An International, Multidisciplinary Consensus Set of Patient-Centered Outcome Measures for Substance-Related and Addictive Disorders.

Background: In 1990, the United States' Institute of Medicine promoted the principles of outcomes monitoring in the alcohol and other drugs treatment field to improve the evidence synthesis and quality of research. While various national outcome measures have been developed and employed, no global consensus on standard measurement has been agreed for addiction. It is thus timely to build an international consensus. Convened by the International Consortium for Health Outcomes Measurement (ICHOM), an international, multi-disciplinary working group reviewed the existing literature and reached consensus for a globally applicable minimum set of outcome measures for people who seek treatment for addiction. Methods: To this end, 26 addiction experts from 11 countries and 5 continents, including people with lived experience (n = 5; 19%), convened over 16 months (December 2018-March 2020) to develop recommendations for a minimum set of outcome measures. A structured, consensus-building, modified Delphi process was employed. Evidence-based proposals for the minimum set of measures were generated and discussed across eight videoconferences and in a subsequent structured online consultation. The resulting set was reviewed by 123 professionals and 34 people with lived experience internationally. Results: The final consensus-based recommendation includes alcohol, substance, and tobacco use disorders, as well as gambling and gaming disorders in people aged 12 years and older. Recommended outcome domains are frequency and quantity of addictive disorders, symptom burden, health-related quality of life, global functioning, psychosocial functioning, and overall physical and mental health and wellbeing. Standard case-mix (moderator) variables and measurement time points are also recommended. Conclusions: Use of consistent and meaningful outcome measurement facilitates carer-patient relations, shared decision-making, service improvement, benchmarking, and evidence synthesis for the evaluation of addiction treatment services and the dissemination of best practices. The consensus set of recommended outcomes is freely available for adoption in healthcare settings globally.

For Better and For Worse: Frequent Gamblers Use Dual Counterfactuals to Justify Continued Gambling.

How might frequent gamblers convince themselves to keep playing despite persistent losses or after a win that should be savored? The purpose of this research is to examine the unexplored question of how frequent gamblers' use counterfactual thinking to motivate their desire to continue gambling. Using a sample of n = 69 high and n = 69 low frequency gamblers in a field setting, we found that infrequent gamblers tended to consider how the perceived outcome of losing "could have been better" (i.e., upward counterfactual thinking), and how a winning outcome "could have been worse" (i.e., downward counterfactual thinking). This pattern of counterfactual thinking is considered typical in many settings and may, in a gambling context, support a potentially more responsible approach by helping infrequent gamblers to learn from past mistakes to avoid significant future losses and to savor wins to protect returns gained. Alternatively, we found that frequent gamblers were more likely to generate 'dual counterfactuals' which include both upward and downward counterfactuals in response to losses and wins. We argue that this dual pattern of counterfactual thinking may allow frequent gamblers to more easily justify their desire to continue gambling. Findings suggest that challenging gamblers counterfactual thinking patterns could assist clinicians in moderating the potential for high-risk behaviors.

Clarifying gambling subtypes: the revised pathways model of problem gambling.

BACKGROUND AND AIMS: The pathways model is a highly cited etiological model of problem gambling. In the past two decades, a number of studies have found support for the model's utility in classifying gambling subtypes. The aims of this paper were to refine empirically the model subtypes and to revise and update the model based on those findings. DESIGN AND MEASUREMENT: Observational study using data collected from treatment-seeking problem gamblers using the Problem Gambling Severity Index (PGSI) and the Gambling Pathways Questionnaire (GPQ). SETTING: Treatment clinics in Canada, Australia and the United States. PARTICIPANTS: A convenience sample of 1168 treatment-seeking problem gamblers, aged 18 years or older. FINDINGS: Empirically validated risk factors were analyzed using latent class analyses, identifying a three-class solution as the best-fitting model. Those in the largest class (class 1: 44.3%, n = 517) reported the lowest levels of all etiological risk factors. Participants in class 2 (39.5%, n = 461) reported the highest rates of anxiety and depression, both before and after gambling became a problem, as well as childhood maltreatment, and a high level of gambling for stress-coping. Those in class 3 (16.3%, n = 190) reported high levels of impulsivity; risk-taking, including sexual risk-taking; antisocial traits; and coping to provide meaning in life and to alleviate stress. CONCLUSIONS: The revised pathways model of problem gambling includes three classes of gamblers similar to the three subtypes in the original pathways model, but class 3 in the revised pathways model is distinct from class 2, showing higher levels of risk-taking and antisocial traits and gambling motivated by a desire for meaning/purpose and/or to alleviate stress. Class 2 in the revised pathways model demonstrates high levels of childhood maltreatment as well as gambling for stress-coping.

