EMERGE: A New Standard for Responsible Gaming Education for Employees

The last session of the NCRG conference introduced EMERGE, an interactive responsible gaming training program designed for gaming employees. Kevin Mullally, General Counsel and Director of Government Affairs, Gambling Laboratories Int., moderated the session and Christine Reilly, Executive Director, Institute for Research on Pathological Gambling and Related Disorders, presented the EMERGE program.

EMERGE, which stands for Executive Management and Employee Responsible Gaming Education, is the only employee training program developed by Harvard Medical School faculty and one of the first web-based programs.

Mullally pointed out that it wasn't so long ago when research on problem gambling was practically non-existent and people in the gaming industry knew very little about how to define or even talk about problem gambling. Reilly and Mullally both stressed that EMERGE is an important tool as casino employees and industry members strive to protect and promote the health and safety of their customers. Reilly explained that the American Gaming Association's (AGA) Code of Conduct requires member casinos to educate employees and make information available on problem gambling.

Reilly explained that through EMERGE, employees learn how and why people become addicted, the nature and prevalence of gambling disorders, what constitutes responsible gaming and how to respond to requests for information on these issues. She stressed that employees are not trained to approach customers and should not do so even if they think a customer has a problem. Even trained clinicians have difficulty identifying someone with a gambling problem.

The program can be customized for the participating company to ensure the training reflects their responsible gaming practices and policies. She explained that because EMERGE is interactive and web-based, employees can move at their own pace. The program is available online 24/7, so companies can train a large number of employees and it automatically tracks employee participation and quiz results, sending them back to company management.

Reilly gave a demonstration of the EMERGE program, which uses audio, video, photos and graphics to accompany the text. At the end of each "chapter", the employee takes a quiz on what he or she has just learned. Since casino employees may be at higher risk for gambling problems, EMERGE is also a way to educate the employee and let them know where to seek help if the program raises questions about their own behavior or that of a family or friend.

Words into Action: Responsible Gaming and its Impact on the Casino Floor

Glenn Christenson, chairman of the Nevada Governor’s Problem Gambling Advisory Committee, opened today’s session by asserting that problem gambling is one of the most important issues facing the gaming entertainment industry, but that with that challenge comes the opportunity to be proactive in educating employees and patrons about responsible gaming.

Bill Bingham, vice president of table games at Bellagio Hotel and Casino, began the discussion with a brief overview of the evolution of the response to problem gambling in the state of Nevada. According the Bingham, As late as 1994, the industry in Nevada, with the exception of one or two forward-thinking companies, weren’t doing anything in the realm of responsible gaming. There was no signage or employee training, and at the same time, the issue wasn’t a big one in the public eye, so there was no media pressure to focus on the issue.

In 1995, with the formation of the Nevada Council on Problem Gambling, gaming companies began to post signage and provide collateral material to employees and patrons that included information on how to get help for a gambling problem. These actions were taken before there were specific regulatory requirements to do so. The American Gaming Association then created the AGA Code of Conduct, which pulled together national best practices for responsible gaming and other responsible operating practices. According to Bingham, the AGA Code of Conduct meets or exceeds all state regulatory requirements.

Michael Tunney, regional learning and development manager for Boyd Gaming Corporation, explained the practices Boyd Gaming Corporation has put in place. One of the important challenges Boyd faced, said Tunney, is the fact that the company operates properties in several states throughout the U.S. This means that the regulatory requirements for responsible gaming practices can differ greatly, making it hard to create a standard training program for employees.

Tunney explained that Boyd met this challenge by taking the best practices from all its different jurisdictions and regulatory environments and combining them into one program that is used at all their properties throughout the country. The only exception, he said, is self-exclusion programs, which differ from state to state because they are very complicated to put into place, and in states where regulators are not involved in helping run the program, it is incredibly difficult for a company to run these types of programs on its own.

Tunney said that Boyd includes responsible gaming training as part of its orientation package, and now is examining the possibility of a staged training process, in which employees will receive additional training as they move up the ladder and take positions with greater responsibility within the company.

In his presentation, Dr. Robert Ladouceur, professor of psychology at Laval University in Quebec, asserted that interventions need to be focused on excessive gambling habits – spending too much time and money gambling – pointing out that what constitutes an excessive gambling habit will be different for different people. Ladouceur went on to recommend setting up policies and practices that will prevent problem gambling.

In creating these programs, said Ladouceur, it is important to keep in mind two basic principles: (1) the final decision to gamble belongs to the individual, and (2) the decision to gamble must be based on informed choice. He emphasized that the gaming industry’s role is to help inform the individual’s choice. He also stressed that casinos should avoid using intrusive or imposed measures because these approached may actually produce a negative effect, increasing the problem. He added, “These employees are not doctors or therapists,” saying they should be trained to educate patrons, but they are not trained to provide professional counseling. He said he sees future research exploring the line defining the casinos’ realm of responsibility.

Ladouceur went on to discuss findings from a few studies showing that employee training can help employees be more informed about responsible gaming, but suggesting that refresher courses may be needed at more frequent intervals to ensure long-term retention. In addition, he spoke to the attendees about the importance of evaluation, saying “Don’t spend any money on these programs if you don’t intend to evaluate, because if you can’t tell if it’s being effective, you’re part of the problem.”

For gaming companies looking for a scientific evaluation of their programs, Ladouceur recommended the following requirements: the scientist must be competent and have good credibility; the scientist also should be able to work well with various groups of people; the scientist should having different if not conflicting interests; the scientist must be objective; and the scientist must not have an anti-gambling bias.

