2020 Drug Overdoses Were “Horrifying”

August 31, 2021

Dr. Nora Volkow, Executive Director
National Institute on Drug Abuse

The provisional drug overdose death statistics for 2020 confirmed the addiction field’s worst fears. More people died of overdoses in the United States last year than in any other one-year period in our history. More than 93,000 people died. The increase from the previous year was also more than we’ve ever seen—up 30 percent. These data are telling us that something is wrong. In fact, they are shouting for change.

The provisional drug overdose death statistics for 2020 confirmed the addiction field’s worst fears. More people died of overdoses in the United States last year than in any other one-year period in our history. More than 93,000 people died. The increase from the previous year was also more than we’ve ever seen—up 30 percent. These data are telling us that something is wrong. In fact, they are shouting for change.

It is no longer a question of “doing more” to combat our nation’s drug problems. What we as a society are doing—putting people with drug addiction behind bars, under-investing in prevention and compassionate medical care—is not working. Even as we work to create better scientific solutions to this crisis, it is beyond frustrating—it is tragic—to see the effective prevention and treatment tools we already have just not being used. The benefits of providing effective substance use disorder treatments—especially medication for opioid use disorder—are well-known. Yet decades of prejudice against treating substance use disorders with medication has greatly limited their reach, partly accounting for why only 18% of people with opioid use disorder receive medications. Historical reluctance to provide these treatments and of insurers to cover them reflects the stigma that has long made people with addiction a low priority.

We must eliminate the attitudes and infrastructure barring treating people with substance use disorders. This means making it easier for clinicians to provide life-saving medications, expanding models of care like digital health technologies and mobile clinics that can reach people where they are, and ensuring that payers cover treatments that work. The science of the matter is unequivocal: Addiction is a chronic and treatable medical condition, not a weakness of will or character or a form of social deviance. But stigma and longstanding prejudices—even within healthcare—lead decision-makers across healthcare, criminal justice, and other systems to punish people who use drugs rather than treat them. That approach may be simpler than asking us as a society to have compassion or care for people with a devastating, debilitating, often fatal disorder. But the risk of incarceration does not deter drug use, let alone address addiction; it perpetuates stigma, and disproportionately harms the most vulnerable communities.

Evidence-based harm reduction, such as syringe services programs, also need to be a part of any solution to our drug crisis, as these have been shown to reduce HIV and hepatitis C transmission, and help link people to treatment for addiction and other conditions. While the federal government has embraced evidence-based harm-reduction programs, many communities continue to resist them, erroneously thinking they sanction or encourage drug use. Multiple independent studies have shown that they don’t. Researchers are also evaluating innovative but historically controversial strategies operating abroad like overdose prevention centers, where people can use substances under medical supervision and access other health services, to evaluate cost-effectiveness and ability to reduce deaths and improve health.

Part of the failure of the current approach to the drug crisis arises from the unrealistic expectation that people should—and can—just stop using drugs. Little concern is shown for people with addiction unless and until they are drug-free, but the reality is that difficulties and resumed use typically mark the recovery journey. Compassion, care, and support need to extend to those still using drugs and those who return to drug use, not just to those who can satisfy the stringent standards of abstinence. Everyone with a substance use disorder, regardless of whether they are currently using drugs, needs good healthcare and may also need help with housing, employment, and childcare needs.

To prevent young people from misusing drugs and to keep people from all ages from developing substance use disorders, our nation must address the social and economic stressors that increase the risk of drug use, such as poverty and housing instability, unsafe neighborhoods and schools, and other effects of a changing economy including social isolation and despair. Drug overdose deaths are one component of the “deaths of despair” that, along with suicide and alcohol-related illness, have caused life expectancy to decline in the U.S., even before the 1.5-year drop in 2020 caused largely by the COVID-19 pandemic. On the ground, evidence-based interventions can make a big difference: Universal prevention programs as well as interventions targeted to the most at-risk families and youth not only reduce the risk of later drug taking and addiction but have radiating benefits on other aspects of mental and physical health.

This poses a question of collective willingness to invest in these measures. The long-term savings in healthcare and justice costs relative to the costs of prevention interventions can be substantial. But they are long-term investments with benefits that will take time to accrue, and the nature of our society is to look at short-term bottom lines and expect immediate results. Radical change to save lives is long overdue. It is crucial that scientists help policymakers and other leaders rethink how we collectively address drugs and drug use, looking to the evidence base of what improves health and reduces harms across communities, and funding research to develop new prevention and treatment tools.

Find Help Near You

The following can help you find substance abuse or other mental health services in your area: www.samhsa.gov/find-treatment. If you are in an emergency situation, people at this toll-free, 24-hour hotline can help you get through this difficult time: 1-800-273-TALK. Or click on: www.suicidepreventionlifeline.org. A step by step guide on what to do to help yourself, a friend or a family member on the Treatment page.