Study framing influences crowdsourced rates of problem gambling and alcohol use disorder.

OBJECTIVE: Crowdsourcing is an increasingly popular source of participants in studies of problem gambling. Studies with crowdsourced samples have reported prevalence rates of problem gambling between 10 and 50 times higher than traditional sources of estimates. These elevated rates may be due to study framing motivating self-selection. In this preregistered study, we examined whether study framing influences self-reported problem gambling severity and harmful alcohol use in a sample of participants recruited from a popular crowdsourcing website. METHOD: Two recruitment notices for an online questionnaire were placed on Amazon Mechanical Turk (MTurk). Notices were framed as "Gambling and Health" or "Alcohol and Health." Only participants who passed data checks were retained for confirmatory analyses (N = 564; 44% of recruited participants). Participants in the gambling framing (N = 261) and in the alcohol framing (N = 303) were compared on the Problem Gambling Severity Index (PGSI) and Alcohol Use Disorders Identification Test (AUDIT). RESULTS: Problem gambling rates and severity scores were significantly greater for participants in the gambling framing compared to those in the alcohol framing. Self-reported scores of harmful alcohol use were significantly greater for participants in the alcohol framing compared to those in the gambling framing, but there was no significant difference in prevalence rates for harmful alcohol use. CONCLUSIONS: Study framing is an important consideration for gambling and alcohol research. We found that study framing may substantially increase the observed rates of problem gambling severity in crowdsourced samples, potentially via encouragement of self-selection. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Impacts of the COVID-19 Shutdown on Gambling Patterns in Australia: Consideration of Problem Gambling and Psychological Distress.

OBJECTIVES: The COVID-19 pandemic reduced access to gambling and contributed to widespread psychological distress. Psychological distress is a known risk factor for problem gambling as it can motivate excessive gambling as a coping response. The availability of gambling is considered a factor in maintaining problems. This paper aimed to investigate the impact of the shutdown of gambling venues on Australians, particularly among those vulnerable to mental health problems and gambling disorder. METHODS: Australian adults who had gambled at least once in the past 12 months (N = 764, 85.2% male) completed an online cross-sectional survey. Self-report measures retrospectively assessed typical monthly gambling frequency and expenditure before and after the COVID-19 venue shutdown, problem gambling, and psychological distress. RESULTS: Significant median decreases in gambling frequency were observed, both online and overall. No relationship was found between psychological distress and baseline or increases in gambling. Greater problem gambling severity was related to higher baseline gambling, but not to increases in gambling. Exploratory analysis showed that individuals engaged in moderate-risk gambling, but not problem gambling, were more likely to report increased gambling frequency compared to nonproblem and low-risk gamblers combined. CONCLUSIONS: Findings provide important insights into how changes in availability influence gambling participation, and for understanding the effectiveness of forced restrictions and venue exclusion strategies. Most people moderated their gambling when venue-based gambling was unavailable and opportunities for sports betting were limited. However, harms experienced by individuals with some gambling problems may have been exacerbated during the period of limited access. Policies to enhance prevention and treatment of gambling problems are necessary even when availability is reduced.

Motor cortex dysfunction in problem gamblers.

