Reversing the trend of substance abuse, no matter the cause is in the public interest. But it’s important to ask:
Are substance addictions different than behavioral addictions?
Who in Iowa is seeking treatment; for what addiction; and does geography make a difference in their efforts to receive it?
The legislature just initiated an ambitious effort to change behavior. What will the effect be on the state’s population?
Here to help us address these and other questions are: Arthur Schut, President and CEO of the Mid-Eastern Council on Chemical Abuse.
And Mark VanderLinden is Coordinator of the Iowa Gambling Treatment Program at The Iowa Department of Health.
Beck: Gentlemen, thank you for being here. Let me just start with that first question that we posed. Are there differences between chemical addictions and what we consider maybe a behavioral addiction which might be gambling? Are there differences between the two?
VanderLinden: I think that absolutely there are similarities and there are differences. The one most obvious different, I think, would be that in a gambling addiction you're not ingesting some type of chemical or some type of substance. But are there similarities? Absolutely. For example, if you look at what are the diagnostic criteria for pathological gambling which is a gambling addiction and what are the diagnostic criteria for a substance dependence and you would see a lot of crossover in those areas. For example, a pre-occupation with the behavior or with the consumption of the substance. Problem gamblers or pathological gamblers absolutely have a pre-occupation and continuously are thinking about it throughout the day similar to a substance addiction. Another one would be tolerance, a very good example. For a substance addiction you would see an individual needing to consume that substance more frequently and at increasing rates. It's similar with gambling addiction, you see the individual needing to gamble more frequently with increasing amounts of money.
Beck: Mr. Schut, the legislature, as we have mentioned, just banned smoking in public places. We often hear people talk about smoking or marijuana as being what we call this term "gateway" drugs. Does one addiction often feed another? And do you have any hope that the ban on smoking in public places will one, either reduce smoking, or two, even have an impact on drinking or other addictions?
Schut: Well, the number one gateway drug is alcohol and tobacco as well or nicotine. And there is a relationship between alcohol use and tobacco use. There is also a relationship between access and availability and consumption and there is a relationship between consumption and problem consumption. So, anything that restricts access, restricts consumption, restricts problems.
Beck: So, in an odd turn of events the legislature left casino floors open to smoking. So, there is a marriage there between possible addictions for people.
Schut: There is that possibility. The vast majority of people who go to gaming establishments do so with discretionary income and do so responsibly. There are people that have problems with it. The same thing is true with alcohol. The vast majority of people who consume alcohol do so in a moderate level. There are people who have problems with it. Nicotine is a little bit more difficult because in that case you have a product when used as intended really causes serious problems across the board largely.
Beck: Should the state, as it employs a ban like this in an attempt to reduce smoking in Iowa or to protect the health of these workers, should there be a responsibility of the state to also increase cessation programs or funding for that? Or should it be a personal responsibility?
Schut: I think that if you look at the cost benefit to all of us there is a huge benefit in reduction of hospital costs, ER costs, accidents depending on the drug, length of hospitalization for any given illness if you also use other substances. So, in the end run really just looking from an economic standpoint it pays all of us to do something in terms of treatment and prevention.
Beck: Mr. VanderLinden, this year the legislature shifted some money from the gambling treatment program to substance abuse funding. Was that a concern for you?
VanderLinden: It certainly is a concern any time that we see a budget reduction in the programs, how it will ultimately end up impacting the services that we are able to provide we're still in a process of trying to figure out. We recognize that there is a definite link between gambling addiction and substance addiction and we want to make sure that individuals that are seeking help whether they go to a substance abuse treatment facility or whether they go to a gambling treatment agency are getting the help that they need so that there is no wrong door that is there.
Beck: It help readily available or is it readily available to say someone in Des Moines but not as readily available in other parts of the state?
VanderLinden: Yeah, it's available wherever you are in the state. One thing that Iowa has been very committed to and should be commended for is that we have developed a statewide system so that no matter where you are, what county you live in that there is treatment that is available. Certainly there's differences across the state of who is actually accessing treatment and I think that if populations adjusted we're still seeing more individuals from larger cities, larger towns in Iowa seeking treatment at a greater rate than we are in smaller towns in Iowa and something that we need to continue to take a look at and figure out why is that and what do we need to do differently to make sure that persons in even the most remote counties in the state of Iowa are getting the help that they need.
Beck: So, you think it's not that it's not available in those remote parts of the state; it's that maybe people aren't seeking it?
VanderLinden: I think that's right.
Beck: That surprises me. I would have thought we didn't have as much available in those places.
Schut: I think it depends on which kind of drug treatment or alcohol treatment you're talking about. In terms of alcohol services and drug treatment services there usually are waiting lists, there's usually difficulty getting access. I do know that if you would compare access to primary healthcare for other kinds of illnesses and access to healthcare that is especially clinic specific for substance use disorders, gambling, other behavioral health conditions there is more difficult access, there is less source of payment and there are less resources committed to doing that.
Beck: Is there a magic number of resources? Do you have this goal of how much you'd like the state to commit to this? Is it something we're never going to attain because there's never going to be enough money to meet that goal?
