a patient can consent to a procedure and still experience a sort of alienation of self as part of the outcome.

Broadly, one of the main issues with human trials is this principle of autonomy, as patients with addictive disorders may not have the capacity to fully and knowledgeably consent to such a process. The science of addiction demonstrates how severe SUD impairs the prefrontal systems responsible for deliberative reasoning, especially in the moments when it matters the most [5]. As a result, assessing consent in this population requires an in-depth examination and vetting of their decision making.

On the other hand, refusing DBS because of diminished capacity is another ethical contradiction. As Caplan observed in coerced addiction treatment, there is a paradox in denying autonomy to restore it [6]. If addiction is damaging to an individual’s agency, then pushing to withhold a potential intervention in the name of protecting that agency becomes a circular argument. To solve quandaries like this one, a test like the MacArthur Competence Assessment Tool for Clinical Research can be useful [7]. Measures like this that assess one’s decision-making capacity provide an alternative path that takes into account the complicated relationship between addiction and autonomy. 

Questions of Identity

DBS for addiction raises further questions about what happens to the notion of self when brain circuitry is surgically altered. Some studies posit that DBS significantly alters a patient's personality and identity [8]. It is possible, however, that these discussions have misinterpreted psychosocial reintegration difficulties as DBS-related personality changes [8]. Essentially, the concern may be overstated, but it cannot be dismissed. There is as yet no decisive data supporting whether or not patients undergoing neuromodulation experience a change in their sense of self, as some reports indicate that patients can struggle to evaluate if their "improved" self post-DBS feels authentic or artificially induced [8].

For addiction specifically, this problem has an additional dimension. Conventional recovery from SUD is often perceived by patients as a hard-won transformation. The struggle against addiction becomes part of an individual’s narrative. What happens to that narrative when the craving simply disappears because of an external device? 

A Framework for Proceeding Carefully

Consensus statements on DBS underscore the significance of a multidisciplinary team approach  with those from different fields, including psychiatry, neurology, neurosurgery, and surgery, to collaborate in assessing and treating patients. Additionally, an ethical committee should oversee the interventions for further improvement of patient outcomes [9]. Robust longitudinal follow-ups and standardized criteria for treatment resistance need to be implemented before DBS can become the convention for addiction treatment. 

While DBS offers transformative potential, its application must be guided by ethics and patient-centered care. The population experiencing active addiction is vulnerable, and Deep Brain Stimulation is a very invasive procedure. This combination demands unique care and attention to detail to allow DBS to continue progressing as a viable treatment pathway for those with substance use disorders. 

Reviewed By: Laila Khan-Farooqi

Designed By: Selena Xiao

References

[1] Rezai, A. R., Mahoney, J. J., Ranjan, M., Haut, M. W., Zheng, W., Lander, L. R., ... & Hodder, S. L. (2023). Safety and feasibility clinical trial of nucleus accumbens deep brain stimulation for treatment-refractory opioid use disorder. Journal of Neurosurgery, 140(1), 231–239.

[2] Luigjes, J., van den Brink, W., Feenstra, M. (2012). Deep brain stimulation in addiction: a review of potential brain targets. Mol Psychiatry 17, 572–583.

[3] Chang, R., Peng, J., Chen, Y., Liao, H., Zhao, S., Zou, J., & Tan, S. (2022). Deep Brain Stimulation in Drug Addiction Treatment: Research Progress and Perspective. Frontiers in psychiatry, 13, 858638. 

[4] Lee, K. E., Bhati, M. T., & Halpern, C. H. (2016). A Commentary on Attitudes Towards Deep Brain Stimulation for Addiction. Journal of neurology & neuromedicine, 1(8), 1–3. 

[5] Yuen, J., Kouzani, A. Z., Berk, M., Tye, S. J., Rusheen, A. E., Blaha, C. D., Bennet, K. E., Lee, K. H., Shin, H., Kim, J. H., & Oh, Y. (2022). Deep Brain Stimulation for Addictive Disorders-Where Are We Now?. Neurotherapeutics : the journal of the American Society for Experimental NeuroTherapeutics, 19(4), 1193–1215. 

[6] Caplan, A. (2008). Denying autonomy in order to create it: The paradox of forcing treatment upon addicts. Addiction, 103(12), 1919–1921.

[7] Lo, C., Mane, M., Kim, J. H., Berk, M., Sharp, R. R., Lee, K. H., & Yuen, J. (2023). Treating addiction with deep brain stimulation: Ethical and legal considerations. The International journal on drug policy, 113, 103964. 

[8] Shaw, J., Pyreddy, S., Rosendahl, C., Lai, C., Ton, E., & Carter, R. (2025). Current Neuroethical Perspectives on Deep Brain Stimulation and Neuromodulation for Neuropsychiatric Disorders: A Scoping Review of the Past 10 Years. Diseases (Basel, Switzerland), 13(8), 262. 

[9] Iqbal, J., Mansour, M. N. M., Saboor, H. A., Suyambu, J., Lak, M. A., Zeeshan, M. H., Hafeez, M. H., Arain, M., Mehmood, M., Mehmood, D., & Ashraf, M. (2023). Role of deep brain stimulation (DBS) in addiction disorders. Surgical neurology international, 14, 434. 