From the scientist’s perspective, the company seeking an evaluation: must show a real commitment in responsible gaming; provide access to its data relevant to responsible gaming; be ready to modify some of its practices according to the results obtained by the study; and provide long-term funding support, meaning that research and evaluation take time and the company has to be willing to commit the resources to ensure a thorough and meaningful evaluation.

Interview with Glenn Christenson of the Nevada Governor’s Problem Gambling Advisory Committee

Click here for the NCRG Blog Team interview with Glenn Christenson, chairman of the Nevada Governor’s Problem Gambling Advisory Committee and managing director of Velstand Investments, LLC, about his NCRG Conference experience. Christenson moderated one of today’s sessions, Words Into Action: Responsible Gaming and its Impact on the Casino Floor.

Reflections on 50 Years of Gamblers Anonymous

In commemoration of the 50th anniversary of the founding of Gamblers Anonymous, a three-member plenary panel shared their personal experiences with the GA Twelve-Step Program and reflected on the place of GA in today’s efforts to promote recovery from gambling addiction.

One of the panelists, Ed Talbott, with Ad Care Hospital, recounted his story of how gambling slowly took control of his life. Now 30 years in recovery, he started gambling at age 17. He went to the racetrack and won. A seed was planted, he said. The gambling took off once he married and had a family. He began working at a Greyhound race track, and ended up losing everything, including, he said, his self respect, family relationships, job and thousands of dollars. When he finally went to his first GA meeting, he decided to keep attending and it helped transform his life.

Ed said he has seen some changes at GA over the years, for example, the types of gambling problems have expanded. In his day, the race track was popular. He sees people with problems now relating to the internet, lottery, casino and sports gambling. He said that GA has kept pace with these different types of gambling and also seems more open to recommending professional help for attendees if needed beyond GA.

Brenda Rose, another panelist, spoke about her multiple addictions over the years to drugs, alcohol and later gambling. After losing everything, the GA Twelve-Step Program helped her and “let her live again.” She said she still goes to the meetings and is learning to live one day at a time.

Dr. Rena Nora, who is the medical director of the Intensive Outpatient Program for Problem Gamblers at the VA Southern Nevada Healthcare System, has worked in this area for 28 years. She initially started a program in Atlantic City for compulsive gamblers and now is in Nevada. Dr. Nora said she never was trained formally in treating problem gamblers – her training was through attending meetings of GA over an intense three-month period. Her relationship with GA has been positive over the years. They work cooperatively, with GA even referring people to her for counseling and other needs. GA is also a good resource to find volunteer subjects for her research work. Dr. Nora concluded her presentation by saying that although there is no vaccine for problem gambling, they can find ways to manage the illness.

Founded in 1957, GA is based on the Twelve-Step Program of Alcoholics Anonymous.

Challenging One-Size Fits All: Traditional and Contemporary Medicine as Partners in Healing Addictions in Native Communities

Dr. Dale Walker, a psychiatrist and member of the Cherokee tribe, spoke today about ways to prevent and treat addiction in native communities. Walker is the director of the One Sky Center, an organization focused on promoting effective and culturally appropriate prevention and treatment in American Indian and Native Alaskan communities.

Walker said the best practice for gambling prevention and treatment within native communities is to combine evidence-based knowledge with indigenous knowledge, through what he called integrative medicine. He explained that integrative medicine combines the best aspects of traditional and conventional medicine by focusing on patient-centered care that combines science and evidence-based medicine with cultural sensitivity and an understanding of wellness and the power of the mind. He went on to say that this model would be the best approach for any group bound by ethnic, religious or geographic similarities.

Walker said the principles of integrative medicine state that is better to prevent than to treat later. He explained that because people are unique, treatments must be customized. Walker pointed out that important tenets of integrated medicine include recognizing the interaction between the body, mind and spirit, and the belief in the innate healing power of the body.

Walker said native casinos are an important part of life on the reservation, regardless of whether they yield revenues, because it is the gathering place and a central part of community life, as well as a place for interaction with those living outside of the reservation.

He also pointed to a World Health Organization study that found that alcohol use was the fourth leading cause of disability around the world. Walker went on to say that the native population has six times the rate of alcoholism than the population at large. Walker explained that treatment of both addiction and other health problems faces difficulties in native communities due to lack of access to health care and information about health care. He further explained the health care system available to natives is highly fragmented, with coverage gaps, a lack of resources, and clashing ideologies about medical training and treatment between traditional and conventional medical practitioners.

Are Gambling Behaviors Stable or Shifting Over Time?

According to DSM-IV, pathological gambling is defined as “persistent and recurring maladaptive gambling behavior,” and is widely considered to have a progressive course. Both Dr. LaPlante and Dr. Nelson presented recent empirical work that challengea this conventional wisdom.

Debi LaPlante, Ph.D., instructor of psychology in psychiatry at Harvard Medical School, addressed population-level stability, especially the effect of exposure, and individual-level stability in relation to persistence, selective-stability and progression.

With regard to population-level stability, the typical public health infection curve can be used as an analogy to understand the long-term consequences of exposure to gambling. The infection curve shows a high increase shortly after exposure, followed by a decline over time due to adaptation and resistance. This model receives general empirical support, and is supported by data from a recent study of online gambling behavior (bwin) showing that new subscribers show a rapid adaptation in their gambling activities. Data from bwin also suggests that a small segment of the new subscribers were heavily involved in gambling and adapted slower or not at all to the new exposure. The effects of exposure seem to differ in relation to individuals, regions, time points, and the initial effect of exposure declines over time.

