Colin O’Gara does a good line in mordant laughter, sardonic grins and ironic chuckles. He even manages one response – which can only be described as a guffaw – during the couple of hours I spent with him in his office at St John of God’s in Stillorgan.

The extraordinary thing for someone working in his field is that his thoughts, comments, and observations all come underpinned by hope. The hope comes not from a belief that society is evolving into one more aware of addiction or that a country like Ireland is recognising the warped relationship it has with drink, but from the manner in which individuals overcome their problems, often with the help of others.

This is what O’Gara has devoted his life to, working as head of addiction services at St John of God Hospital and also Clinical Professor of Psychiatry at UCD.

 “It’s important not to be cynical, right? Because 10 years plus down the line, I see a lot of people get cynical,” he says. We will return to the hope but there is also a lot to be concerned about. Ireland finally has a gambling regulator but this is the start of the work because the brief is dauntingly wide and can only be tackled, O’Gara says, with substantial funding.

And that is just gambling and tech based addictions, although the smart phone has changed how people get access to drugs while Ireland’s relationship with drink has been unaltered. “Alcohol is 90 per cent plus of what we deal with here. Alcohol is far and away by a country mile the staple, it’s the base on which everything else resides.”

The reason for this is simple, O’Gara believes. “The attitude towards drink in, say, the US is very different to here and I don’t believe that has changed one bit, because that’s propagated by parents. And parents have not changed their attitudes in my view. The definition of addiction is persistence of a behaviour in the face of adverse consequences, that’s the World Health Organisation’s definition.”

One of the ways in which he could gauge any change is if people realise they have a problem before the real destruction begins or when the adverse consequences are a little less adverse. That remains uncommon.

“Am I seeing people here because they’ve had one episode of having their teeth smashed up after falling? No. It tends to be multiple. Yes, occasionally, you get somebody who’s anxious and they want to come and see me as a result. But no, usually the GP has had multiple episodes of harm, be it social, occupational, physical, and then they come to us.”

The pursuit of unhappiness

It starts early and it remains entwined in so much of what we do. “Firstly, we have a cultural problem with drink. I mean, that’s a massive issue and it’s ingrained, and it’s unique to Ireland, probably the British Isles as well. It’s integrally linked with sport. Rugby, I would say probably is at the pinnacle of it, and then it trickles down from there, but you look at GAA and any sport really – except the elite level, it’s probably changed now. But you know, you’re hearing about cocaine and the GAA and gambling in the GAA…10 per cent of the population are alcohol dependent and 40 to 50 per cent of the population are engaged in repetitive, dangerous binge drinking that’s causing harm. The stats are off the charts.”

O’Gara understands the motivation too and studies back it up. “People are getting unhappier,” he says. “Life is stressful and that’s where substances come in. Are we self medicating is the question. And ‘Yes’ is the answer.” 

He can gauge the ups and downs of an economy by the drugs that people develop issues with. He first talked to the hospital about joining in 2006 and the intention was to provide treatment for cocaine addiction which was spiralling during the boom. He joined in 2007 and then “the economy fell out of the sky and cocaine fell out with it.” But addiction itself was recession proof and Ireland’s relationship with drink never changed. Cocaine has returned for other reasons.

Alcohol is no different to any other drug. He points to the study by David Nutt in the UK who looked at the relative harm of different drugs, with alcohol always coming out on top.

He’s unconvinced by the suggestion that young people are moving away from substance abuse.

“I’m not convinced because because if you look at kids in transition year now, they have transition year balls which are drinking fests. Still going back to my generation, it’s the same thing. It’s the same pre-drinking. There might be kids in their early 20s that are body conscious and might go do triathlons instead, and that’s probably represented somewhat in the stats, but not to any great degree. It’s probably in some regards been substituted by cocaine because cocaine is incredibly common. So people might not be drinking, but they might be using substances to keep the weight down. Why would I take such a calorific infusion, basically 10 pints equals 10 cheeseburgers.”

There has been a painfully slow understanding of addiction and still it comes laced with stigma. There might be little shame in having ten pints on a Friday night but there is more shame for the person who wants to address it.

The willpower myth

“The biggest barrier to treatment is stigma. And that’s across all addictions – the stereotype is, pull your socks up, the stereotype is, it’s not a medical illness, the stereotype is, you’ve created it yourself. And the most important piece of it is that it’s under your subjective control. It’s about control, that gambling addiction, alcohol addiction, every addiction is under the person’s control. And that’s unfortunately the prevailing stereotype.”

It’s seen as a failure of willpower?