“Tranq” and the Changing Drug Supply: A New Phase of the Opioid Crisis?

In recent years, the opioid crisis has evolved past prescription drugs and heroin into a landscape primarily focused on synthetic substances like fentanyl. Today, a new and increasingly concerning trend has emerged: the widespread presence of xylazine, a veterinary sedative, in the illicit drug supply. Often referred to as “tranq,” xylazine is currently reshaping the risks of substance use. Does the emergence of drugs like xylazine represent a new phase of the addiction crisis?

What Is Xylazine?

Xylazine is a non-opioid sedative primarily used in veterinary medicine. It is not approved for human use and yet is weirdly found mixed with opioids such as fentanyl in the illicit drug supply [1].  When consumed, xylazine can slow breathing, lower heart rate, and cause profound sedation. Because it is not an opioid, its effects are not reversed by naloxone (Narcan), the standard medication used to treat opioid overdoses [2].  This creates the worst scenario: individuals experiencing an overdose may not respond fully to life-saving interventions.

A More Unpredictable Drug Landscape

The rise of xylazine reflects a general societal shift toward increasingly unpredictable drug mixtures. Fentanyl, already one of the most potent opioids of today, is now frequently combined with substances like xylazine to prolong and intensify its effects  [3].  Recent studies have detected xylazine in a significant portion of drug samples, including along major trafficking routes (such as the U.S.–Mexico border)  [4]. Public health officials have identified this trend as an emerging threat, signaling concern about its rapid spread. In addition to overdose risk, xylazine has been linked to severe skin wounds and infections, sometimes leading to tissue death and amputation [1]. These complications introduce new clinical challenges that differ from usual and traditional opioid-related harms.

Addiction Without Awareness

One of the most concerning aspects of xylazine is that many individuals may not know they are consuming it. Because it is often mixed into other drugs without users’ knowledge, this means exposure can occur unintentionally [1].  This raises important ethical questions about autonomy and consent. If individuals are unable to know what substances they are using, can their behavior be seen as fully voluntary? The unpredictability of the drug supply blurs the line between intentional use and unintended harm. At the same time, the increasing complexity of substances may intensify dependence. Regardless, potentially reinforcing repeated use will only further complicate withdrawal and recovery.

Ethical Tensions: Harm Reduction vs. Escalating Risk

The rise of xylazine highlights a growing tension in addiction policy. Harm reduction strategies, such as naloxone distribution and safe-use education, have been central to reducing overdose deaths. However, these approaches were developed in response to opioid-only substances. As new drug combinations emerge, existing tools may become less and less effective. If naloxone cannot fully reverse overdoses involving xylazine, should public health strategies shift? Or should they expand to include new interventions, such as drug-checking technologies and updated clinical protocols? These are the pressing concerns. Additionally, there are also broader ethical concerns: the drug supply is evolving faster than policy and healthcare systems can adapt, conditions that make it increasingly dangerous.

Toward Adaptive Solutions

Responding to this new phase of the opioid crisis will likely require more flexible and responsive public health strategies. Expanding access to drug-checking tools (including test strips that can detect substances like xylazine) may help individuals make more informed decisions. In addition, increasing clinical awareness is critical. Healthcare providers must be able to at least recognize and treat problems associated with emerging substances. 

More broadly, the rise of xylazine highlights the ever-growing importance of addressing addiction as an evolving issue. Policies and interventions that fail to adapt risk becoming ineffective in the face of changing conditions.

Conclusion

The emergence of xylazine in the drug supply signals a shift like the addiction crisis, one defined not only by substance use but instead by uncertainty. As drugs become more complex and less predictable, traditional distinctions between use, risk, and responsibility become increasingly blurred. Almost impossible. Whether this represents a temporary trend or a lasting transformation remains unclear. What is certain, however, is that addiction policy and public health responses must evolve alongside these substances.

Review Editor: Nicholas Wang

Design Editor: Aditi Avinash

References (APA 7th Edition)

[1] Centers for Disease Control and Prevention. (2024). What you should know about xylazine.

https://www.cdc.gov/overdose-prevention/about/what-you-should-know-about-xylazine.html

[2] Drug Enforcement Administration. (2023). DEA reports widespread threat of fentanyl mixed with xylazine. https://www.dea.gov/alert/dea-reports-widespread-threat-fentanyl-mixed-xylazine

[3] Manvich, D. F., & Martinez, L. R. (2025). Fentanyl and emerging drug combinations in the evolving opioid crisis. Rowan University. https://today.rowan.edu/news/2025/03/manvich-martinez-fentanyl.html

[4]University of California San Diego. (2024). Xylazine detected in U.S.–Mexico border drug supply, study finds. https://today.ucsd.edu/story/xylazine-detected-in-u.s-mexico-border-drug-supply-study-finds

[5]American College of Surgeons. (2025). Surgeons handle new and alarming pathology: Xylazine wounds. https://www.facs.org/for-medical-professionals/news-publications/news-and-articles/bulletin/2025/october-2025-volume-110-issue-9/surgeons-handle-new-and-alarming-pathology-xylazine-wounds/