Problem Gambling Screening Guide
Guidelines for Integrating Gambling Screening and Assessment
into Current Practice
A Toolkit for Behavioral Health Providers and Medical
Professionals
Problem Gambling Screening Guide
Guidelines for Integrating Gambling Screening and Assessment into Current Practice
A Toolkit for Behavioral Health Providers and Medical Professionals
250 W. Pratt Street, Suite #1050 | Baltimore, MD 21201 | 667-214-2120
www.MdProblemGambling.com | HELPLINE 1-800-GAMBLER
Page 1 of 32
TABLE OF CONTENTS
Table of Contents ................................................................................................... 1
Introduction ........................................................................................................... 2
About this Guide ..................................................................................................... 3
Defining Gambling .................................................................................................. 4
What is Gambling Disorder ....................................................................................... 6
Gambling Disorder and Social Determinants of Health ................................................... 8
Screening for Gambling ......................................................................................... 10
Brief Interventions for Gambling ............................................................................. 12
Integrating Gambling into a Biopsychosocial Assessment............................................. 13
Resources for Help and Treatment ........................................................................... 18
APPENDIX A - DSM 5: Gambling Disorder Criteria ...................................................... 23
APPENDIX B - Lie-Bet ............................................................................................ 24
APPENDIX C - BBGS .............................................................................................. 25
APPENDIX D - PGSI ............................................................................................... 26
APPENDIX E - Peer Map ......................................................................................... 27
APPENDIX F - Turtle Card ....................................................................................... 28
References .......................................................................................................... 29
Problem Gambling Screening Guide
Guidelines for Integrating Gambling Screening and Assessment into Current Practice
A Toolkit for Behavioral Health Providers and Medical Professionals
250 W. Pratt Street, Suite #1050 | Baltimore, MD 21201 | 667-214-2120
www.MdProblemGambling.com | HELPLINE 1-800-GAMBLER
Page 2 of 32
INTRODUCTION
The Maryland Center of Excellence on Problem Gambling (the Center) is committed to
enhancing the expertise of behavioral health providers and medical professionals to address
problem gambling and gambling disorder through increased screening, assessment,
awareness, intervention, and treatment strategies. One of the Center’s key initiatives is to
bring attention to the impact gambling behaviors can have on one’s recovery, health, and
well-being.
Each year the Center recognizes Gambling Disorder Screening Day, an annual one-day
event recognized on the second Tuesday in March, in collaboration with Problem Gambling
Awareness Month. This Day was first promoted by the National Council on Problem
Gambling and the Cambridge Health Alliance Division on Addiction to educate and support
healthcare providers in screening for Gambling Disorder. Screening, although not a
diagnosis, aids in identifying individuals who may need further assessment for potential
gambling-related problems. The goal is to provide early detection and reduce the risk of
disease, or to detect a potential problem sooner and offer the most effective treatment.
Although gambling problems are common among youth, negative harms due to gambling
behaviors and the need for treatment often do not occur until adulthood. Therefore, this
guide emphasizes screening and treatment for adults. We recognize there are higher
prevalence rates of gambling among youth and by collaborating with community agencies,
we can increase problem gambling treatment and prevention initiatives. The Center offers
prevention strategies if your organization works with youth.
By promoting this screening guide, The Center will enhance healthcare providers’
knowledge and awareness of the value of gambling screening. Therefore, more clients will
be screened for gambling related problems, making them aware of the risks and referred to
treatment, if needed.
We will continue to expand the information that is provided in this guide as research and
awareness of the potential harms of gambling increases in Maryland.
Mary Drexler, MSW Kristen Beall LCSW-C, ICGC-I, CAC-AD
Program Director Clinical Manager
Problem Gambling Screening Guide
Guidelines for Integrating Gambling Screening and Assessment into Current Practice
A Toolkit for Behavioral Health Providers and Medical Professionals
250 W. Pratt Street, Suite #1050 | Baltimore, MD 21201 | 667-214-2120
www.MdProblemGambling.com | HELPLINE 1-800-GAMBLER
Page 3 of 32
ABOUT THIS GUIDE
The Center’s mission is to promote healthy and informed choices regarding gambling.
National research shows that most adults who gamble, do so responsibly; however, in the
United States, an estimated 2 million adults (1%) will meet the criteria for severe gambling
problems. Another 4-6 million adults (2-3%) are considered to have mild or moderate
gambling problems, meaning they do not meet the full diagnostic criteria for gambling
disorder, yet they are experiencing significant distress attributable to their gambling
behavior.
NCPG estimates the national social cost of problem gambling is 7 billion dollars annually.
These costs have an impact on the healthcare system, as persons with gambling-related
problems are more likely to smoke, consume excessive amounts of caffeine, and have more
emergency department visits. This guide will demonstrate the correlation of the risk factors
to developing a gambling disorder to further the impact on the Social Determinants of
Health.
The Center hopes this guide will serve as a comprehensive resource for Maryland’s
healthcare providers (Behavioral Health and Medical Professionals) to understand the
importance of addressing problem gambling through evidenced based screening. This guide
will provide recommendations for brief interventions and where to refer those seeking help
in Maryland. Common misconceptions and concerns expressed by providers and how to
dispel such myths are included. This guide will also illustrate how to incorporate gambling
questions into a full biopsychosocial assessment.
Problem Gambling Screening Guide
Guidelines for Integrating Gambling Screening and Assessment into Current Practice
A Toolkit for Behavioral Health Providers and Medical Professionals
250 W. Pratt Street, Suite #1050 | Baltimore, MD 21201 | 667-214-2120
www.MdProblemGambling.com | HELPLINE 1-800-GAMBLER
Page 4 of 32
DEFINING GAMBLING
Gambling dates back to a time before written history. The Bible references the casting of
lots to render an impartial, unbiased decision on important matters. In the United States,
during the period of financial depression and following the Revolution, lotteries were a
common means of obtaining large amounts of money and used to fund buildings at Harvard
University and other Government projects. Today, State lotteries are the most common
type of gambling in the country.
Defining gambling can be simple, but when it comes to identifying what is and is not a
gambling activity – the lines can seem blurry. The definition of gambling is the act of
risking something of value (money or property) on an activity that has an unknown
outcome. Gambler’s Anonymous defines gambling as any form of wagering, with or without
money, on an outcome that is unknown. Unknown Outcome is the common denominator
when it comes to defining gambling, yet many fail to recognize that Bingo, Raffle Tickets, or
Day-Trading are forms of gambling.