“Yes, correct. And it’s a deficit of will and if you’re addicted, you’re deficient in will and you need to get your act together. And stigmatised views towards mental health and addiction are notoriously difficult to change.”

There are ways of changing them he believes. “I would say the celebrity endorsement is the flipside of a gambling celebrity endorsement, which is an absolute disaster, in terms of the effect that it has on children, but the opposite effect, celebrity endorsement saying, ‘Look, I suffer from an addiction, I’m otherwise I’m otherwise very well. I’ve achieved a lot and I can have this parallel thing going on in my life’. That’s been very helpful.”

More than 20 years ago, Tony Adams wrote an autobiography Addicted, which detailed his experiences with drink and his recovery with the help of Alcoholics Anonymous. It was a landmark book.

AA was founded in 1935 and it is an organisation which, O’Gara says, remains critical in Ireland. 

“I would say, and I’ve said it time and time again, the mutual support groups, in particular AA, are head and shoulders above any input that’s available in Ireland at the moment, So what do I mean by that? The availability, the network, the structure in terms of fellowship, the sponsorship, the steps model, this is AA in particular, GA or NA or CA or Marijuana Anonymous, whatever piece of it you’re going to is an incredible input. And I’ve seen time and time again, people get well from that. I cannot speak highly enough of it.”

There are other approaches to go alongside it as well. “It’s not all about mutual support. It’s important to look at other facets of recovery, such as the possibility of medication, which at times can be incredibly important, psychological evidence and evidence-based psychological therapies, talking therapies like CBT, ACT, cognitive behavioural therapy, or, you know, if you’ve emotional dysregulation, dialectical behavioural therapy. So there’s a lot of effective talk therapies as well.”

The barrier is the stigma rather than the effectiveness of the treatment and O’Gara says there was a stigma too in working in the field. “As a doctor, it’s like, why are you doing that? Why didn’t you do something proper? Why didn’t you be a surgeon? Oh, god, yeah. What’s wrong with him, what made him do that?”

When he trained at the Maudsley in the UK, he encountered the brightest people who were attracted to that field. “The psychiatric bulletin, which was a little kind of magazine that went with the British Journal of Psychiatry, would always carry somebody who’s retiring, they’d do an interview with them, and they’d always ask, do you feel stigmatised by your your profession? And it’d be 50-50.”

The guffaw in our conversation comes when I ask him how slow has Ireland been in recognising the dangers of gambling.

“It’s been appalling,” he says, “appalling and depressing. Alan Shatter’s Bill was 2012 and now it’s 2023.”

He looks at what’s happening in the UK and the suggestions that while front of shirt sponsorship by betting companies might be banned but there may be a problem with hoarding. “Really what’s happening is the lobby. There’s a very strong lobby in the UK and similarly here. But if that’s this pace that we’re going to be changing, it’s not going to change without any rapidity, that’s for sure.”

Silent Spring

In 1962, Silent Spring, a book by Rachel Carson was published. It showed the environmental harm caused by pesticides. The book led to the end of the use Dichlorodiphenyltrichloroethane, know as DDT which after Carson’s book was no longer seen as essential, but as poison.

 Last week the British Medical Journal published an opinion piece – “Harm built in-why the gambling industry needs a Silent Spring moment”. 

“As we struggle with a cost-of-living crisis, we must ask why we seem unable to act against a powerful industry that, in effect, acts as a mechanism for transferring money from the poor and vulnerable to the wealthy and privileged,” the authors wrote. “When will the gambling industry have its Silent Spring moment?”  

O’Gara was encouraged by this and many other developments. “I wrote my first article on this in the Irish Medical Times, it must have been 2009 or something. But it’s just encouraging to see mainstream public health people starting to say, ok, all right, clearly, we’ve got an issue here. This is a highly addictive behaviour, we’ve kind of neglected to see the harms and it’s gone way out of control. We need to kind of change entirely, because there’s an element of us almost pandering to the fact that it’s there, to the industry. We should try and work around the industry rather than changing this and going, whoah, hang on, guys, this is a serious problem. This is like DDT in the 60s, this is causing serious harm here.” 

Nobody is suggesting prohibition he says because it wouldn’t work, but he wants the newly established regulator’s office to be funded in a way which makes a real difference.

If Ireland has a particular relationship with addiction, maybe it can now lead the way in treatment. The Gambling Regulation Bill published last year contains a section on a Social Impact Fund which will come from industry revenue. O’Gara has previously suggested one per cent would be a reasonable figure. Now he takes a different view.

“The regulator’s office should make an assessment. They should go and price the cost of gambling harm in Ireland. If we’re going to be realistic, let’s cost it up and then go back to the industry and say this is what’s needed to cover the harm from the product. And whatever that percentage is, we go with that…I did say in the past one per cent – but, hey, that’s a better way of doing it.”