With regard to individual-level stability, analyses on data from four former studies conducted by Winters et al., Abbott et al., Shaffer & Hall, and DeFuentes et al. indicate that the common wisdom that gambling is a persistent disorder is false – pathological gamblers do actually improve more than expected. The data show that high severity gamblers and low severity gamblers are equally likely to improve, and do not support the assumption about selective stability. Finally the data show that the progression or worsening of gambling symptoms is less common than expected.

LaPlante also emphasized the importance of recognizing the people who do not improve or recover from gambling symptoms, who do not adapt to new exposure, and who jump addictions. In addition, though people do not meet the diagnostic criteria for pathological gambling they can still experience problems.

Sarah Nelson, Ph.D., instructor of psychology in psychiatry at Harvard Medical School, presented data on individual stability across time, especially with focus on the fluctuations in the number of symptoms endorsed and the symptom profile.

According to DSM-IV a diagnosis of pathological gambling is given when a patient endorses five of the ten symptoms of pathological gambling. Even though the number of symptoms is crucial for a diagnosis, differences in symptom profile can make a huge clinical difference.

Research has found that the most reported symptoms are chasing, escape and preoccupation. Women are more likely than men to report “gambling to escape from problems.” “Risked relationships because of gambling” and “committing illegal acts to finance gambling” are the least reported symptoms, and are only reported by the most severe gamblers.

Analysis of the NESARC data – a national telephone survey – showed high fluctuations of the number of symptoms endorsed prior to the past year compared to the past year, high fluctuations in the specific symptoms endorsed prior to the past year compared to the past year, that stability decreases with the severity of gambling, that the most stable symptoms are escape and preoccupation, and that escape reported prior to past year is the best predictor of past year pathological gambling.

Nelson emphasized the importance of repeated assessment of gambling symptoms and the need for longitudinal studies of pathological gamblers. Though the overall gambling prevalence is relatively stable, this does not mean that individuals who meet the diagnosis are the same across time. According to Nelson, there seem to be great fluctuations in the number of symptoms and the specific symptoms over time.

CAUTION: Warning Messages Work – Don’t They?

Today’s session on warning messages combined lessons learned from tobacco research with findings from preliminary gambling-focused studies. Douglas A. Luke, Ph.D., professor of community health at Saint Luis University School of Public Health, and director of the Center for Tobacco Policy Research, began the discussion by presenting a history of warning labels, which began in 1957 when the first legislation requiring cigarette packs to carry a warning label was introduced in the U.S. Congress.

Luke emphasized the fact that cigarette warning labels in the United States are hard to see – whether on cigarette packages or in advertisements. He contrasted U.S. labels against those from other countries, particularly Canada, where the labels are more dynamic, colorful and direct. He also referred to pending legislation expanding FDA regulation over warning labels that calls for warning messages that are more direct.

According to Luke, research shows that the warning labels that are most effective are prominent (in size, graphics/color and contrast), novel – using a new idea or message, “graphic” – using images to get the point across, comprehensive and relevant. Recent research also has documented that effective warning labels can lead to greater knowledge about the risks of smoking, greater negative affect towards smoking cues, reduced attractiveness of smoker images, reduced attractiveness of cigarette packaging, increased attention to quit and increased actual quit rates.

Luke pointed out that while the tobacco research can be informative for problem gambling stakeholders, the end goal of tobacco warning labels is much different from those that might be used in gambling. Since even one cigarette can have an adverse health consequence, the ultimate goal is to get people to quit smoking or never to start, said Luke. But with gambling, he said, it is an activity that can be enjoyed responsibly by the majority of the population, so the goal is safe use, not abstinence.

James Whelan, Ph.D., associate professor of psychology at The University of Memphis, gave attendees an overview of a few studies conducted with gambling warning labels. He began by pointing out characteristics that need to be in place to show that a warning label ahs had an effect. These characteristics include message integrity (i.e. is it a good, relevant message?), delivery (is the message delivered in a way that it can be acquired by the intended recipient?), and reception (has the message been actively received?).

According to Whelan, message integrity is important because people believe they have control over the situation and consider luck to be internal and/or predictable, a phenomenon he referred to as “magical thinking.” This “magical thinking” is important to understand and consider in the development of effective warning messages, said Whelan.

Overall, the research has shown that warning messages can be delivered with integrity and they can influence thoughts and behaviors. Whelan spoke about the fact that, with the video technology used on slot machines, warning messages for gambling have the ability to be more creative, more visually engaging and more interactive than the static tobacco warning labels are.

Through the research, said Whelan, investigators have determined that, to be effectively received, warning messages should be memorable, be short and worded for audience, be interactive (e.g. the gambler would have to touch the message on the screen to make it close), reduce the effort needed to comply, and embedded in an educational effort

To access Whelan’s 2006 study, Use of warning messages to modify gambling beliefs and behavior in a laboratory investigation, click here, or visit the Institute for Research on Pathological Gambling and Related Disorders’ NCRG Conference Resource Page. When prompted, please enter the case-sensitive password: institute.

Gambling and Co-occurring Disorders: Landmark Research from the National Comorbidity Survey

The author of more than 500 journal articles, book chapters and other reports on mental health, Dr. Ronald Kessler today presented findings from the National Comorbidity Survey Replication (NCS-R), a landmark stud of mental health in the United States that included questions about gambling behaviors for the first time in the 2001-2003 version.

The NCS-R was designed to examine a nationally representative household sample of English-speaking adults (18-years-old and older). The data was collected from February 2001 through April 2003 from households in the continental United States. The survey also used a multistage cluster area probability sampling design, which means it didn’t take samples from places such as New York City, where it would be difficult to find a nationally representative sample.