When we begin to address gambling with those we serve, we must start with the definition
and then provide examples. Many of the misconceptions about gambling begin by not
understanding the full definition or the many forms that gambling encompasses. Many
youth and adults also engage in online or video gaming. Within these virtual games are
Loot Boxes which monetize free-play games. Loot boxes are available to purchase with real
money to obtain a randomized prized to enhance the gamers play experience. These
gamers are risking their money on an unknown outcome.
Another barrier to integrating gambling screening is a provider’s belief that clients are
unable to financially afford to engage in gambling activities. This conflict is often a lack of
understanding of the various types of gambling and lends to the importance of going
beyond asking persons the single question: “do you gamble?”. Gambling does not only
take place at a casino, and even then, there are games that are “affordable” within those
establishments. Even more, this sheds light on the limited discussions surrounding financial
wellness within healthcare settings. Here in Maryland, the majority of residents gamble via
the Lottery where a ticket can cost as low as 50 cents. Yet, due to the limited research and
so many new ways to gamble developing across the nation – persons could be engaging in
gambling, and they may not even be aware.
In addition, providers lack awareness that clients are engaging in gambling activities and
may not see the need for screening. Yet, this is part of the reason gambling addiction
remains hidden; the absence of regular screening for gambling will continue to conceal the
person in need of help. Persons with a gambling problem remain unseen as there is no
physical toxicology screen that can be implemented for this addictive disorder, no risk of
overdose, and the financial devastation all keep gambling disorder a hidden addiction.
Problem Gambling Screening Guide
Guidelines for Integrating Gambling Screening and Assessment into Current Practice
A Toolkit for Behavioral Health Providers and Medical Professionals
250 W. Pratt Street, Suite #1050 | Baltimore, MD 21201 | 667-214-2120
www.MdProblemGambling.com | HELPLINE 1-800-GAMBLER
Page 5 of 32
Examples of the Types of Gambling
• Lottery
Scratch-offs
Morning, Mid-day, Evening drawings
• Casino Games
Electronic Gaming Machines (Slots, Poker)
Table Games (Poker, Roulette)
• Sports Betting
Fantasy Sports
Horse Racing
• Office Pools
• Church & Community fundraisers
Casino Night
Wheels of chance
• Bingo
• Raffles
• Dice or Card games
• Any wagering on an event or activity with an unknown outcome
Problem Gambling Screening Guide
Guidelines for Integrating Gambling Screening and Assessment into Current Practice
A Toolkit for Behavioral Health Providers and Medical Professionals
250 W. Pratt Street, Suite #1050 | Baltimore, MD 21201 | 667-214-2120
www.MdProblemGambling.com | HELPLINE 1-800-GAMBLER
Page 6 of 32
WHAT IS GAMBLING DISORDER
In 2013, the Diagnostic and Statistical Manual (DSM) 5 was released and changes to
gambling disorder diagnosing were made. One such change was reclassifying and
renaming Gambling Disorder as a Substance-Related and Addictive Disorder. Formally
classified as an Impulse Control Disorder, Pathological Gambling, was classified with other
diagnoses such as kleptomania. Gambling is now recognized as an addictive disorder by
the behavioral health and medical community. It is the only non-substance addiction in this
classification.
There are several reasons for this reclassification. Growing research reveals gambling
disorder has common elements to substance use disorders. Some of the visible similarities
include the devastating impact on families, preoccupation with the addictive behavior, and
the financial consequences. Less obvious are the changes that happen in the brain. Brain
imaging studies and neurochemical tests have shown that gambling activates the reward
system in much the same ways as substances. In fact, in persons who gamble, dopamine
(the feel-good neurotransmitter) is released not only when winning, but also when losing.
To diagnose a Gambling Disorder as mild, a minimum of four of the nine criteria must be
met over a 12-month period; however, persons who meet subclinical criteria for a Gambling
Disorder remain at risk. Those that meet 1-3 of the criteria do not meet the threshold for a
formal diagnosis, yet their gambling behaviors could be causing significant distress.
Moreover, some persons may only meet the criteria for a Gambling Disorder episodically,
such as persons who only bet on seasonal sports. Included in this guide is the DSM 5
diagnostic criteria for Gambling Disorder (See APPENDIX A).
Problem Gambling Screening Guide
Guidelines for Integrating Gambling Screening and Assessment into Current Practice
A Toolkit for Behavioral Health Providers and Medical Professionals
250 W. Pratt Street, Suite #1050 | Baltimore, MD 21201 | 667-214-2120
www.MdProblemGambling.com | HELPLINE 1-800-GAMBLER
Page 7 of 32
Gambling Disorder Risk Factors
Current research related to gambling and gambling disorder continue to indicate the
following factors that increase one’s susceptibility to problems arising related to gambling:
Male
An early big win
Early age of starting gambling
Adverse Childhood Experiences / Trauma
Intimate Partner Violence / Domestic Violence
History of risk-taking or impulsive behavior
Having mistaken beliefs about the odds of winning
History of substance use or other behavioral health disorder
Family History of gambling problems or substance abuse
Member of a disenfranchised/marginalized group or living in a disadvantaged
neighborhood
Proximity to or Working in a casino or other gambling venue
These are factors to consider when thinking about what makes someone more at-risk for
developing a gambling disorder. The list above is not limited. In fact, women that develop
a problem with gambling usually do so later in life.
Problem Gambling Screening Guide
Guidelines for Integrating Gambling Screening and Assessment into Current Practice
A Toolkit for Behavioral Health Providers and Medical Professionals
250 W. Pratt Street, Suite #1050 | Baltimore, MD 21201 | 667-214-2120
www.MdProblemGambling.com | HELPLINE 1-800-GAMBLER
Page 8 of 32
GAMBLING DISORDER AND SOCIAL DETERMINANTS OF
HEALTH
The Social Determinants of Health (SDOH) are the non-medical factors that influence health
outcomes. They are the conditions in the environment where people live, learn, work, play,
and worship that affect a wide range of health risks and outcomes. These wider set of
forces and systems shape the conditions of daily life and contribute to wide health
disparities and inequities. For example, people who do not have access to grocery stores
with healthy foods are less likely to have good nutrition.