A Most Vexing Problem

Written by Steven Barto, B.S., Psy., M.A. Theology

FOR THE FOURTH TIME this newscast I grabbed for the remote and muted yet another 90-second commercial touting the glorious new activity of gambling online. Sexy young voluptuous blondes and brunettes with plunging necklines smile seductively and splay decks of cards, gesturing. These TV ads bear the names of so-called “trustworthy” gambling institutions, and promise a risk-free day of odds-laying up to $500, failing to remind that the house always wins in the end or such games of chance would shrivel up and blow away. One TV spot says “…now you can have the name of MGM Grand Casino in your pocket.” Never has a more ironic statement been made!

Steve Rose, PhD, a certified gambling counselor and problem-gambling prevention specialist, writes, “Since the pandemic began, there has been an explosion of online gambling.” With experts warning of this ticking time bomb, responsible gambling safeguards are sparse. Admittedly, online gambling is not new. However, the pandemic accelerated demand, leading to higher rates of riskier gambling. According to a report published by the Responsible Gambling Council (RGC) of Canada, one out of three online gamblers admit to being influenced by pandemic lockdowns (1).

Due to ease of access, online platforms make it easier to use gambling as a way to cope with underlying issues such as anxiety and depression. In fact, the RGC survey found that anxiety and depression are major factors contributing to high-risk gambling. Individuals with severe depression are almost five times more likely to engage in high-risk gambling. Typical depression symptoms such as low mood, apathy, and social isolation are a barrier to people traveling to live venues to gamble. With online gambling, anxious and depressed people can engage in round-the-clock gambling while distracting themselves from their circumstances from the ease of their living room.

A Prolific Online Presence

I did an Internet search with the words the perils of impulsive online gambling. The site listed at the top of my search results was an AD, which said Pennsylvania Online Casino – Real Cash Payouts in 24 Hours! The second result listed said Best Online Casinos in PA 2021 – Get $1,500 Welcome Bonus! Internet gambling is reeling in college students and young children along with adults. The COVID-19 crisis, and the confinement and other restrictions associated with it, represent a unique situation that carries financial consequences for the population. People worrying about the future, possibly spending more time than usual online, are at risk for falling hard for distraction or “easy solutions” to their woes.

Sports gambling in particular has soared during the pandemic and continues to climb. CBS News reports that gamblers placed $4.3 billion in bets on Super Bowl LV, marking “the largest single-event legal handle in American sports betting history.” In sports betting, a “handle” refers to the total amount of money wagered by bettors. About 7.6 million people placed bets on the game through platforms like FanDuel and DraftKings, marking a 63% increase from bets place on the 2020 Super Bowl. Additionally, more than 47 million Americans placed bets on March Madness games (2). Casey Clark, a senior vice president at the gaming association, said “You weren’t going to in-person sporting events and you weren’t going to brick-and-mortar sportsbooks [where gamblers can wager on various competitions].” He said more than 100 million people live in a state where gambling is now legal. Not long ago, that was only in Nevada (3).

Salerno and Pallanti write, “The COVID-19 pandemic has exerted a dramatic impact on everyday life globally. In this context, it has been reported that the lockdown and social distancing may have exerted an impact even on gambling behavior, not only by increasing gambling behavior in those affected by this disorder but even contributing to the occurrence of new cases” (4). According to their peer-reviewed paper, studies performed in different countries around the world have reported psychological and mental health problems due to the changes caused by the pandemic, including stress, anxiety, and depressive symptoms. Moreover, the lockdown and social distancing exerted an impact on gambling behavior, not only by increasing gambling incidents in those affected, but even contributing to the occurrence of new cases of problematic gambling.

Hodgins and Stevens write, “…the impacts of the COVID-19 pandemic on gambling and problematic gambling are diverse – possibly causing a reduction in current or future problems in some, but also promoting increased problematic gambling in others” (5). The study says, “At the same time that land-based gambling accessibility decreased during the pandemic, online gambling sites continued to operate. Some media reports indicated that online gambling business flourished during this time, and that the pandemic served to promote this increasingly popular gambling format” (6). Online gambling sites typically include the full range of types of gambling, including lottery ticket sales, casino table games such a roulette, blackjack and craps, slot machines, online poker and sports betting.