The sampling design identified 10,843 pre-designated respondents from 177 counties in 34 states. Out of this group, Kessler and his colleagues running the survey were able to secure 9,282 completed interviews, which equates to a 70.9 percent “response” rate. The fieldwork for this survey included the work of more than 300 national, NCS-R certified interviewers from the Survey Research Center (SRC) University of Michigan and 18 SRC regional supervisors. Interviews were conducted face-to-face using a laptop computer-assisted technique, and the average interview lasted 2.5 hours. The data collected was weighted to mirror the U.S. population.

One of the interesting findings from the survey is that 46.4 percent of the respondents had a mental disorder at some point in their lives, as defined by the DSM-IV and WHO Composite International Diagnostic Interview. Kessler pointed out that while this finding may seem surprising, it makes sense given the fact that 99.9 percent of the population has experienced a physical disorder during their life, giving the example of a hangnail.

The survey findings also put the lifetime prevalence estimate of DSM-IV pathological gambling at 0.7 percent. Kessler pointed out that this number actually was lowered to 0.5 percent once respondents with bipolar I and bipolar II were excluded from the sample (according to the diagnostic code, people suffering from bipolar I and II cannot be diagnosed with pathological gambling as problem gambling behavior is considered a symptom of the bipolar disorder).

In addition, the survey was able to identify significant predictors of pathological gamblers. According to Kessler, pathological gamblers are more likely to be young (18-44), male, non-hispanic black, and have less than a college education.

Data from the survey shows several other patterns with relation to pathological gambling, including the prevalence of co-occuring disorders and how many pathological gamblers recover form the disorder. Kessler and his colleagues have made the data publicly available to encourage further, more detailed studies by researchers all over the world. The data can be found at www.hcp.harvard.edu/ncs.

Interview with Douglas Luke of the Saint Louis University School of Public Health

Click here for the NCRG Blog Team interview with Douglas Luke, Ph.D., professor of community health at the Saint Louis University School of Public Health and director of the Center for Tobacco Policy Research, about his NCRG Conference experience. Luke presented in one of today’s sessions, CAUTION: Warning Messages Work – Don’t They?

Outstanding Poster Award Presentation

Dr. Richard LaBrie of Harvard Medical School's Psychiatry Department presented this year's Outstanding Poster Award to the University of Sydney's Alex Blaszczynski and Sally Monaghan for their study entitled Pop-up Messages on Electronic Gaming Machines: Effect on Gambling-Related Thoughts and Behavior. Blaszczynski is a professor of Clinical Psychology and Monaghan is a DCP/Ph.D. student at the University of Sydney's School of Psychology. Their study found that pop-up messages on electronic gaming machines have more impact on thoughts and behaviors during play than more static messages that occurred after the session had ended.

This year 27 groups submitted posters with empirical research, 17 of which were from countries outside the United States.

Interview with Phil Satre of the National Center for Responsible Gaming

Click here for the NCRG Blog Team interview with Phil Satre, chairman of the National Center for Responsible Gaming, and retired chairman and CEO of Harrah’s Entertainment, Inc. Satre is one of the co-hosts of the 8th annual NCRG Conference on Gambling and Addiction.

Interview with Rani Desai of the Yale School of Medicine

Click here for the NCRG Blog Team interview with Rani Desai, Ph.D., associate professor of psychiatry and epidemiology at Yale School of Medicine, about her NCRG Conference experience. Desai presented in one of today’s sessions, Are Older Adults Who Gamble Really at a Higher Risk? Click here for our blog coverage of the session.

Are Older Adults Who Gamble Really at a Higher Risk?

Dr. Rani Desai of Yale's School of Medicine presented a study today that examined older adults and gambling. Given that older adults are one of the fastest growing demographic segments of the population, she said it is important to understand the risk factors and health correlates for recreational gamblers.

Desai explained that gambling has both positive and negative effects for older adults. She pointed out that some gambling provides opportunities for socialization, and sensory and cognitive stimulation. In her study she found residential and assisted-care facilities use gambling activities as part of their programming and report that bingo and other gambling activities are the biggest social activities at the homes.

Desai pointed out that older adults do have some unique risk factors related to their age. She found they have a preference for slot machines, which she notes may be more addictive than other kinds of casino games. She also pointed out that older adults are vulnerable because they cannot recoup losses as they are no longer working and because they are more at-risk for decreased cognitive function and dementia that could lead to poor decision making.

But overall, Desai said she found that older gamblers were, in fact, healthier. They rate their own physical health as significantly better than older non-gamblers and do not have the increased risk of drug and alcohol abuse that younger gamblers do. In light of these findings, Desai posed the question: Does this mean gambling is good for you? She said, Maybe. She explains that healthy aging literature has shown that older adults who remain socially and physically active do live longer and gambling activities can provide an opportunity for these kinds of activities. She goes on to note that as a scientist, she must also consider that older adults who gamble may already be healthier than their non-gambling counterparts, as they are well enough to go out and participate in gambling activities.

Joni Vander Bilt of the University of Pittsburgh also presented a study on older adults and gambling with similarly interesting findings. She said that the older gamblers tended to be male and less educated than non-gamblers, but she said they also have greater social support systems, tend to be less depressed, and have better health and higher cognitive function than their non-gambling counterparts.

To access Desai's full study, click here. For more information, visit the NCRG Conference Resource Page.

Where is Public Health Policy on Gambling Headed?