Problem Gambling Screening Guide
Guidelines for Integrating Gambling Screening and Assessment into Current Practice
A Toolkit for Behavioral Health Providers and Medical Professionals
250 W. Pratt Street, Suite #1050 | Baltimore, MD 21201 | 667-214-2120
www.MdProblemGambling.com | HELPLINE 1-800-GAMBLER
Page 9 of 32
The World Health Organization (WHO) and the Centers for Disease Control and Prevention
(CDC) recognize five categories that should be considered to determine the social aspects
that influence health outcomes:
1. Economic Stability: The connection between one’s financial resources, income, and
their health. Key factors include poverty, housing instability, and food insecurity.
2. Education Access and Quality: The connection between one’s education to health
and wellbeing. Key factors include early childhood education, language and literacy,
and high school graduation.
3. Social and Community Context: The connection between the characteristics of the
contexts where one lives, learns, works, and plays and their health and wellbeing.
Key factors include discrimination, racism, incarceration, social cohesion, and civic
participation.
4. Health Care Access and Quality: The connection to ones understanding of health
services and their own health. Key factors include health literacy, access to health
care, and access to insurance.
5. Neighborhood and Built Environment: The connection between where a person
lives (housing, neighborhood, and environment) and their health and wellbeing. Key
factors include access to foods that support healthy eating patterns, crime and
violence, and quality of housing.
When considering the factors that relate to one’s health outcomes the same factors
contribute to gambling related problems or increase the susceptibility to having problems
related to gambling. Persons living in poverty might see gambling as a financial solution to
problems that may be related to the SDOH. It is not uncommon to hear a story related to
someone gambling to keep their gas and electric running for the next month.
As more research is done, we will likely see correlations to the SDOH and the risk factors
for problems related to gambling.
Problem Gambling Screening Guide
Guidelines for Integrating Gambling Screening and Assessment into Current Practice
A Toolkit for Behavioral Health Providers and Medical Professionals
250 W. Pratt Street, Suite #1050 | Baltimore, MD 21201 | 667-214-2120
www.MdProblemGambling.com | HELPLINE 1-800-GAMBLER
Page 10 of 32
SCREENING FOR GAMBLING
The Center encourages behavioral health providers and medical professionals to include an
evidenced-based gambling screening as part of their regular screening and assessment
process. It is important to note here that before asking any questions about gambling, the
definition and examples of the types of gambling should be discussed with your clients.
Asking simply if the client does or does not gamble makes room for interpretation from both
the clients’ and healthcare professionals’ perspective. Casinos, since their arrival in
Maryland, are often seen as the most common form of gambling, yet the Lottery is more
accessible and is the most common form of gambling. With the roll out of legalized sports
betting in Maryland, there will be even greater access to ways persons can gamble.
Many persons with lifetime gambling problems report they have never received treatment
for this specific issue. However, those that have problems related to their gambling are
usually in treatment for another behavioral health disorder, yet gambling problems go
undetected. Research has shown that co-occurring behavioral health disorders are common
amongst those with an identified gambling disorder. Primarily evident are Anxiety related
disorders, specifically Post Traumatic Stress Disorder (PTSD), Personality disorders (cluster
B), Affect disorders, and other substance use disorders. Furthermore, according to the
DSM-5, up to 50% of those diagnosed with a gambling disorder have contemplated suicide;
another 17% have attempted suicide. Given these statistics, it is critical to assess for
gambling related problems, as they may contribute to a pre-existing behavioral health
disorder.
Brief screening tools can be implemented at any phase of the treatment process. It is
encouraged that gambling screens are incorporated into existing forms required for
admission and repeated during treatment plan reviews or yearly physicals. The three brief
evidenced-based gambling screening tools highlighted in this guide are described next and
can be viewed at the end of this guide (See APPENDIX A, B, C). Later in this guide,
incorporating gambling questions into a biopsychosocial assessment will be discussed.
Problem Gambling Screening Guide
Guidelines for Integrating Gambling Screening and Assessment into Current Practice
A Toolkit for Behavioral Health Providers and Medical Professionals
250 W. Pratt Street, Suite #1050 | Baltimore, MD 21201 | 667-214-2120
www.MdProblemGambling.com | HELPLINE 1-800-GAMBLER
Page 11 of 32
Lie-Bet Tool:
The Lie-Bet questionnaire is a two-item tool that has been deemed valid and reliable for
ruling out pathological gambling behaviors. If an individual answers yes to one or both
questions on the Lie-Bet questionnaire, further assessment is indicated (See APPENDIX B).
Brief Biosocial Gambling Screen:
Is a three-question brief screening instrument that helps a person decide whether to seek a
more formal evaluation or treatment for their gambling behavior. You can also use this with
your clients to determine if a more comprehensive screen is necessary. This tool is
developed by the Division on Addiction, Cambridge Health Alliance (See APPENDIX C).
Problem Gambling Severity Index:
An abbreviated version of the original tool called the Canadian Problem Gambling Index, it
consists of nine items rather than 31. Clients can use it as a self-assessment tool, or it can
be used as part of your regular screening process (See APPENDIX D).
Problem Gambling Screening Guide
Guidelines for Integrating Gambling Screening and Assessment into Current Practice
A Toolkit for Behavioral Health Providers and Medical Professionals
250 W. Pratt Street, Suite #1050 | Baltimore, MD 21201 | 667-214-2120
www.MdProblemGambling.com | HELPLINE 1-800-GAMBLER
Page 12 of 32
BRIEF INTERVENTIONS FOR GAMBLING
Once screening is completed, give feedback about the results. Become open-minded as
you work to understand the client’s perspective of their behavior. Engage in a conversation
about the client’s readiness to change, talk about the pros and cons of maintaining or
abstaining from gambling.
Inform the person about safe limits regarding gambling, such as the amount of money used
for gambling and the time spent participating in gambling activities. The Center has several
free awareness materials that can be displayed in your offices and used to have a
conversation about gambling.
Below is The Center’s “Turtle Card”, that gives examples of low and high-risk gambling on a
business card. It can be used during a brief intervention or even as a tool for a group
discussion.