Like a Drug

Gambling, a leisure pursuit for most individuals, has the potential to cause harm to the gambler, their family and the community (7, 8). It is considered to be a potentially addictive behavior, which for some individuals can lead to gambling disorder (GD). GD is found in the DSM-5 under Unspecified Other (or Unknown) Substance-Related Disorder. This category applies to presentations in which symptoms characteristic of an other (or unknown) substance-related disorder cause clinically significant distress or impairment in social, occupational, or other important areas of functioning predominate, but do not meet the full criteria for, any specific substance-related disorder or any of the disorders in the substance-related disorders diagnostic class (9). It is critical to note that, according to clinical studies, gambling addiction activates the same brain pathways as drug and alcohol cravings. Online gambling is considered to be a particularly problematic gambling format given the relative lack of constraints on how and when it can be accessed, its solitary nature, and the wide variety of types of gambling available.

David Zendle says a variety of practices have recently emerged which relate to both video games and gambling. He writes, “These range from opening loot boxes, to e-sports betting, real-money video gaming, token wagering, and social casino spending” (10). A blurring of the lines has occurred between video games and gambling activities. The most widely-discussed example of this convergence are loot boxes: Items in video games that may be bought for real-world money, but which contain randomized contents. In other words, your expenditure may lead to a “goose egg,” but the risk becomes tantalizing. Loot boxes share several formal features with gambling, and there has been widespread interest in the idea that engaging with loot boxes may lead to problem gambling. The more frequently gamers use loot boxes, the more severe their gambling problems tend to be (11). Certainly, you can see how this phenomenon places chronic gamers (especially younger players) at great risk for developing a gambling addiction.

Gamblers Anonymous (GA) was founded in 1957. It is an international fellowship of people who have a compulsive gambling problem whose approach is based upon the 12-step method of recovery from addiction initially established by Alcoholics Anonymous. Related programs include Narcotics Anonymous, Cocaine Anonymous, and Over-eaters Anonymous. GA believes gambling disorder involves repeated problematic gambling behavior that causes significant problems or distress. It is also called gambling addiction or compulsive gambling. Though Gamblers Anonymous is not associated with any religious group or political affiliation, some people find the 12-step principle of surrendering your problems to a higher power to have distinctly religious overtones. However, Gamblers Anonymous is welcoming of people of all ages, religions, and racial backgrounds—you just need to want to end your gambling addiction.

Gamblers Anonymous is a community of people who want the same goal: freedom from gambling addiction. Many Gamblers Anonymous members may also be struggling with other mental health or behavioral addictions. As a group, Gamblers Anonymous members share their wisdom, experiences, ideas for maintaining recovery, and healthy habits so that others may benefit. Members offer each other support, understanding, compassion, and solace when times are tough. Often, Gamblers Anonymous members will serve as sponsors to newer members who need more intensive support or a person to call when urges hit.

Are You Addicted to Gambling?

According to the DSM-5, persistent and recurrent problematic gambling behavior leading to clinically significant impairment or distress is indicated by the individual exhibiting four (or more) of the following in a 12-month period (12):

  1. Needs to gamble with increasing amounts of money in order to achieve the desired excitement.
  2. Is restless or irritable when attempting to cut down or stop gambling.
  3. Has made repeated unsuccessful efforts to control, cut back, or stop gambling.
  4. Is often preoccupied with gambling (e.g., having persistent thoughts of reliving past gambling experiences, handicapping or planning the next venture, thinking of ways to get money with which to gamble).
  5. Often gambles when feeling distressed (e.g., helpless, guilty, anxious, depressed).
  6. After losing money gambling, often returns another day to get even (“chasing” one’s losses).
  7. Lies to conceal the extent of involvement with gambling.
  8. Has jeopardized or lost a significant relationship, job, or educational or career opportunity because of gambling.
  9. Relies on others to provide money to relieve desperate financial situations caused by gambling

Concluding Remarks

Television advertisements for gambling sites is a huge issue with me. I am sensitive to addiction issues because of my 40-year-plus struggles with alcohol and drug addiction. Looking over the nine criteria listed above for gambling addiction, I can honestly say I exhibited much of the same obsessive behaviors as they pertained to drinking and getting high. Addiction messes with the brain chemistry of the addict by taking hostage the chemicals associated with pleasure. The “computer chips” of the brain are neurons: billions of cells that are organized into circuits and networks. Each neuron acts as a switch controlling the flow of information. If a neuron receives enough signals from other neurons that it is connected to, it fires, sending its own signal on to other neurons in the circuit. To send a message, a neuron releases a neurotransmitter into the gap (or synapse) between it and the next cell. The neurotransmitter crosses the synapse and attaches to receptors on the receiving neuron, like a key into a lock. This causes changes in the receiving cell. Other molecules called transporters recycle neurotransmitters (that is, bring them back into the neuron that released them), thereby limiting or shutting off the signal between neurons.