This question drew a large crowd to this morning’s first plenary, where moderator Don Feeney, research and planning director of the Minnesota State Lottery, kicked off the discussion by saying that historically, public health policy tends to treat problem gambling as “someone else’s problem.” And as “someone else’s problem,” the issue becomes conveniently invisible.

Feeney, with more than 20 years of experience working with public and elected officials at the state level, went on to say that, to the extent problem gambling hasn’t been invisible in state-level public policy, the policy isn’t based on science – it is based on guilt. To these states, he said, the important matter is that something has been done, but what that something is doesn’t necessarily matter.

According to Feeney, elected officials are very good barometers of their constituencies and, therefore, one of the challenges problem gambling policy faces is that the conventional wisdom that exists within the public is also evident in the officials. To the public, a problem gambler is “that guy next door” who visits the casino frequently and is irresponsible with his money. People still view problem gambling as a moral problem and consider it to be different from chemical addictions. This conventional wisdom trivializes the issue, said Feeney, and therefore diminishes the need for a public response in the eyes of the public and elected officials.

“There is a lot of work to be done to overcome conventional wisdom,” said Feeney, “Which is a tremendous barrier to effective public policy.”

Feeney went on to say that stakeholders in the prevention and treatment of problem gambling need to make elected officials understand what it is. He emphasized the need for those who work in the field of problem gambling to develop advocacy skills, saying “We need to know how to effectively work with our elected officials. These are not skills you are born knowing, they can be learned. Knowing who to talk to, what their key issues are, and finding a champion.”

Feeney pointed out that one champion in a legislature of a few hundred can be a powerful tool. “We need to find those champions and advocates, work with them, and try our best to educate the others.”

With that, Feeney introduced Dr. Westley Clark, director of the Center for Substance Abuse Treatment at the Substance Abuse and Mental Health Services Administration (SAMHSA). Dr. Clark presented on the federal government’s response to problem gambling, which has been minimal because it was determined in 1999 by the congressional National Gambling Impact Study Commission that problem gambling is a state responsibility. Clark said SAMHSA has almost exclusively deferred to states and nonprofit organizations when it comes to problem gambling.

Forty-eight of the 50 states in the U.S. receive proceeds from some type of gambling. Clark pointed out this conflict of interest a one challenge facing the development of effective public health policy on pathological gambling. He also pointed to the “perceived need for treatment by those who are affected by the condition” as a major problem for those concerned about problem or pathological gambling.

Clark cited research showing that problem gambling is more common among people with alcohol use disorders than it is among those without such disorders. Due to this and the high rate of other co-occurring disorders, Clark pointed out that SAMHSA is faced with a dilemma about whether or not to get involved as the organization currently does not address gambling problems.

In addition, he emphasized that there currently is no public health paradigm for problem gambling, and encouraged those in the audience interested in the issue to pursue and encourage that goal. He concluded his presentation by providing recommendations for the development of state-level public health policy, which are: assume a neutral stance, recognize the state’s ethical responsibility, work with the gaming industry, learn from other states and be flexible in the planning.

To open his presentation, Gary Fisher, professor in the College of Health and Human Services at the University of Nevada, Reno, reminded the audience that there will be natural conflicts between industries that produce products that can cause harm and the people who are seeking to prevent or treat that harm.

He pointed out a disconnect in the substance abuse field with regard to the size of the problem and the size of the solution. For example, though alcohol abuse results in double the economic costs of drug abuse, said Fisher, government funding doesn’t reflect this as the National Institute for Alcohol Abuse receives less than half the funding of the National Institute for Drug Abuse.

He also pointed to the stigma surrounding addiction – addicts are perceived as weak-willed, and the public perceives that treatment doesn’t work because they see movie stars, athletes, politicians, and their friends and family continually bouncing in and out of treatment programs.

Fisher said alcohol policy is the best place for guidance because it is very comparable to gambling due to the fact that it is legal and can be used safely. Alcohol policies include environmental strategies, such as limiting the locations where it can be sold and the days on which it can be sold. According to Fisher, these types of strategies might also work for casinos.

He emphasized the need for a commitment to treatment, competing marketing campaigns and the need to find common ground where industry, government, nonprofit and all other stakeholders can come together. In addition, he stressed the importance of states taking action, saying that “you can’t count on the federal government” to take the lead.

Interview with Howard Shaffer of Harvard Medical School and the Division on Addictions

Click here for the NCRG Blog Team interview with Howard Shaffer, associate professor of psychology in the department of psychiatry at Harvard Medical School and director of the Division on Addictions at the Cambridge Health Alliance. Shaffer is one of the co-hosts of the 8th annual NCRG Conference on Gambling and Addiction, and on Sunday was presented with the NCRG Scientific Achievement Award in the category of senior investigator.

NCRG Conference: Day 2 At-a-Glance

The 8th annual NCRG Conference on Gambling and Addiction continues today with a full day of sessions. Here’s a quick look at the sessions and special events taking place today.