Impairments in response inhibition have been implicated in gambling psychopathology. This behavioral impairment may suggest that the neural mechanisms involved in response inhibition, such as GABAA -mediated neurotransmission in the primary motor cortex (M1), are also impaired. The present study obtained paired-pulse transcranial magnetic stimulation markers of GABAA and glutamate receptor activity from the left M1 of three groups-problem gamblers (n = 17, 12 males), at-risk gamblers (n = 29, 19 males), and controls (n = 23, six males)-with each group matched for alcohol use, substance use, and attention-deficit hyperactivity disorder (ADHD) symptomology. Response inhibition was measured using the stop signal task. Results showed that problem gamblers had weaker M1 GABAA receptor activity relative to controls and elevated M1 glutamate receptor activity relative to at-risk gamblers and controls. Although there were no differences in response inhibition between the groups, poorer response inhibition was correlated with weaker M1 GABAA receptor activity. These findings are the first to show that problem gambling is associated with alterations in M1 GABAA and glutamate-mediated neurotransmission.

Problematic risk-taking involving emerging technologies: A stakeholder framework to minimize harms.

BACKGROUND AND AIMS: Despite the many benefits of technological advancements, problematic use of emerging technologies may lead to consumers experiencing harms. Substantial problems and behavioral addictions, such as gambling and gaming disorders, are recognized to be related to Internet-based technologies, including the myriad of new devices and platforms available. This review paper seeks to explore problematic risk-taking behaviors involving emerging technologies (e.g., online gambling and gaming, online sexual behaviors, and oversharing of personal information via social networking sites) that have the potential to lead to problematic outcomes for individuals. RESULTS AND DISCUSSION: Previous research has focused on policy frameworks for responding to specific issues (e.g., online gambling), but a broader framework is needed to address issues as they emerge, given lags in governments and regulators responding to dynamically evolving technological environments. In this paper, key terms and issues involved are identified and discussed. We propose an initial framework for the relative roles and responsibilities of key stakeholder groups involved in addressing these issues (e.g., industry operators, governments and regulators, community groups, researchers, treatment providers, and individual consumers/end users). CONCLUSION: Multidisciplinary collaboration can facilitate a comprehensive, unified response from all stakeholders that balances individual civil liberties with societal responsibilities and institutional duty of care.

Development and psychometric evaluation of the Recovery Index for Gambling Disorder (RIGD).

Objective: Recovery from Gambling Disorder lacks established operational criteria and a dedicated outcome measure. Cross-study comparisons and treatment efficacy determinants are difficult without a valid and widely used tool to assess recovery. The current article describes the development and psychometric evaluation of the Recovery Index for Gambling Disorder (RIGD). Method: Item development was based on an integration of academic, clinical, and consumer perspectives of recovery. Expert feedback and cognitive interview techniques were employed to review and refine the initial item pool. An empirical evaluation of the RIGD was conducted using 204 adult participants (63.7% male) with experience of seeking formal help for gambling problems. Results: Partial-least squares structural equation modeling resulted in a 32-item solution across 6 recovery dimensions: gambling reduction, urge coping, recovery wisdom, life functioning, interpersonal relationships, and mental health. The RIGD structural model explained 71.9% of variance in an external self-report global measure of recovery. Convergent validity was evidenced by significant correlations between all RIGD dimensions and other related measures, with the exception of recovery wisdom. Criterion-related validity was demonstrated as RIGD composite scores accurately classified nonproblem from problem gamblers, with a conservative cut-off score of 45. Test-retest reliability was established over a 2-week interval. Conclusions: The RIGD is an empirically supported instrument designed to broadly measure recovery from Gambling Disorder. Valid and uniform measurement of recovery is important given its central role in advancing effective treatments and shaping gambling help service policy internationally. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Reducing Internet Gambling Harms Using Behavioral Science: A Stakeholder Framework.

Internet gambling provides a unique environment with design mechanics and data-driven opportunities that can impact gambling-related harms. Some elements of Internet gambling including isolation, lack of interruption, and constant, easy access have been argued to pose specific risks. However, identifiable player accounts enable identification of behavioral risk markers and personalized private interfaces to push customized messages and interventions. The structural design of the Internet gambling environment (website or app) can have a strong influence on individual behavior. However, unlike land-based venues, Internet gambling has few specific policies outlining acceptable and unacceptable design practices. Harm minimization including responsible gambling frameworks typically include roles and responsibilities for multiple stakeholders including individual users, industry operators, government regulators, and community organizations. This paper presents a framework for how behavioral science principles can inform appropriate stakeholder actions to minimize Internet gambling-related harms. A customer journey through internet gambling demonstrates how a multidisciplinary nexus of collaborative effort may facilitate a reduction in harms associated with Internet gambling for consumers at all stages of risk. Collaborative efforts between stakeholders could result in the implementation of appropriate design strategies to assist individuals to make decisions and engage in healthy, sustainable behaviors.

