Gambling and Alcohol Addiction: Why They Occur Together

Gambling disorder and alcohol use disorder co-occur at a high rate, and DSM-5 moved gambling alongside the substance use disorders because gambling engages the same brain reward circuitry that substances engage.

Roughly half of people with gambling disorder also report problems with alcohol, illicit drugs, or prescription sedatives and painkillers. Neither condition reliably starts first, which is why both belong in one treatment plan rather than in a queue.

Key Takeaways

• Around half of people with gambling disorder also report problems with alcohol, illicit drugs or prescription sedatives and painkillers, per a 2025 comorbidity review.
• DSM-5 diagnoses gambling disorder at 4 or more of 9 criteria, down from the 5 of 10 that DSM-IV required for pathological gambling.
• People with gambling disorder and people with substance use disorders show similar functional changes in reward circuitry, which researchers read as a shared vulnerability.
• Prospective studies find no fixed order between gambling and a co-occurring disorder, so sequencing treatment rests on an assumption the evidence does not support.
• Cognitive behavioral therapy reduced gambling disorder severity across 29 pooled randomized trials, and the same analysis found no significant effect at follow-up.
• Suicidal ideation reaches 22.9 percent among patients treated for gambling disorder, the highest rate among the behavioral addictions examined.

How Often Do Gambling and Alcohol Addiction Occur Together?

Roughly half of people with gambling disorder also report problems with alcohol, illicit drugs, or prescription sedatives and painkillers, according to figures reported in a 2025 comorbidity review. Gambling disorder itself reaches 0.4 to 4.0 percent of adults across epidemiological studies.

Those rates climb inside substance use treatment populations. A study of 6,613 people recruited for genetic research on substance dependence diagnosed pathological gambling in 8.5 percent of the sample, and the same authors noted that earlier studies of people with substance use disorders reported 20.5 percent and 55.0 percent. The spread across those three figures tracks who was sampled: research volunteers sit at the low end and clinical populations at the high end.

The 2025 review reached the same conclusion from the other direction, recording a high rate of comorbidity between problem gambling and substance and alcohol use disorders, together with mood and anxiety disorders. Two independent literature bases point the same way.

That clustering is the reason dual diagnosis treatment screens for gambling behavior at intake instead of waiting for a patient to raise it. A person who arrives asking for help with drinking carries a meaningful chance of a second diagnosis nobody has named yet.

Why Does Gambling Engage the Same Brain Pathways as Alcohol?

People with gambling disorder and people with substance use disorders show similar functional changes in the brain’s reward circuitry, a pattern researchers read as a shared underlying vulnerability across addictive disorders. The circuit involved is the mesolimbic dopamine pathway.

Mesolimbic dopamine transmission is the common target of drugs of abuse, and that shared action forms the foundation of the modern concept of the brain reward system. Gambling reaches the same system through behavior rather than through a substance, which is the whole reason a behavior without a chemical qualifies as an addictive disorder at all. The dopamine reward pathway works the same way whether the trigger arrives in a glass or on a screen.

The finding came from a study that scanned people with pathological gambling and people with cocaine dependence while they played a simulated slot machine. Both groups showed altered reward and loss processing against the comparison group, and the similarity across the two groups is what pointed to shared vulnerability rather than two separate mechanisms.

What Is the Near-Miss Effect?

A near miss is a losing outcome that lands close to a win, and near misses raise the signal in brain reward circuitry above the level a clear loss produces. Slot machines, scratch cards and multi-leg sports bets generate near misses at a high rate by design.

The near-miss effect explains a pattern that confuses families. A person keeps playing through a losing session, and the longer the session runs the harder stopping becomes. The machine is not paying out money, but the brain keeps registering reward-like signals from outcomes that cost money. Two reels matching while the third lands one position short is, financially, a total loss. Inside the reward system it reads as something closer to success.

That mechanism matters for anyone trying to make sense of their own behavior. Continuing to play after heavy losses is not a failure of character or arithmetic. It is a response to a signal the machine was built to produce.

Which Condition Starts First, Gambling or Drinking?

There is no fixed order. Prospective studies show that gambling sometimes precedes the onset of the co-occurring disorder, and that in other cases the timing runs the other way. The research does not establish one direction as the rule.

That finding carries a direct clinical consequence. A plan that sequences the two conditions, resolving the drinking first and scheduling the gambling for some later date, rests on an assumption the evidence does not support. Waiting also gives the untreated condition room to pull the treated one back.

The reverse case matters just as much. Someone who enters alcohol addiction treatment and stops drinking without addressing gambling has removed one behavior and left the other with more time, more money and less scrutiny attached to it. Both diagnoses belong in the same treatment plan from the start.

What Are the Signs of Gambling Disorder?