Plenary Sessions:
8:30 – 9:45 a.m. – Where is Public Health Policy on Gambling Headed?
Moderator:
Don Feeney, Research and Planning Director, Minnesota State Lottery
Presenters:
H. Westley Clark, Ph.D., J.D., M.P.H., C.A.S., F.A.S.A.M., Director, Center for Substance Abuse Treatment, Substance Abuse and Mental Health Services Administration
Alexandra Vuksich, Commissioner, California Gambling Control Commission
Gary L. Fisher, Ph.D., Professor, College of Health and Human Sciences, University of Nevada, Reno
Location:
Champagne 1/2

9:45 – 11 a.m. – Are Older Adults Who Gamble Really at a Higher Risk?
Moderator:
Sarah E. Nelson, Ph.D., Instructor of Psychology in Psychiatry, Harvard Medical School
Presenters:
Joni Vander Bilt, M.P.H., Senior Researcher, University of Pittsburgh and Western Psychiatric Institute & Clinic
Rani Desai, Ph.D., Associate Professor of Psychiatry and Epidemiology, Yale School of Medicine
Location:
Champagne 1/2

11:30 a.m. – 12:30 p.m. – Gambling and Co-occurring Disorders: Landmark Research from the National Comorbidity Survey
Moderator:
Howard J. Shaffer, Ph.D., C.A.S., Associate Professor of Psychology in the Department of Psychiatry, Harvard Medical School, and Director, Division on Addictions, Cambridge Health Alliance
Presenter:
Ronald Kessler, Ph.D., Professor of Health Care Policy, Harvard Medical School
Location:
Champagne 1/2

4:45 – 5:45 p.m. – Reflections on 50 Years of Gamblers Anonymous
Moderator:
Kathy Scanlan, Executive Director, Massachusetts Council on Compulsive Gambling
Presenters:
Rena Nora, M.D., Medical Director, Intensive Outpatient Program for Problem Gamblers, VA Southern Nevada Healthcare System
Ed Talbott, Community Service Representative, Ad Care Hospital
Location:
Champagne 1/2

Track A: Scientific and Clinical
2 – 3:15 p.m. – Are Gambling Behaviors Stable or Shifting Over Time?
Moderator:
Richard LaBrie, Ed.D., Instructor in the Department of Psychiatry, Harvard Medical School, and Associate Director for Research and Data Analysis, Division on Addictions, Cambridge Health Alliance
Presenters:
Debi A. LaPlante, Instructor of Psychology in Psychiatry, Harvard Medical School
Sarah E. Nelson, Ph.D., Instructor of Psychology in Psychiatry, Harvard Medical School
Location:
Champagne 1/2

3:45 – 4:45 p.m. – Challenging One-Size Fits All: Traditional and Contemporary Medicine as Partners in Healing Addiction in Native Communities
Moderator:
Peter Nathan, Ph.D., University of Iowa Foundation Professor Emeritus of Psychology and Public Health
Presenter:
R. Dale Walker, M.D., Professor of Psychiatry and Public Health and Preventative Medicine, Oregon Health and Science University, and Director, One Sky National Resource Center for American Indian/Alaska Native Substance Abuse Services
Location:
Champagne 1/2

Track B: Government and Industry
2 – 3:15 p.m. – CAUTION: Warning Messages Work – Don’t They?
Moderator:
Connie Jones, Director of Responsible Gaming, International Game Technology
Presenters:
Douglas A. Luke, Ph.D., Associate Professor of Community Health, Saint Louis University School of Public Health, and Director, Center for Tobacco Policy Research
James P. Whelan, Ph.D., Associate Professor of Psychology, The University of Memphis
Location:
Champagne 3/4

3:45 – 4:45 p.m. – On-site Resources in Casinos: Do They Improve the Odds of Safer Gaming?
Moderator:
Jennifer Shatley, Program Vice President of the Code of Conduct, Harrah’s Entertainment, Inc.
Presenters:
Laurie Bell, Director of Prevention Programs, Responsible Gaming Council (Ontario)
Chris Downy, Executive Director, Australian Casino Association
Bev Mehmel, Director of Responsible Gaming, Manitoba Lotteries Corporation
Location:
Champagne 3/4

Special Events
12:30 – 2 p.m. – Poster Award Presentation and Networking Luncheon
Location:
Versailles

Scientific Achievement Award Presentation

Dr. Howard Shaffer, an early pioneer in the field of addictions and gambling disorders research, was named as the recipient of the 2007 NCRG Scientific Achievement Award today in the senior investigator category.

The award was presented by Dr. Peter Nathan, the University of Iowa Foundation Professor Emeritus of Psychology and Public Health, who called Shaffer a "towering figure in gambling research."

The senior investigator award honors scientists whose career work has led to important advancements, discoveries or developments in the field of gambling-related research. Shaffer, associate professor of psychology in psychiatry at Harvard Medical School and the director of the Division on Addictions, Cambridge Health Alliance, was selected by an independent awards committee in recognition of his groundbreaking research on gambling and for the profound impact it has had on the way that scientists understand and study addiction.

Shaffer’s distinguished career in research has yielded a number of “firsts” that have significantly advanced understanding of disordered gambling behavior. His 1997 meta-analysis of the prevalence rates of gambling disorders in the United States and Canada have been widely recognized as the first reliable estimates of the prevalence rate of the disorder (1 to 1.5 percent).

He also led the first longitudinal study of the health risks of casino employees, the first national survey of gambling behaviors and policies on U.S. college and university campuses, the first study of Internet sports gambling using actual monetary transaction data, and the first model for understanding addiction as a syndrome.

Beyond his many contributions as a scientist, Shaffer has helped create and strengthen the necessary infrastructure for the growing field of gambling research through his work as editor of the Journal of Gambling Studies and Psychology of Addictive Behaviors and his founding of the Institute for Research on Pathological Gambling and Related Disorders, supported by the NCRG. He has written more than 250 chapters, journal articles, and reviews, and published more than 120 newspaper articles and 10 books or monographs.

To see the tribute video for Dr. Shaffer that was shown at the awards presentation, click here.