Screening is still the first step. If screened positive, and if the client is ready, further
assessment is recommended. Next, we will discuss ways to incorporate gambling related
questions into a biopsychosocial assessment. At the end of this guide, we will discuss
resources for referral that include the Center’s Certified Peer Recovery Specialists,
Gambler’s Anonymous, and information about the no cost treatment that is offered to
Maryland individuals and their families that have problems with gambling.
Low Risk Gambling is Done:
As a form of recreation, not to make money or make up for previous losses.
With limits on time, frequency, and duration.
In a social setting with others not alone.
With money you can afford to lose.
High Risk Gambling – Situations When You Are:
Coping with grief, loneliness, anger, or depression.
Under financial pressure and stress.
Recovering from mental health or substance use disorders.
Using alcohol or other drugs.
Under legal age to gamble.
Problem Gambling Screening Guide
Guidelines for Integrating Gambling Screening and Assessment into Current Practice
A Toolkit for Behavioral Health Providers and Medical Professionals
250 W. Pratt Street, Suite #1050 | Baltimore, MD 21201 | 667-214-2120
www.MdProblemGambling.com | HELPLINE 1-800-GAMBLER
Page 13 of 32
INTEGRATING GAMBLING INTO A BIOPSYCHOSOCIAL
ASSESSMENT
Biopsychosocial Assessments evaluate the biological, social, and psychological aspects that
can be contributing to a problem or problems with a client. It is considered a holistic
assessment, examining various aspects of a client’s life, including culture, education and
work history, family and marriage difficulties, and medical issues to better identify an
individual’s needs.
This in-depth assessment is primarily utilized by Behavioral Health providers; however,
Medical Professionals should be aware of these aspects of the assessment. Furthermore,
Healthcare systems are increasingly developing integrated models of care, incorporating
teams of Peers, Physicians, Social Workers, Community Health Workers, Nurses, and other
helping professionals to meet the full needs of the client for their best health.
This guide will discuss ways to incorporate gambling related questions into the following
aspects of your assessment:
Behavioral Health (Mental Health and Substance Use)
Family History/ Cultural Traditions
Support System/ Financial
Employment/ Education
Legal History
Medical
Biological
•associated with the
relationship of disease
and bodily health
Psychological
•aspects of mental
and emotional
wellness that relate
to behavior
Social
•interpersonal
factors such as
social interactions
and community
activities
Problem Gambling Screening Guide
Guidelines for Integrating Gambling Screening and Assessment into Current Practice
A Toolkit for Behavioral Health Providers and Medical Professionals
250 W. Pratt Street, Suite #1050 | Baltimore, MD 21201 | 667-214-2120
www.MdProblemGambling.com | HELPLINE 1-800-GAMBLER
Page 14 of 32
Behavioral Health (Mental Health and Substance Use)
Various research has shown that persons with mental health and substance use disorders
develop problematic gambling behaviors at a high rate. The relationship of developing such
co-occurring disorders could be bidirectional. For example, loss of money due to gambling
may increase symptoms of depression; alternatively, persons who have depression may
gamble as a form of escape from painful feelings.
Common mental health disorders that have been associated with problematic gambling
include, but are not limited to Anxiety related disorders, Affect disorders and Personality
disorders. Persons who have experienced trauma as a child or an adult are at an increased
risk. Post-Traumatic Stress Disorder (PTSD) is also a common diagnosis amongst our first
responders and military population who are more likely to be risk-takers.
Suicidal ideation is seen at a higher rate of those diagnosed with gambling disorder
compared to the general population. Fifty percent of persons with a gambling disorder have
contemplated suicide and approximately 17% have attempted suicide. Persons with
problematic gambling may believe they are worth more dead than alive and seek ways to
have their families benefit from life-insurance policies. Furthermore, the secret nature of
suicide keeps gambling disorder a hidden addiction.
In this section of the assessment past and current treatment attempts are examined,
including participation in 12-step recovery programs. Research has demonstrated that
persons with lifetime gambling problems report receiving treatment for “something”, as
mental health and substance use disorders are common amongst problem gamblers. The
absence of regular screening continues to hide the person in need of help for a co-occurring
problem
Lastly, participating in gambling activities can increase the likelihood of a relapse to
substances or return of mental health symptoms. Gambling is seen as a socially
acceptable, harmless activity and few people are aware of the potential for developing a
gambling disorder. Persons with behavioral health disorders can view gambling activities or
venues as a safe space to spend their time and money. The negative consequences of
gambling can lead to a return of old patterns, such as using substances.
Problem Gambling Screening Guide
Guidelines for Integrating Gambling Screening and Assessment into Current Practice
A Toolkit for Behavioral Health Providers and Medical Professionals
250 W. Pratt Street, Suite #1050 | Baltimore, MD 21201 | 667-214-2120
www.MdProblemGambling.com | HELPLINE 1-800-GAMBLER
Page 15 of 32
Family History/ Cultural Tradition
As with other behavioral health disorders and medical diseases, family history has an
impact on health outcomes. The risk of developing a gambling disorder increases if
problematic or disordered gambling occurs in the family. Witnessing the behaviors
associated with gambling activities in the household or amongst peers in the neighborhood
leaves an impression on a developing mind.
Gambling occurs at higher rates within minority populations, who for cultural reasons may
be less likely to seek treatment. Furthermore, those that that have cultural values and
beliefs that favor gambling such as those associated with “luck or fate” are more at risk.
The forms of gambling that are favored by cultures differ and can include wagering on
horses to card games.
Problems related to gambling not only impact the individual; families and friends of a
person with a gambling disorder are also affected. Your client may be suffering from the
financial consequences of their own or their significant others gambling behaviors. The
Center recognizes that having conversations about gambling not only help to identify the
individual with a problem but may assist in identifying the individual impacted by someone
else’s gambling.
Support System/ Financial
Homelessness is a possible consequence of disordered gambling. Borrowing money from
friends and family, taking out lines of credit, and receiving cash advances from student
loans are all actions that those with a gambling disorder may use to sustain their behavior.
Problematic gamblers can exhaust those they seek support from financially and
emotionally. Lying is a sign of gambling disorder that undermines the relationship of
supportive loved ones.
Financial destruction is a consequence of disordered gambling. Conversations about
budgeting and fiscal responsibility remain sensitive and private. While there are services
for assistance, the shame in asking for and receiving help vary by individual. Having a
professional on staff that feels comfortable discussing financial health is recommended.