Drugs interfere with the way neurons send, receive, and process signals via neurotransmitters. Some drugs, such as marijuana, opioid pain medications, and heroin, can activate neurons because their chemical structure mimics that of natural neurotransmitters in the body. These chemicals are dopamine, oxytocin, serotonin, and endorphins (abbreviated DOSE). Because heroin and other substances are extremely potent compared to these naturally-occurring brain chemicals, the brain is incapable of producing them at a level that can reproduce the intensity, leading the addict to develop a craving for his or her drug of choice.

Gambling addiction works by hijacking the brain’s neurochemicals and learned behaviors that activate the brain’s reward center. Remarkably, gambling behavior in such individuals has the same capacity to stimulate the brain as does dopamine, oxytocin, serotonin, and endorphins. In addition, the gambling addict feels rewarded by the intermittent thrill of winning. When the need to win outweighs the risk of losing, the gambling addict begins to exhibit many of the criteria noted in the DSM-5 listed above. At this point, gambling is no longer a form of entertainment. Gambling, as with drug or alcohol addiction, becomes both the problem and the solution. In other words, the addict is now locked into a pattern of behavior where he or she continuously expects to replicate the early “high” of gambling or abusing addictive substances. The brain is hijacked by the randomness of reward.

Addiction can rewire the chemical circuitry of the brain to the point that it seems impossible to quit the addictive behavior. Even though gambling does not involve ingesting chemical substances, it produces the same response as any drug. Gambling addiction is not about money or greed. As the harms outweigh the entertainment value, the gambler looses control and becomes fixated on winning back losses. Because compulsive gambling is a progressive illness, the will to gamble becomes irresistible. Adolescents and teens are at risk for developing a gambling addiction at a time when social and emotional growth is most vulnerable to change. Adolescence is characterized by increased risk-taking, novelty seeking, and locomotor activity, all of which suggest a heightened appetitive drive.

Although teens can gamble casually, the pressure to “fit it” or establish “street cred,” and times of stress or depression, can trigger overwhelming urges to gamble. Widespread neurobiological changes such as shifts in brain matter composition can complicate addiction in teens. Finally, adolescents appear especially sensitive to rewarding cues, as evidenced by exaggerated neural responses when exposed to dopamine. During adolescence, brain cells continue to bloom, with notable changes in the prefrontal cortex, which is involved in decision making and cognitive control, as well as other higher cognitive functions. Accordingly, I believe additional study is indicated regarding teen risk for developing a gambling addiction.

Help is Available Right Now!
National Problem Gambling Helpline

1 (800) 522-4700
SAMSHA National Helpline
1 (800) 662-HELP

References

(1) “The Emerging Impact of Covid-19 on Gambling in Ontario,” Centre for the Advancement of Best Practices, Responsible Gambling Council (July 2020). URL: https://www.responsiblegambling.org/wp-content/uploads/RGC-COVID-and-Online-Gambling-Report_Jul.AP_-1.pdf
(2) Kristopher Brooks, “Sports Gambling Has Soared During the Pandemic and Continues to Climb,” (March 29, 2021). URL: https://www.cbsnews.com/news/sports-gambling-betting-draft-kings-fanduel-american-gaming-association/
(3) Ibid.
(4) Luana Salerno and Steffano Pallanti, “COVID-19 Related Distress in Gambling Disorder,” (Feb. 25, 2021), Frontiers in Psychiatry. URL: https://doi.org/10.3389/fpsyt.2021.620661
(5) David C. Hodgins and Rhys M.G. Stevens, “The Impact of COVID-19 on Gambling and Gambling Disorder: Emerging Data,” (April 19, 2021). URL: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8183251/
(6) Ibid.
(7) “Spain orders ‘social shield’ to fast track gambling advertising window,” SBC News (2020). ULR: https://sbcnews.co.uk/europe/2020/04/01/spain-orders-social-shield-to-fast-track-gambling-advertising-window/
(8) “Coronavirus: Gambling firms urged to impose betting cap of 50 pound a day,” The Guardian (2020. URL: https://www.theguardian.com/sport/2020/mar/22/coronavirus-gambling-firms-urged-to-impose-betting-cap-of-50-a-day
(9) American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders, 5th ed. (DSM-5) (Arlington, VA: American Psychiatric Association, 2013), 585.
(10) David Zendle, “Beyond Loot Boxes: A Variety of Gambling-like Practices in Video Games are Linked to Both Problem Gambling and Disordered Gaming,” PeerJ (July 14, 2020). URL: https://peerj.com/articles/9466/
(11) In Addictive Behaviors, Vol. 96 (Sept. 2019), 26-34. URL: https://doi.org/10.1016/j.addbeh.2019.04.009
(12) American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders, 5th ed. (DSM-5), Ibid., 585.