There is in O’Gara, as with so many others, a sense that the time now required radical action.

“This is the Silent Spring moment…It’s like climate change. I think we’re going to look back on gambling in ten or 20 years and say what were we doing? In terms of having kids exposed to the product, having sport completely invaded by it, and effectively allowing that to run out of control.”

In the UK, the CEO of Bet365 Denise Coates was paid one billion by the company over the past three years, although this year’s salary has dropped to £263 million from a high of £421 million the year before the pandemic.

“If you’ve gambling heads paying themselves 350 million a year that is a social justice issue,” O’Gara says. 

Gambling harm is silent too. “Gambling is more insidious, more pernicious. And it’s even more dangerous because of the gamblification of sport. Kids – and this has been shown – are unable to decipher the distance between sport and gambling, they see them as both the same thing.”

He talks about games for kids of three like Talking Tom Gold Run where there is a spinning wheel. “It’s the initiation, it’s the introduction to the concept of chance and the possibility you can win big or that you cannot acquire something without the gambling feature involved.”

There are games which have a loot box component which the gaming companies won’t remove. “E-sports is just exploding, the loot box piece. The next wave is the loot box. They won’t take them out of the games because they’re worth too much money but it’s also gamblification of the internet gaming experience.” 

He praises minister James Browne for the energy and commitment he brought to getting the gambling bill published but warns that if it’s believed that the creation of a regulator is enough, then it will be no good. ‘In terms of public office this has got to be the biggest public office endeavour ever. It’s massive.’ 

Given the money made from gambling, there is no argument against the treatment of those with addiction and vulnerabilities being well resourced. The percentage of those at risk is higher than sometimes suggested, he says.

“The industry are in a difficult position now because the lid has been lifted on harm, and the story is getting worse and worse for them all the time. It was very nice to be able to corral it and say one per cent had an issue and again, there’s a stereotyping and there’s a stigma, that these one per cent of freaks would develop this. But actually, sorry, it’s much more like we’re approaching 50 per cent. And studies would suggest 60 to 80 per cent of what they’re taking in is from problem gamblers. So irrespective of vulnerability, what is the product bringing in? And it’s predominantly from problem gamblers.” Again, he talks about the silent harm. “The in play betting has changed the way that young men look at sport. You know, people in late teens, early 20s are watching sports with a view to any opportunity to gamble within that particular sport. That’s worse than the drink issue because on the face of it’s harmless. With drink, people will get intoxicated and get their fingers burnt. With gambling, you can lose a bit of money, but who knows about that? Who sees that? Most people hide that. And that’s why it’s par for par more dangerous, it’s silent.”

He praises those who have come forward to talk about their own issues with gambling and notes how they have predominantly come from the GAA, perhaps because of the association’s own strong stance on gambling.

“Isn’t it interesting that you have almost a predominance of all GAA sports people who’ve come forward? Oisin McConville, Niall McNamee, Davy Glennon. There’s just a long list. And they keep coming, because they feel in some way that they can do that. Probably Oisin started iut in fairness to him, he led the way. And he deserves a huge amount of credit for that. He really does. And I would say, obviously, it’s an organisation, but one man contributed so much and it was him.”

Gambling advertising should go he says and he describes RTE’s decision to have their football coverage sponsored by Paddy Power as “indefensible, utterly indefensible”.

There are other forms of addiction appearing all the time.

“We’ve treated stock gambling for years, of course it’s an addiction, without a shadow of a doubt – you’re gambling on a graph of something that can go up or down. We’ve seen the more riskier form, CFDs, how that can end up but crypto is the new form for Generation Z, that’s what they’re saying you got to do. YouTubers saying I got rich off this, but ultimately, it’s a complete scam. I mean cryptocurrency is a highly volatile trade or bet just like a sporting event.”

He is happy that injecting clinics have opened and thinks decriminalisation of drugs and removing people from the criminal justice system is essential. He would like to see a pilot for legalisation too but cautions about how it would be introduced.

“I do feel that in Ireland, we have long engrained, maybe not hedonistic tendencies, but certainly partying tendencies, that would beat many other countries in the world. I think we need to be cautious around opening gates so they don’t become flood gates, in terms of drug use.”

Towards the end of the interview, I ask him if he feels any hope. He is animated again.

“Oh, God. yeah. I say to my patients on a daily basis that I would have given up this long ago and gone on to something else if I didn’t see people getting well. People get well here here all the time. It’s one of the huge blessings of a job where you can see people coming out the other side and sit with them in this space here. It’s fabulous.”