Resources for financial restoration are given at the end of this guide. Additionally, the
Center’s Certified Peer Recovery Specialist have the ability to connect clients to the
appropriate resources.
Problem Gambling Screening Guide
Guidelines for Integrating Gambling Screening and Assessment into Current Practice
A Toolkit for Behavioral Health Providers and Medical Professionals
250 W. Pratt Street, Suite #1050 | Baltimore, MD 21201 | 667-214-2120
www.MdProblemGambling.com | HELPLINE 1-800-GAMBLER
Page 16 of 32
Employment/ Education
Preoccupation with gambling is a symptom of gambling disorder. The inability to meet
deadlines or always arriving late can be a sign of a problem that needs to be addressed.
The problematic gambler is distracted by having to monitor the changing statistics, scores,
or stock to ensure their next win, hoping to avoid a loss. The changes to the gambling
landscape in Maryland will include access to gambling on-line. Increase in access to
gambling activities will increase the risk of gambling related problems and limitations should
be considered in educational and employment settings.
Legal History
All States, except Utah allow some form of legalized gambling. Yet, the legal consequences
of gambling go beyond underage gambling, illegal betting, or bookmaking. Theft,
embezzlement, and fraud are commonly seen among those with a gambling disorder.
Although “illegal acts” is no longer a diagnostic criterion for gambling disorder, those with
problematic gambling seek solutions to continue their behavior, often with a confidence
they will return the money.
Understanding Joy: The Devastation of a Gambling Addiction, is a revealing documentary
on the destructive nature of gambling addiction. Produced by the Center, this documentary
tells the story of Joy, a 56-year-old mother who once held a job as a bookkeeper for a small
business in Western Maryland. Joy shares her story with fellow inmates at the Maryland
Correctional Institute for Women, serving a sentence for her second conviction of theft after
stealing more than $100,000 from her employer.
Temptation also lurks inside the prison, where inmates wager candy, shower gel, potato
chips and other commissary items in illegal sports pools and other games. Studies indicate
that the rate of problematic gambling is higher among prison inmates than the population
at large. Additionally, researchers for the U.S. Department of Justice have found that
inmates are three to five times more likely to develop a gambling problem.
Problem Gambling Screening Guide
Guidelines for Integrating Gambling Screening and Assessment into Current Practice
A Toolkit for Behavioral Health Providers and Medical Professionals
250 W. Pratt Street, Suite #1050 | Baltimore, MD 21201 | 667-214-2120
www.MdProblemGambling.com | HELPLINE 1-800-GAMBLER
Page 17 of 32
Medical
Mentioned earlier was the Social Determinants of Health (SDOH), the non-medical factors
that contribute to health care costs. Questions related to the SDOH may be conducted in
medical settings and should be considered here. As an example, persons who live near a
casino, are at greater risk of developing problems related to gambling. The environment
where the casino is located may increase the likelihood of violence in that neighborhood and
decrease the access to healthy foods. A person’s access to quality education could change
because of the location of the casino forming new school districts. All scenarios can impact
on one’s health outcomes.
Furthermore, persons with problems gambling or a gambling disorder can spend hours at a
time gambling. Of Marylanders, 35.3%, gamble for 1-2 hours at a time, 29% gamble for 3-
5 hours and another 6% gamble for 6-12 hours. This form of distraction can cause lapses in
taking life-sustaining medication, like for high blood pressure or diabetes, at the
appropriate times. Additionally, the amount of money that is lost gambling will have an
impact on a person’s ability to afford their medications. Persons aged 55 and over, living
on a fixed income, and retired are susceptible to negative harms due to gambling activities,
thus impacting their finances in a negative way, consequently harming their health.
Questions concerning past and present medications are included in this part of the
biopsychosocial assessment. Healthcare professionals should be aware that Dopamine
agonists may lead to compulsive behavior such as gambling. Dopamine agonists are most
often used to treat Parkinson’s disease (e.g., Mirapex) and Restless Legs Syndrome (e.g.,
Requip) but are also prescribed for other conditions. Abilify, another dopamine agonist
commonly used to treat schizophrenia, has also been found to increase gambling related
behaviors.
Problem Gambling Screening Guide
Guidelines for Integrating Gambling Screening and Assessment into Current Practice
A Toolkit for Behavioral Health Providers and Medical Professionals
250 W. Pratt Street, Suite #1050 | Baltimore, MD 21201 | 667-214-2120
www.MdProblemGambling.com | HELPLINE 1-800-GAMBLER
Page 18 of 32
RESOURCES FOR HELP AND TREATMENT
Center Resources
Free Gambling Help and Treatment
The Center works closely with stakeholders throughout the State, bringing together experts
from a variety of disciplines. The Center, in partnership with The Maryland Department of
Health’s Behavioral Health Administration, manages the Maryland Problem Gambling
Provider Referral Network Directory. This Directory lists those providers throughout
Maryland who offer free counseling for gambling disorder, for both individuals and family
members. You can find the Directory on the Center’s websites as well as on the Maryland
Alliance for Responsible Gambling’s website; it is also utilized by the Maryland Problem
Gambling Helpline staff (1-800-GAMBLER).
1-800-GAMBLER
Call or text TODAY! 1-800-426-2537
Certified Peer Recovery Specialists
The Center also has on staff 5 Certified Peer Recovery Specialists that have lived experience
with gambling addiction. Peers are available to provide individual support to the person
with a gambling disorder and offer referrals to appropriate resources such as those listed
below. The Center’s Peers spread awareness of the Center’s mission by providing gambling
awareness presentations to psychoeducational groups often eliciting conversations about
gambling activities they have been a part of or witnessed in their family. A regional map
with their contact information is included (See APPENDIX E).
Problem Gambling Screening Guide
Guidelines for Integrating Gambling Screening and Assessment into Current Practice
A Toolkit for Behavioral Health Providers and Medical Professionals
250 W. Pratt Street, Suite #1050 | Baltimore, MD 21201 | 667-214-2120
www.MdProblemGambling.com | HELPLINE 1-800-GAMBLER
Page 19 of 32
Self-Help Groups
Gambler’s Anonymous (GA)
A fellowship of men and women who share their experience, strength, and hope with each
other that they may solve their common problem and help others to recover from a
gambling problem. The only requirement for membership is a desire to stop gambling.