Innovations in Public Policy: Gambling Court and the Iowa Gambling Treatment Program

Judge Mark Farrell presented findings and observations today from the Amherst Gambling Treatment Court, which he created in 2001. The court was modeled after drug courts to provide treatment and rehabilitation as an alternative to traditional court systems. Farrell pointed out that most problem gamblers who run afoul of the law tend to commit non-violent crimes, especially identity theft, forged checks, theft from family and employers, and shoplifting to resell the stolen items. Much like the defendants in drug courts, the crimes were committed with the intention of acquiring more money with which to fund their habits.

Farrell said, however, that he has seen an increase in more serious crimes in the last few years, including burglary, felony-level street crime and drug-related crime, which he believes represent an even stronger case for the treatment and rehabilitation of individuals who have or could become a danger to the community if their addiction is left untreated.

Farrell explained that the therapeutic court system, like traditional courts, first arraigns the defendant on formal charges. If the judge refers the defendant for assessment, the defendant is back before the court within one week for an initial assessment. Following that, the defendant undergoes a full screening for pathological gambling within two weeks. Farrell pointed out that in traditional court systems, months pass before the defendant appears in court again. In the therapeutic system, the defendant is immediately evaluated, and enters into a treatment program and starts probation.

Farrell further explained that the most difficult aspect of the gambling court is identifying who is a problem gambler. He explained that the medical field has not yet created a test to prove whether someone has been gambling. He said that in lieu of a definitive test, pathological gambling is diagnosed by meeting several predetermined criteria.

Farrell went on to say that defendants who are non-compliant in the program can face sanctions from a judge, ranging from warnings in open court all the way to termination from the treatment from the program and jail time.

Mark Vander Linden from the Iowa Health Department's Gambling Treatment Center showed how they have also adopted policies that require gaming revenues fund services to treat gambling. He explains that the Health Department's goal is to ensure that the public health community is well-versed in and focused on strategies for treating problem gambling. In Iowa, said Vander Linden, the Health Department is committed to raising public awareness of problem gambling and have set up a help line, 1-800-BETS-OFF. He said that a range of prevention, education and treatment options, as well as a stronger community-based initiative is helping them reach out to at-risk communities.

Find a Responsible Gaming Quarterly article with more information on the Amherst Gambling Treatment Court here.

Can Medication Manage Disordered Gambling Behavior? Newest Trends in Research.

According to Dr. Jon Grant, associate professor of psychiatry at the University of Minnesota Medical Center, medication can help manage disordered gambling, but there isn’t a “magic pill” that can cure gambling disorders.

Grant pointed out that drug companies haven’t been all that interested in the medication and treatment of gambling addiction – even those companies who are very interested in creating medication to treat substance addiction. His experience has shown that these companies don’t see pathological gambling as a real problem. Grant implied a link between this disinterest and the fact that all medication being tested for use in the treatment of gambling addiction is “off label” as the FDA has not approved any drugs for gambling addiction. The medication used, said Grant, is largely borrowed from what’s already being used for drug addiction.

One overarching theme Grant revisited throughout the session is that not all pathological gamblers are created equal – meaning that people categorized as pathological gamblers are driven by different motivators to participate in gambling behavior, and that there are different types of biology for different types of gamblers. In early pharmacological research on addicted gamblers, Grant explained, all addicted gamblers tended to be lumped into one category. This meant that the effectiveness of medications could be “watered down” simply because the medication being tested may not be treating the right biological factors for everyone in the group.

Grant pointed out that by understanding what goes on in brain, we can understand better how to target it. Over the years, Grant and his colleagues have found that the practice of subtyping pathological gamblers – dividing them into categories based on what drives them to gamble – helps to target medications in a way that can show improved responses to medication. Since it is incredibly difficult and expensive to do genetic testing on every single patient, Grant explained that subtyping can be a “stand in” for biology.

Subtyping looks at a pathological gambler’s family history and comorbitites (i.e. other disorders they may have). Grant presented four subtypes: anxiety-driven gamblers, affective/mood-driven gamblers, impulse-driven gamblers and urges/cravings-driven gamblers.

Particular progress has been made in the area of treating pathological gamblers driven by cravings. Grant and his colleagues recently completed the first study to replicate the results of successful medication treatment for gambling addiction in craving gamblers. The drug they studied was naltrexone, an opiod antagonist that has been approved for more than 20 years for treating alcoholism. Interestingly, Grant pointed to research which shows that pathological gamblers are much more likely to report cravings (60 to 70 percent) than are alcoholics (20 to 30 percent).

Some progress also has been made in other categories. While the studies have been sparse, there has been some evidence showing that gamblers who are anxiety driven may benefit from medication that helps to alleviate that anxiety. For impulse-driven gamblers – those Grant described as people who regularly decide to engage in gambling behavior despite the potential negative consequences – Grant suggested that there may be an underlying attention deficit issue, and that it may be helpful to test and, if appropriate, treat gamblers in this group for these types of disorders.

Grant noted that medication is studied on its own – not in conjunction with other therapies – because researchers have to be able to determine if the medication actually works. Yet, in clinical settings, Grant explained that medication usually is used in combination with other methods such as Gamblers Anonymous, self-exclusion programs and other individual therapeutic treatment options. In response to a question at the end of the session about the long-term effects of medication, Grant said that not much is known, but that the target treatment time for medication in his clinical work is one year, with other therapies used in conjunction and continuing to be used afterward.

To access Grant’s 2006 study, Medication Management of Pathological Gambling, click here, or visit the Institute for Research on Pathological Gambling and Related Disorders’ NCRG Conference Resource Page. When prompted, please enter the case-sensitive password: institute.