The Relationship Between In-Play Betting and Gambling Problems in an Australian Context of Prohibited Online In-Play Betting.

Internationally, Internet gambling is increasingly permitted under regulated licensing conditions; however, the specific products that are legal varies between jurisdictions. Online sports and race wagering are now legal in many jurisdictions, but in-play betting (also referred to as "live action" or "in-the-run" betting) is often restricted. In-play betting enables bets to be placed on an event after it has commenced. Prohibitionist policies often cite the potential for this type of betting to increase risk of gambling problems. This study aimed to identify which online bettors are most likely to engage in in-play betting, and to investigate the relationship between in-play betting and gambling problems. Online survey responses were collected from 501 Australian past-month online sports bettors in the context of in-play betting only being available on offshore gambling sites or via telephone betting. Thirty-four percent of participants had placed a bet in-play in the past month. Participants placing in-play bets differed from those who had not in terms of education, employment status, ethnicity, age, and gambling involvement. Those who bet in-play had higher problem gambling severity scores than those who did not bet in-play. Problem gambling severity significantly predicting in-play betting, holding other variables constant. Findings are consistent with previous research indicating that the relationship between in-play gambling and problems holds across jurisdictions which have prohibited and legalized in-play betting. The findings suggest that in-play betting should warrant specific regulatory attention and interventions to minimize gambling harms among individuals that engage with this activity.

The Role of Body Image on Psychosocial Outcomes in People With Diabetes and People With an Amputation.

INTRODUCTION: Research indicates that body image disturbance is associated with poorer psychosocial outcomes for individuals with physical health conditions, with poorest body image reported for individuals with visible bodily changes. Using White's (2000) theoretical model of body image the present paper aimed to examine the nature of these relationships in two distinct groups: individuals with an amputation and individuals with diabetes. It was hypothesized that body image disturbance would be associated with psychosocial outcomes and would mediate the relationships between self-ideal discrepancy and personal investment in psychosocial outcomes. METHODS: Individuals with diabetes (N = 212) and individuals with an amputation (N = 227) provided details regarding their medical condition, and completed measures assessing body image, investment, self-ideal discrepancy, depression, anxiety, and quality of life. Structural equation and invariance modeling were used to test the model paths and the invariance of the model. RESULTS: As hypothesized, body image disturbance was found to mediate the relationships between personal investment and psychosocial outcome, and between self-ideal discrepancy and psychosocial outcome. The predicted paths were invariant across groups, although the model accounted for more variance in people with an amputation than people with diabetes. CONCLUSION: Body image disturbance, personal investment, and self-ideal discrepancy are important factors contributing to psychosocial outcome for individuals with diabetes and individuals with an amputation. These findings not only confirm the validity of the model in these two groups, but they emphasize the importance of targeting body image in future psychological interventions for individuals with a health condition.

Use of Consumer Protection Tools on Internet Gambling Sites: Customer Perceptions, Motivators, and Barriers to Use.

Internet gambling has been widely legalised in recognition of its capacity to, and the importance of, providing consumer protection tools to prevent and minimise gambling-related harms. Most licensed Internet gambling sites are required to provide consumer protection tools, including activity statements, deposit limits, and time-outs (temporary self-exclusion). However, few Internet gambling customers engage with the tools. An online survey of 564 customers of Australian Internet gambling sites aimed to understand the extent to which consumer protection tools are used, characteristics of those using these tools, and the perceptions and attitudes towards tool use, including barriers to use. Most participants were aware of the tools and had accessed activity statements; few had used deposit limits (24.5%) or time-outs (8.1%) but use of these restrictive tools was higher among those at-risk of gambling problems. Satisfaction with tools was generally high among users and tools were mostly used as intended; however, only moderate changes in behaviour were reported. Participants predominately did not use the restrictive tools as they did not see these as relevant for them, and they were perceived to be intended for people with gambling problems. The findings are important to drive necessary improvements to consumer protection efforts including efforts to encourage perception that tools are relevant for all customers. Changes to current practice, including terminology and promotion of tools, are needed by Internet gambling operators and policy makers to improve the utilisation and effectiveness of consumer protection tools to enable sustainable gambling among the broader cohort of Internet gamblers.