• Main Website:
https://gamblersanonymous.org/ga/
• Maryland Hotline Number: 855-2CALL-GA (855-222-5542)
• U.S. Meetings: https://www.gamblersanonymous.org/ga/locations
• Virtual Meetings: https://www.gamblersanonymous.org/ga/virtual-meetings
• GA Maryland Intergroup
o Main Website:
https://dmvgamblinghelp.org/
o Email: MarylandI[email protected]
o Maryland Hotline: 888-520-8755
o Learn more about Pressure Relief Groups by contacting:
MarylandMee[email protected]
Gam-Anon
A 12 Step self-help fellowship of men and women who have been affected by the gambling
problem of another. All meetings are open to anyone who is affected by the gambling
problem of a family member, loved one or friend.
• Main Website:
https://www.gam-anon.org/
• Maryland Hotline Number: 888-230-1123
• Maryland Meetings:
https://www.gam-anon.org/meeting-directory/us-meeting-
directory/maryland
• U.S. Meetings: https://www.gam-anon.org/meeting-directory/us-meeting-directory
• Virtual Meetings: https://www.gam-anon.org/meeting-directory/virtual-meetings
Problem Gambling Screening Guide
Guidelines for Integrating Gambling Screening and Assessment into Current Practice
A Toolkit for Behavioral Health Providers and Medical Professionals
250 W. Pratt Street, Suite #1050 | Baltimore, MD 21201 | 667-214-2120
www.MdProblemGambling.com | HELPLINE 1-800-GAMBLER
Page 20 of 32
SMART (Self-Management And Recovery Training) Recovery Meetings
A global community of mutual-support groups. At meetings, participants help one another
resolve problems with any addiction (to drugs or alcohol to gambling or over-eating). Using
a science-based approach emphasizing self-empowerment and self-reliance. SMART can be
used both as a stand-alone program or in combination with other recovery paths.
• Main Website:
https://www.smartrecovery.org/
• U.S. Meetings: https://meetings.smartrecovery.org/meetings/location/
• Phone Number: 440-951-5357
Maryland Organizations
Maryland Coalition of Families (MCF)
A State-wide nonprofit dedicated to connecting, supporting, and empowering families who
are experiencing behavioral health problems.
Family peer support is all about connecting families through shared experience. When
someone you love has a behavioral health issue, it can be life-changing to hear from and
talk with someone who has gone through similar experiences. Through family peer support,
MCF helps families feel less isolated and help them to become their own advocates.
• Main Website:
https://www.mdcoalition.org/
• For Gambling Help: http://www.mdcoalition.org/who-we-help/problem-gambling/
• Email: help@mdcoalition.org
• Phone Number: 410-730-8267
National Alliance on Mental Illness (NAMI) - Maryland
NAMI is the nation's largest grassroots mental health organization dedicated to building
better lives for the millions of Americans affected by mental illness. The NAMI organization
operates at the national, state, and local level.
NAMI Maryland is the NAMI state organization in Maryland. NAMI Maryland provides
educational resources and events, statewide outreach, advocacy, and affiliate organizational
support.
Local NAMI affiliates in Maryland offer free peer support, education, and outreach programs,
and engage mental health advocates in their communities.
• Main Website:
http://namimd.org/
• NAMI Warm-Line: 1-877-878-2371
• Crisis Text Line - Text "NAMI" to 741741
• Phone Number: 410-884-8691
• Email: info@namimd.org
Problem Gambling Screening Guide
Guidelines for Integrating Gambling Screening and Assessment into Current Practice
A Toolkit for Behavioral Health Providers and Medical Professionals
250 W. Pratt Street, Suite #1050 | Baltimore, MD 21201 | 667-214-2120
www.MdProblemGambling.com | HELPLINE 1-800-GAMBLER
Page 21 of 32
CASH (Creating Assets, Savings, and Hope) Campaign of Maryland
Promotes economic advancement for low-to-moderate income individuals and families in
Baltimore and across Maryland. CASH accomplishes its mission through operating a
portfolio of direct service programs, building organizational and field capacity, and leading
policy and advocacy initiatives to strengthen family economic stability.
• Main Website:
https://cashmd.org/
• Phone Number: 410-528-8006
• Email:
[email protected]
Consumer Credit Counseling Services of Maryland (CCCSMD)
A certified nonprofit provider of budget, credit, and debt counseling. CCCSMD has helped
thousands of people who are struggling to pay their bills sort through the confusion, create
a realistic budget to achieve their goals, and start on the road to financial security.
The CASH Campaign provides direct services that help people achieve their financial goals.
These programs include free tax preparation, financial education, financial coaching, public
benefits screening, Money Power Day and more! We also work with organizations and their
staffs through training or other technical assistance to help them deliver financial capability
services to the people they serve.
• Main Website:
https://cccsmd.org/
• Phone Number: 1-800-642-2227
• Email: info@cccsmd.org
Maryland Legal Aid (MLA)
Provides life-changing civil legal assistance to eligible residents in every part of the State.
As a private, non-profit law firm, MLA provides a full range of free civil legal services to low-
income people statewide, in Baltimore City and in Maryland’s 23 counties, from 12 office
locations.
• Main Website:
https://www.mdlab.org/
• Regional Contact information: https://www.mdlab.org/contact-us/
Maryland Center for Legal Assistance (MCLA)
A wholly owned subsidiary of Maryland Legal Aid, the Maryland Center for Legal Assistance
operates the District Court Help Resource Centers in Baltimore City, Glen Burnie, Upper
Marlboro, and Salisbury and the Maryland Courts Help Centers in Annapolis and Frederick.
The Maryland Courts Help Centers provides free limited legal services.
• Main Website:
https://www.mdcla.org/
• Phone Number: (410) 260-1392
Problem Gambling Screening Guide
Guidelines for Integrating Gambling Screening and Assessment into Current Practice
A Toolkit for Behavioral Health Providers and Medical Professionals
250 W. Pratt Street, Suite #1050 | Baltimore, MD 21201 | 667-214-2120
www.MdProblemGambling.com | HELPLINE 1-800-GAMBLER
Page 22 of 32
National Resources
The National Council on Problem Gambling (NCPG)
The organization was founded in 1972 by Msgr. Joseph A. Dunne and Dr. Robert Custer,
among others. The Council established two principles that remain in effect today: that the
organization would be the advocate for problem gamblers and their families, and that it
would take no position for or against legalized gambling.