DSM-5 diagnoses gambling disorder when a person meets at least 4 of 9 criteria. The four criteria endorsed most often are preoccupation with gambling, chasing losses, needing to increase the amount of money wagered, and relying on other people for money.

• Preoccupation with gambling, endorsed by 90.4 percent
• Chasing losses, endorsed by 82.6 percent
• Needing to increase the amount of money gambled, endorsed by 65.2 percent
• Relying on others for money, endorsed by 54.8 percent

Those endorsement rates describe one specific group in the research: the people who met DSM-5 criteria for gambling disorder without meeting the older and stricter DSM-IV criteria for pathological gambling. They are the group the threshold change brought into the diagnosis, which makes their most common signs the ones a newer or milder presentation is most likely to show.

Needing to increase the amount wagered is tolerance. It is the same criterion that appears in alcohol use disorder, where a person needs more drinks to reach the effect fewer drinks once produced. Chasing losses has a parallel too: continuing despite mounting harm. Anyone weighing gambling addiction treatment for themselves or a family member is looking at a criteria set built on the same logic as the substance use disorders.

What Changed When DSM-5 Replaced Pathological Gambling?

DSM-5 renamed the condition, lowered the diagnostic threshold, and removed one criterion. Pathological gambling became gambling disorder, the threshold dropped from 5 of 10 criteria to 4 of 9, and the illegal acts criterion came out.

The authors who set out the rationale for those changes were members of the DSM-5 work group, so the reasoning comes from the people who made the decision rather than from commentators afterward. Lowering a threshold by one criterion sounds minor. In the 6,613-person sample it moved the diagnosed rate from 8.5 percent to 10.3 percent, an increase of 20.4 percent in the number of people who qualified.

Those additional people are not borderline cases in any clinical sense. In that study, the group who met DSM-5 criteria but not DSM-IV criteria sat between the no-diagnosis group and the both-diagnoses group on comorbid substance use disorders, on which criteria they endorsed, and on the types of gambling they reported. They were also more likely than the no-diagnosis group, and less likely than the both-diagnoses group, to acknowledge having a gambling problem.

How Do Gambling and Alcohol Addiction Differ Between Women and Men?

Women with gambling disorder carry a heavier psychiatric burden than men with the same diagnosis. They are more likely to present with mood disorders, suicidality, mania, anxiety and alcohol dependence, according to the 2025 comorbidity review.

That difference shapes what an adequate assessment covers. For a woman presenting with gambling disorder, screening for alcohol dependence, mood symptoms and suicide risk is not an optional extra step, because the base rates for all three run higher.

Treatment for co-occurring depression belongs in the same conversation as the gambling itself rather than in a referral made months later. The DSM-5 threshold change also landed differently by sex in the 6,613-person sample: the diagnosed rate rose 18.9 percent among the 1,150 men and 26.9 percent among the 357 women.

What Does Treatment for Gambling and Alcohol Addiction Involve?

Cognitive behavioral therapy reduces gambling disorder severity. A 2023 systematic review and meta-analysis pooled 29 randomized trials covering 3,991 participants and measured a large reduction in gambling disorder severity at the end of treatment against minimally treated and untreated control groups.

That is the strongest evidence tier available for this condition: not one trial, but 29 of them pooled. The reported effect size for gambling disorder severity was g = -1.14, with a 95 percent confidence interval running from -1.68 to -0.60. The interval sits entirely below zero, which means the direction of the finding holds even at its weakest end.

The same review reported evidence of publication bias, so the pooled figure reads as the optimistic end of a range rather than a precise expectation. That is the honest way to present it.

What Happens After the First Phase of Treatment?

The same 2023 meta-analysis found no significant effect of cognitive behavioral therapy on follow-up outcomes. The gains measured at the end of treatment did not hold at later assessment. The authors report that limitation directly, and it is the most useful finding on this page.

Read plainly, it says a single course of therapy ending at discharge is not the finished job. Structure after the intensive phase is where a result either holds or slips, and that is the gap step-down care after residential treatment is built to cover. For someone carrying both gambling disorder and alcohol use disorder, the period after formal treatment ends is also the period when money, unstructured time and old routines all return at once.

What Should Families Watch For?

Financial concealment is the sign families notice first, because gambling disorder produces no breath odor, no slurred speech and no physical withdrawal. Relying on other people for money was endorsed by 54.8 percent of the newly diagnosed group, which means requests for money often arrive before anyone names the problem.

Alcohol use disorder shows itself. Gambling disorder hides inside ordinary phone use, and a person can meet 4 of 9 diagnostic criteria while sitting in a family room. That asymmetry is why a household frequently identifies the drinking months or years before the gambling, and why treatment that addresses only the visible condition leaves the concealed one running.

Preoccupation is the other early signal, endorsed by 90.4 percent. It looks like a person mentally elsewhere: replaying a session, planning the next one, calculating what a recovery would take. Families often read that as stress or distraction rather than as the most commonly endorsed criterion for the disorder.