VanderLinden: I think that Iowa is a large state and with 99 counties and the number of small towns that we have across the state and the increasing number of gambling venues that we have. We have 20 casinos and 2600 lottery outlets across the state. So, virtually every corner that you go to there's going to be some opportunity for you to gamble. Can we ultimately end up having our gambling treatment be as accessible as the gambling opportunity? Probably not. But we want to make sure that even if the lottery outlet is closer or the casino is closer that we're able to get that treatment to you as quickly, as easily and efficiently as possible.
Beck: You receive a portion of gambling revenue, that's how your program is funded, is that correct?
VanderLinden: That's correct.
Beck: What is the portion? And how is that determined?
VanderLinden: We receive one half of one percent of gross revenue from casinos and one half of one percent of gross revenue from the lottery.
Beck: Was that scientific? Did you know that was the percent of people that would be addicted? Or was it not scientific at all?
VanderLinden: I think that there is some level of it being scientific. There was a desire to take a look at what would an ideal gambling treatment program look like that would allow us to roll it out across the entire state and how much would that cost. And the one half of one percent actually capped it at $6 million is what we determined would be the closest that we could come to actually meeting that need.
Beck: Mr. Schut, is there a dollar figure that you think would work for substance abuse treatment? Or is it a moving target?
Schut: It is a moving target and it clearly is grossly underfunded if you look at the amount of resources available compared to the amount of demand for service. And that is true actually nationwide. So, there is a low level of funding. And most of the services are provided in the public sector.
Beck: One of the things that we heard discussion of as the legislature considered, not necessarily expansion to the prison system but some changes to it and some expensive changes, was a desire among the board of corrections to build a prison that deals solely with drug offenders. Would there be a benefit? Can you see that being a benefit to those who suffer from a substance abuse and then find themselves in trouble with the law?
Schut: It's clear we do most of what we're doing right now on the back end and so we -- just having a conversation about creating a prison for drug users is an interesting conversation. We're not having a conversation about creating an institution for diabetics or for people with severe hypertension or asthma or cancer. We're talking about creating a prison for drug offenders. And that is because most of our resources are on the back end of the system, not on the front end of the system. And I think you would find in the Department of Corrections some concern about the number of folks who have mental health problems, who have substance abuse disorders, who are in the prison system who I think many folks feel could be prevented from entering the system if we were to allocate resources a little differently.
Beck: We do hear a lot about the connection between mental illness and substance abuse. Is that true of legal addictions, smoking, alcohol? I know that I've heard from people that those who suffer from mental illness often also smoke, that there is a connection and a comfort to that? Is that true?
Beck: We've been doing this kind of work for several decades. Is there a pendulum swing you see in public support or in legislative recognition of the problem?
Schut: Iowa has in general been -- Iowans have a lot of common sense and it resides in the legislature as well as in the general populous and people look at this and say this doesn't make sense to not do something that is more preventative and more proactive about a lot of these kinds of difficulties. And in point of fact there is an offset down the road in terms of dealing with this. So, I think there are times when there is more attention paid, there are times when there is less attention. Obviously we had a governor in Harold Hughes who was a recovering alcoholic who made a commitment and Iowa, in some respects, as a state is ahead of other states. In other respects we lag and there are things that we could do differently.
Beck: Like what?
Schut: If you look at the recent smoking ban we had areas of our state who had done this on their own and actually had been in the front of many other states and now we're behind New York ...
Beck: Ames and Iowa City had attempted to pass the local ordinances.
Schut: Actually they had it and it was overturned. So, if you look at some of the states that traditionally have lagged behind us like New York they have done this in terms of a tobacco ban in front of us.
Beck: Mr. VanderLinden the State Racing and Gaming Commission has put off a decision but is constantly asked to expand the number of gambling licenses. Does that concern you? Would that have an impact? You have mentioned that proximity is an issue for somebody who is addicted to gambling.
VanderLinden: I don't really have an opinion rather or not that would be a good thing. I certainly have been to the Racing and Gaming Commissions and heard the advocates that are very interested in having casinos come into their communities. And I have heard the opponents to that movement as well. I think that what concerns me and what ultimately very important is that there is treatment and that there is education that would be available that would go along with that, if we do see increased gaming that we also see that there is a continued commitment to letting people know that there is treatment available and to also let them know what are the risks of gambling and what are the responsibilities of gambling so that if you do choose to gamble, you're walking through the door and you have all the information that you possibly can about what you're about to engage in.
Beck: Just this session there was a movement, I don't think it went anywhere, but there was some effort to allow people who had self-excluded themselves or banned themselves for a lifetime from a casino because of a fear of an addiction to petition to get back in. What happened with that? And what was your position on that?
VanderLinden: Well, it was ultimately turned down, that the ban if a person chooses to self-ban it remains a lifetime ban from casinos statewide. Did I support a five-year option for it? We actually did end up supporting a five-year option for it. What it really speaks to is the complexity of the situation, that there isn't a one size fits all solution and that there are certainly individuals that right here, right now have a gambling problem but due to a number of circumstances in their lives five years down the road that situation could absolutely change and they could go back to gambling responsibly or gambling healthy. I think that it would need to be very closely monitored because I think that similarly with the complexity that there are individuals who are problem gamblers that would not be able to make that turn and go back to responsible gambling.
Beck: Gentlemen, thank you both for being here today.