• Main Website:
https://www.ncpgambling.org/
• Help by State: https://www.ncpgambling.org/help-treatment/help-by-state/
• Call or Text: 1-800-522-4700
• Chat Online:
ncpgambling.org/chat
Problem Gambling Screening Guide
Guidelines for Integrating Gambling Screening and Assessment into Current Practice
A Toolkit for Behavioral Health Providers and Medical Professionals
250 W. Pratt Street, Suite #1050 | Baltimore, MD 21201 | 667-214-2120
www.MdProblemGambling.com | HELPLINE 1-800-GAMBLER
Page 23 of 32
APPENDIX A - DSM 5: GAMBLING DISORDER CRITERIA
Problem Gambling Screening Guide
Guidelines for Integrating Gambling Screening and Assessment into Current Practice
A Toolkit for Behavioral Health Providers and Medical Professionals
250 W. Pratt Street, Suite #1050 | Baltimore, MD 21201 | 667-214-2120
www.MdProblemGambling.com | HELPLINE 1-800-GAMBLER
Page 24 of 32
APPENDIX B - LIE-BET
LIE-BET TOOL TO RULE OUT PATHOLOGICAL GAMBLING
Historically, clinicians have indicated that another series of questions added to the intake
process would be difficult to include. The instrument will be useful in clinical settings where
clinicians have limited time and often are required to collect a great deal of information
from each patient. A two-question survey will hopefully be met with less resistance and
allow us to establish a “foot hold” within the intake process.
The Lie-Bet tool (Johnson et al., 1988) has been deemed valid and reliable for ruling out
pathological gambling behaviors. The Lie-Bet’s two questions consistently differentiate
between pathological gambling and nonproblem-gambling and are useful in screening to
determine whether a longer tool (e.g., SOGS, DSM-IV) should be used in diagnostics.
Lie-Bet Screening Instrument
1) Have you ever felt the need to bet more and more money?
2) Have you ever had to lie to people important to you about how much you gambled?
Administer Lie-Bet Screening Instrument
“Yes” to one “No” to
or both questions both questions
Reference: Johnson, E.E., Hamer,R., Nora, R.M., Tan, B., Eistenstein, N., &
Englehart, C. (1988). The lie/bet questionnaire for screening pathological
gamblers. Psychological Reports, 80, 83-88.
Crime
Financial Problems
Alcoholism
Drug Abuse
Other Mental Health Issues
Further assessment needed.
Refer the client to gambling
treatment program; call the
National Help Line
1-800-522-4700.
No referral;
follow-up as necessary.
Problem Gambling Screening Guide
Guidelines for Integrating Gambling Screening and Assessment into Current Practice
A Toolkit for Behavioral Health Providers and Medical Professionals
250 W. Pratt Street, Suite #1050 | Baltimore, MD 21201 | 667-214-2120
www.MdProblemGambling.com | HELPLINE 1-800-GAMBLER
Page 25 of 32
www.icrg.org www.divisiononaddiction.org
Call, Text 1‐800‐GAMBLER or chat www.HelpMyGamblingProblem.org
APPENDIX C - BBGS
Brief Biosocial Gambling Screen
Overview
Brief screens can help people decide whether to seek formal evaluation of their
gambling behavior. The 3‐item BBGS is based on the American Psychiatric
Association's Diagnostic and Statistical Manual of Mental Disorders
(DSM‐V) criteria
for gambling disorder.
Scoring
A “yes” response to any single item indicates potential gambling‐related problems
and the need for additional evaluation.
1. During the past 12 months, have you become restless irritable or anxious
when trying to stop/cut down on gambling?
⃝ Yes ⃝ No
2. During the past 12 months, have you tried to keep your family or friends
from knowing how much you gambled?
⃝ Yes ⃝ No
3. During the past 12 months did you have such financial trouble as a result of
your gambling that you had to get help with living expenses from family,
friends or welfare?
⃝ Yes ⃝ No
Problem Gambling Screening Guide
Guidelines for Integrating Gambling Screening and Assessment into Current Practice
A Toolkit for Behavioral Health Providers and Medical Professionals
250 W. Pratt Street, Suite #1050 | Baltimore, MD 21201 | 667-214-2120
www.MdProblemGambling.com | HELPLINE 1-800-GAMBLER
Page 26 of 32
APPENDIX D - PGSI
Problem Gambling Severity Index
This self-assessment is based on the Canadian Problem Gambling Index. It will give
you a good idea of whether you need to take corrective action.
Thinking about the last 12 months…
1. Have you bet more than you could really afford to lose?
0 Never. 1 Sometimes. 2 Most of the time. 3 Almost always.
2. Still thinking about the last 12 months, have you needed to gamble with larger
amounts of money to get the same feeling of excitement?
0 Never. 1 Sometimes. 2 Most of the time. 3 Almost always.
3. When you gambled, did you go back another day to try to win back the money you
lost?
0 Never. 1 Sometimes. 2 Most of the time. 3 Almost always.
4. Have you borrowed money or sold anything to get money to gamble?
0 Never. 1 Sometimes. 2 Most of the time. 3 Almost always.
5. Have you felt that you might have a problem with gambling?
0 Never. 1 Sometimes. 2 Most of the time. 3 Almost always.
6. Has gambling caused you any health problems, including stress or anxiety?
0 Never. 1 Sometimes. 2 Most of the time. 3 Almost always.
7. Have people criticized your betting or told you that you had a gambling problem,
regardless of whether or not you thought it was true?
0 Never. 1 Sometimes. 2 Most of the time. 3 Almost always.
8. Has your gambling caused any financial problems for you or your household?
0 Never. 1 Sometimes. 2 Most of the time. 3 Almost always.
9. Have you felt guilty about the way you gamble or what happens when you gamble?
0 Never. 1 Sometimes. 2 Most of the time. 3 Almost always.
Ferris, J., & Wynne, H. (2001). The Canadian problem gambling index: Final report.
Submitted for the Canadian Centre on Substance Abuse.
TOTAL SCORE
Total your score. The higher your score, the greater the risk that your gambling is a problem.
Score of 0 = Non-problem gambling.