Correction to: Gambling Research and Funding Biases.

Unfortunately, the original publication contains errors. The authors would like to correct the errors.

Staff Perceptions of Responsible Gambling Training Programs: Qualitative Findings.

Staff training in responsible gambling forms an integral component of industry measures designed to respond to and minimize gambling-related harms. Research suggests that venue staff members have the capacity to identify behavioral indicators of problem gambling among patrons, but often are reluctant or fail to respond to patrons unless directly approached for assistance. Understanding the barriers preventing staff from proactively intervening with identified patrons is necessary if a positive shift toward greater levels of assistance for at-risk individuals is to be achieved. A series of focus groups were conducted with management and floor staff (N = 20) from a large New South Wales registered club venue to better understand their experiences and attitudes towards existing responsible gambling training programs. Qualitative phenomenological data were analyzed using inductive thematic analyses and resulted in the identification of three primary domains: ability to identify harmful gambling behaviors; perceived challenges and barriers to intervention; and potential improvements to current programs. Responses were consistent with the literature in demonstrating staff abilities to identify behavioral indicators, but importantly revealed a lack of certainty and understanding in relation to their specific roles, potential legal consequences and implications for employment by taking the initiative to proactively intervene. Recommended improvements to strengthen the effectiveness of programs included the implementation of well-defined protocols setting out role expectations and procedures for floor staff to follow, and importantly, a fundamental shift in middle and senior management culture to one that actively supports and positively acknowledges staff-customer interactions designed to assist problem gamblers.

Isolating the impact of specific gambling activities and modes on problem gambling and psychological distress in internet gamblers.

BACKGROUND: Gambling disorder is related to high overall gambling engagement; however specific activities and modalities are thought to have stronger relationships with gambling problems. This study aimed to isolate the relationship between specific gambling activities and modalities (Internet and venue/land-based) to gambling disorder and general psychological distress. Past-month Internet gamblers were the focus of this investigation because this modality may be associated with gambling disorders in a unique way that needs to be separated from overall gambling intensity. METHODS: Australians who had gambled online in the prior 30 days (N = 998, 57% male) were recruited through a market research company to complete an online survey measuring self-reported gambling participation, problem gambling severity, and psychological distress. RESULTS: When controlling for overall gambling frequency, problem gambling was significantly positively associated with the frequency of online and venue-based gambling using electronic gaming machines (EGMs) and venue-based sports betting. Psychological distress was uniquely associated with higher frequency of venue gambling using EGMs, sports betting, and casino card/table games. CONCLUSIONS: This study advances our understanding of how specific gambling activities are associated with disordered gambling and psychological distress in users of Internet gambling services. Our results suggest that among Internet gamblers, online and land-based EGMs are strongly associated with gambling disorder severity. High overall gambling engagement is an important predictor of gambling-related harms, nonetheless, venue-based EGMs, sports betting and casinos warrant specific attention to address gambling-related harms and psychological distress among gamblers.

Understanding use of consumer protection tools among Internet gambling customers: Utility of the Theory of Planned Behavior and Theory of Reasoned Action.

Consumer protection tools such as activity statements, deposit limits, and temporary self-exclusion are provided by most Internet gambling websites to minimise gambling related harms through the prevention of problems and enhancement of controls for those at risk of disordered gambling. However, customer engagement with these tools is very low. Developing a theoretical framework to understand the reasons individuals use consumer protection tools is important to design strategies to increase uptake. Customers of Australian online wagering sites (N = 564) completed an online survey with a follow-up (N = 193) to assess whether the Theory of Planned Behaviour explained intention to use tools and actual behaviour with additional consideration of past tool use. Results showed that past tool use, attitudes and subjective norms, but not perceived behavioural control, were positively correlated with intention to use consumer protection tools. Intention to use the tools prospectively predicted actual tool use. The study validates past behaviour as a predictor of intention, and intention representing a significant predictor of future behaviour. The Theory of Reasoned Action (without the inclusion of perceived behavioural control), rather than Theory of Planned Behaviour, appears to be a suitable conceptual model to understand consumer protection tool use for Internet wagering websites. Use and application of consumer protection tools on gambling websites is not perceived as effortful, but under volitional control and straightforward. Positively influencing individual attitudes, perceived views of others and past tool use could increase online wagering customers' use of consumer protection tools.