When Gambling Losses Bring Thoughts of Suicide

Suicidal ideation reaches 22.9 percent among patients in treatment for gambling disorder, the highest rate among the behavioral addictions studied. That figure comes from a sample of 4,404 patients assessed at a specialized hospital unit for behavioral addictions, 4,103 of whom had gambling disorder.

The sample is a treatment-seeking one, so the rate describes people who reached a specialist unit rather than the general population. It still marks gambling disorder as the behavioral addiction carrying the heaviest suicidal ideation burden of those examined. Financial loss is a form of harm that arrives suddenly and completely, and it arrives without the warning period that most health consequences give.

Crisis resources. The 988 Suicide and Crisis Lifeline answers three ways: call 988, text 988, or chat at 988lifeline.org/chat. Spanish-language support answers by pressing 2, and the Lifeline’s videophone option serves ASL users.

Where Can You Get Gambling and Alcohol Addiction Treatment in Los Angeles?

New Spirit Recovery treats gambling addiction and alcohol use disorder at its Tarzana, Northridge and Encino locations, with co-occurring conditions addressed in the same treatment plan rather than in sequence.

Because prospective studies establish no fixed order between gambling and a co-occurring disorder, the assessment covers both from the start. The admissions process begins with a clinical assessment that screens for gambling behavior alongside substance use, which matters most for the patient who came in to discuss drinking and has not mentioned the betting.

“When someone comes in for the drinking and nobody names the betting, we are treating half of it and calling that a plan. We ask about money at intake for the same reason we ask about the last drink.” Sean O’Neill, MS, LMFT, Clinical Director at New Spirit Recovery.

Frequently Asked Questions

Is gambling disorder a real addiction?

DSM-5 classifies gambling disorder among the substance-related and addictive disorders. Brain imaging supports that placement: people with gambling disorder and people with substance use disorders show similar functional changes in reward circuitry.

How many criteria does a gambling disorder diagnosis require?

At least 4 of 9. DSM-IV required 5 of 10 criteria for pathological gambling, so DSM-5 both lowered the threshold and removed one criterion, the illegal acts criterion.

Does treating alcohol use disorder resolve the gambling?

Not reliably. Prospective studies show no fixed order between gambling disorder and a co-occurring disorder, so treating one and deferring the other rests on an assumption the evidence does not support.

Does cognitive behavioral therapy work for gambling disorder?

It reduces gambling disorder severity at the end of treatment across 29 pooled randomized trials. The same analysis found no significant effect at follow-up, which is why continuing care after the intensive phase carries real weight.

Why do people keep gambling after they start losing?

Near misses raise reward-circuitry signal above the level a clear loss produces. A session full of near misses keeps generating reward-like signals while the money goes out, and chasing losses is one of the nine diagnostic criteria for gambling disorder.

How common is gambling disorder?

Epidemiological studies place the rate at 0.4 to 4.0 percent of adults. Rates run higher among people who have a substance use disorder, and studies of substance use disorder populations have reported figures as high as 20.5 percent and 55.0 percent.

References

1. Petry, N. M., Blanco, C., Auriacombe, M., et al. (2014). An overview of and rationale for changes proposed for pathological gambling in DSM-5. Journal of Gambling Studies, 30(2), 493-502.
2. Sherva, R., Gelernter, J., Farrer, L., Kranzler, H. R. (2014). DSM-5 gambling disorder: prevalence and characteristics in a substance use disorder sample. Journal of Addiction Medicine, 8(3), 155-161.
3. Sharma, R., Weinstein, A. (2025). Gambling disorder comorbidity: a narrative review. Dialogues in Clinical Neuroscience, 27(1), 171-183.
4. Worhunsky, P. D., Malison, R. T., Rogers, R. D., Potenza, M. N. (2014). Altered neural correlates of reward and loss processing during simulated slot-machine fMRI in pathological gambling and cocaine dependence. Drug and Alcohol Dependence, 145, 77-86.
5. Clark, L. (2014). Disordered gambling: the evolving concept of behavioral addiction. Annals of the New York Academy of Sciences, 1327(1), 46-61.
6. Gooding, N. B., Williams, J. R., Williams, R. J. (2023). Effect of cognitive-behavioral techniques for problem gambling and gambling disorder: a systematic review and meta-analysis. Addiction, 118(12), 2374-2388.
7. Granero, R., Fernandez-Aranda, F., Mestre-Bach, G., et al. (2021). Prevalence of suicidal behavior and associated clinical correlates in patients with behavioral addictions. International Journal of Environmental Research and Public Health, 18(21), 11085.
8. American Psychiatric Association. (2022). Diagnostic and Statistical Manual of Mental Disorders (5th ed., text rev.).