Score of 1 or 2 = Low level of problems with few or no identified negative consequences.
Score of 3 to 7 = Moderate level of problems leading to some negative consequences.
Score of 8 or more = Problem gambling with negative consequences and a possible loss of control.
Problem Gambling Screening Guide
Guidelines for Integrating Gambling Screening and Assessment into Current Practice
A Toolkit for Behavioral Health Providers and Medical Professionals
250 W. Pratt Street, Suite #1050 | Baltimore, MD 21201 | 667-214-2120
www.MdProblemGambling.com | HELPLINE 1-800-GAMBLER
Page 27 of 32
APPENDIX E - PEER MAP
Problem Gambling Screening Guide
Guidelines for Integrating Gambling Screening and Assessment into Current Practice
A Toolkit for Behavioral Health Providers and Medical Professionals
250 W. Pratt Street, Suite #1050 | Baltimore, MD 21201 | 667-214-2120
www.MdProblemGambling.com | HELPLINE 1-800-GAMBLER
Page 28 of 32
APPENDIX F - TURTLE CARD
KEEP GAMBLING FUN AND PROBLEM FREE
Set a limit on how much time and money you will spend and stick
to it.
View gambling as entertainment, not as a way to make money.
Balance gambling with other leisure activities.
If you gamble and spend more time and money than you can afford, a good
strategy is to take a break. Consider seeking help if this is a concern.
Problem Gambling Helpline, Toll-Free, Confidential 24/7
1-800-GAMBLER
www.helpmygamblingproblem.org
Low Risk Gambling Is Done:
As a form of recreation, not to make money or make up for previous losses.
With limits on time, frequency, and duration.
In a social setting with others, not alone.
With money you can afford to lose.
High Risk Gambling – Situations When You Are:
Coping with grief, loneliness, anger or depression.
Under financial pressure and stress.
Recovering from mental health or substance use disorders.
Using alcohol or other drugs.
Under legal age to gamble.
Maryland Problem Gambling Helpline – 1-800-GAMBLER
Problem Gambling Screening Guide
Guidelines for Integrating Gambling Screening and Assessment into Current Practice
A Toolkit for Behavioral Health Providers and Medical Professionals
250 W. Pratt Street, Suite #1050 | Baltimore, MD 21201 | 667-214-2120
www.MdProblemGambling.com | HELPLINE 1-800-GAMBLER
Page 29 of 32
REFERENCES
American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental
Disorders (5th ed.)
American Society of Addiction Medicine (2013) The ASAM Criteria: Treatment Criteria for
Addictive, Substance-Related, and Co-Occurring Conditions (3rd ed.)
Brain Facts.org – Gambling Addiction and the Brain:
https://www.brainfacts.org/diseases-
and-disorders/addiction/2015/gambling-addiction-and-the-brain
Baltimore Sun – Inmates Face Problem Habit:
https://www.baltimoresun.com/maryland/baltimore-city/bs-md-gamblers-in-prison-
20140917-story.html
Cambridge Health Alliance, Division on Addiction – Information about Gambling Disorder:
https://www.divisiononaddiction.org/outreach-resources/gdsd/toolkit/information/
Centers for Disease Control and Prevention – Social Determinants of Health: Know What
Affect Health:
https://www.cdc.gov/socialdeterminants/index.htm
Gambling.Net – Online gambling information:
https://www.gambling.net/history/
Healthline – Parkinson's Drugs May Lead to Compulsive Gambling, Shopping, and Sex:
https://www.healthline.com/health-news/parkinsons-drugs-may-lead-to-compulsive-
gambling-102014#The-Tip-of-the-Iceberg
History Channel – Lotteries helped build libraries, roads and even Harvard:
https://www.history.com/news/13-colonies-funding-lottery
The Harvard Crimson – Records Reveal Harvard Lottery to Bolster Early Building Funds --
Stoughton and Holworthy Owe Existence to Tickets:
https://www.thecrimson.com/article/1927/3/15/records-reveal-harvard-lottery-to-bolster/
National Center for Responsible Gaming – The Evolving Definition of Pathological Gambling
in the DSM-5:
https://icrg.org/sites/default/files/uploads/docs/white_papers/ncrg_wpdsm5_may2013.pdf
Problem Gambling Screening Guide
Guidelines for Integrating Gambling Screening and Assessment into Current Practice
A Toolkit for Behavioral Health Providers and Medical Professionals
250 W. Pratt Street, Suite #1050 | Baltimore, MD 21201 | 667-214-2120
www.MdProblemGambling.com | HELPLINE 1-800-GAMBLER
Page 30 of 32
National Council on Problem Gambling – FAQ and State Resources:
https://www.ncpgambling.org/help-treatment/faq/
https://www.ncpgambling.org/help-treatment/help-by-state/
Responsible Gambling Council – The Science Behind Gambling:
https://www.responsiblegambling.org/for-the-public/about-gambling/the-science-behind-
gambling/
SAMHSA Advisory – Gambling Problems: An Introduction for Behavioral Health Services
Providers:
https://www.ncpgambling.org/wp-content/uploads/2014/04/Gambling-
Addiction-An-Introduction-for-Behavioral-Health-Providers-SAMHSA-2014.pdf
Statewide Gambling Prevalence in Maryland: 2020 – Maryland Center of Excellence on
Problem Gambling, University of Maryland Baltimore:
https://www.mdproblemgambling.com/wp-content/uploads/2022/07/Gambling-Prevalence-
study-2020-FINAL.pdf
U.S. Department of Health and Human Services: Healthy People 2030 – What are Social
Determinants of Health:
https://health.gov/healthypeople/priority-areas/social-
determinants-health
Wikipedia – Cleromancy:
https://en.wikipedia.org/wiki/Cleromancy
World Health Organization – Social Determinants of Health:
https://www.who.int/health-
topics/social-determinants-of-health#tab=tab_1
Problem Gambling Screening Guide
Guidelines for Integrating Gambling Screening and Assessment into Current Practice
A Toolkit for Behavioral Health Providers and Medical Professionals
250 W. Pratt Street, Suite #1050 | Baltimore, MD 21201 | 667-214-2120
www.MdProblemGambling.com | HELPLINE 1-800-GAMBLER
Page 31 of 32
WEAVING TOGETHER A BLANKET OF
HOPE AND HELP