How learning misconceptions can improve outcomes and youth engagement with gambling education programs.

BACKGROUND AND AIMS: Gambling education programs typically focus on promoting gambling as a high-risk activity with harmful effects; however, these programs demonstrate limited effects on the prevention of gambling problems. This paper proposes a clear theoretical framework to inform the content and delivery of gambling education initiatives and draws on psychological and pedagogical research to address some of the practical issues associated with its implementation. METHODS: Literature was reviewed across fields of psychology, public health, and pedagogy to provide key recommendations to improve the outcomes of gambling education. RESULTS: Four key recommendations were made for the development of future gambling education programs centering on theoretical approach, specialized content, and delivery. DISCUSSION AND CONCLUSIONS: Recommended advancements are as follows: (a) evidence suggests shifting away from messages about gambling harms and instead applying a cognitive-developmental framework of problem gambling that may improve youth engagement by increasing personal relevance. (b) The cognitive model of problem gambling suggests that misconceptions about the profitability of gambling games (e.g., the gambler's fallacy) play an important role in the development of problems and should be a key target for education. However, exposing such misconceptions requires the challenge of teaching the mathematical principles that underpin them. (c) The pedagogical field provides valuable insights into teaching complex concepts. Research that applies the conceptual change model to science education suggests misconceptions also facilitate learning new complex information, such as gambling-related mathematical concepts (i.e., randomness and statistics). (d) In addition, improvements in computer-assisted teaching methods provide opportunities to use simulations and visualizations to help teach abstract concepts and correct such misconceptions.

Gambling Research and Funding Biases.

A recent systematic review of the responsible gambling research suggests that there are no significant differences between gambling industry and non-industry funded research with regard to research design and outcomes. This study empirically synthesizes the outcomes of a larger sample of the scientific gambling literature to determine the generalizability of these original results. Our goal was to determine the extent to which funding sources might differentially influence characteristics of research design and outcomes. We conducted a comprehensive review of 18 research databases and examined studies published between January 2008 and August 2018. For four gambling-related journals, we reviewed all of the available studies. For 14 addiction-related journals, we examined only studies that examined gambling-related outcomes. To be included in this study, publications had to be quantitative and include a clear gambling-related hypothesis. After retrieving 1731 gambling studies, we applied the inclusion criteria and retained 720 studies for our final analytic sample. We used hypothesis confirmation and funding source information to determine the presence or absence of funding bias. Gambling industry funded studies were no more likely than studies not funded by the gambling industry to report either confirmed, partially confirmed, or rejected hypotheses. Nonetheless, studies funded by the gambling industry were more likely than other types of funding sources to include a conflict of interest statement. Studies with disclosed funding sources were more likely than those with undisclosed funding sources to include a conflict of interest statement. These findings highlight the importance of transparency and disclosure during research dissemination.

Responsible Gambling Research and Industry Funding Biases.

This brief report examines whether there are differences in aspects of different characteristics, including design/methodologies of responsible gambling (RG), between studies funded by industry as compared to other sources. To investigate this, the authors used those studies included in a recent meta-analysis focusing on the empirical basis of RG initiatives (Ladouceur et al. in Addict Res Theory 25:225-235, 2017). We examined eight associations between funding sources, and different design/methodological characteristics of these studies; type of strategy, inclusion of comparison groups, measurement scales and repeated measures, publication source, number of inclusion criteria met, secondary sources of funding, publication year. The results revealed no statistically significant difference between the funding source, and the index study characteristics. These results do not support claims that funding exerts influence on the design or methodologies of RG studies. However, the absence of statistically significant findings should not be used to assert the absence of a funding effect because there are many reasons for failing to find differences, or interpretation of findings. Unexpectedly, a third of the papers included in this study failed to disclose their funding sources. This finding highlights the need for more open and transparent disclosures.