Does Exposure to New Gambling Lead to Gambling Problems? A Case Study from Canada

As legalized gambling and new casinos are introduced to communities around the world, researchers are reexamining whether exposure to gambling increases gambling problems in those areas.

Robert Ladouceur, professor of psychology at Laval University in Quebec, Canada, presented his recent study today during the afternoon plenary session, Does Exposure to New Gambling Lead to Problem Gambling? A Case Study from Canada, evaluating the impact of a new casino in Hull, Quebec. Ladouceur and co-author Christian Jacques' study weighed the results of Hull residents to the comparison group of residents in Quebec City. He explained that participants in the study answered gambling-related questions one month before the casino opening, one year after the casino opening, and again at the 2- and 4- year marks. Participants were evaluated on how frequently they participated in casino games and gambling activities and the amount of money lost in one day's gambling. They were also questioned on whether they had a pathological gambler in their household.

During the session, Ladouceur reiterated that 70-80% of adults who reside in areas where gambling is available have gambled in the last year. He also noted that less than 1% of the adult population was found to have a gambling problem.

Ladouceur stated that the conventional wisdom is that exposure to gambling leads to problem gambling. At the outset of the study, Ladouceur said he believed that this conventional wisdom held some truth and expected that the study would show that the longer at-risk individuals were exposed to gambling, the higher the rates of problem gambling would be. But he pointed out that this was shown not to be the case. While the study showed a significant increase in gambling activities at the one year mark, the trend did not continue at the 2- and 4- year marks. Ladouceur went on to say the data showed that after an initial increase in gambling in the community when a new casino opens, the frequency in gambling activities decreases over time. He explained this pattern has been exemplified in other studies and is known as the "social adaptation" model. The study points out that this may be because the novelty of casino games wears off and individuals move onto new activities.

When participants were asked at the 4-year mark if a member of their household had a gambling problem, Ladouceur said Hull residents reported more gambling problems than Quebec City. But he pointed out that it was impossible to determine how accurately the participants perceived the problem.

Ladouceur cited other studies that point out that participation in gambling activities is a prerequisite condition for developing gambling problems, in the same way that alcohol consumption is a prerequisite to developing a drinking problem. But he went on say, "In the case of gambling, the exposure to gambling is not sufficient to create a problem." While Ladouceur explained that he originally believed that the hypotheses were logical and made sense in the "conventional wisdom" framework, he concluded that the empirical data did not support it.

To access Ladouceur’s full study click here, or visit the Institute for Research on Pathological Gambling and Related Disorders’ NCRG Conference Resource Page. When prompted, please enter the case-sensitive password: institute.

Opening Plenary: Welcome and Town Hall

Opening the first session of the 2007 NCRG Conference on Gambling and Addiction, NCRG Chairman Phil Satre welcomed nearly 400 attendees from 14 countries around the world and introduced attendees to this year’s conference theme, Responsible Gaming, Regulation and Recovery: Testing Conventional Wisdom. Satre also emphasized that today’s opening session was about hearing attendees voices and opinions.

Dr. Howard Shaffer, director of the Division on Addictions, echoed that message as he told the crowd that today’s opening session would be the first instant response session the NCRG Conference has ever featured. “This is a risky session,” said Shaffer, “It’s unscripted, which means it will require your participation. We are interested in your ideas.”

Before beginning the instant response portion of the session, Shaffer first spoke about the definition of conventional wisdom. Broadly, conventional wisdom in any belief that is widely held and considered unchallengeable, he said. Conventional wisdom has at times kept people from thinking of or considering new and alternative views.

Shaffer pointed out that in youthful fields such as the addictions, “we have to make time to identify our underlying assumptions and test them.” He likened this process to a cold shower – “it can be uncomfortable, but it’s necessary.” According to Shaffer, this conference is organized to provide attendees with a “cold shower” by challenging their own beliefs, beginning with their participation in this town hall session.

Armed with individual keypads, session attendees first answered questions about their occupations and home countries. Based on the responses, 24 percent are in the health care industry, 24 percent are in academic research, 27 percent are in the gaming industry, 14 percent are in government and 12 percent are in other fields. Shaffer called this an interesting and important distribution of participants because it is essential for all stakeholder parties to come to the table to reduce gambling-related harms, and the responses show this conference is providing a forum for these parties to meet. Attendees hailed from the United States (69 percent), Canada (15 percent), Europe (7 percent), Asia (2 percent), Australia (2 percent) and other countries (5 percent).

Shaffer then proceeded with asking attendees to answer several questions about addiction and gambling disorders, emphasizing that these questions, and the conventional truths surrounding them, will be examined in several of the conference sessions occurring over the next few days. These questions – and the attendees’ responses (shown as percentages at the left of the answer selection)– are detailed below:

1. Between 50 and 85 percent of people with an addictive disorder eventually seek formal treatment. What is the main reason that people avoid seeking addiction treatment?
- 5% - Stigma
- 3% - Lack of medical insurance, money
- 6% - Perception of addictive treatment as ineffective
- 26% - Denial
- 58% - All of the above
- 2% - Other

2. About 80 to 90 percent of individuals entering recovery from addiction will relapse during the first year after treatment. What does the high rate of relapse among disordered gamblers tell us about the disorder?
- 5% - It shows that once an addict, always and addict
- 47% - It shows how difficult it is to recover
- 9% - It shows that people with a gambling problem need to be in treatment
- 33% - It shows that addiction runs a chronic course
- 6% - Other

3. Does the introduction of new gambling opportunities lead to more gambling problems in a community?
- 42% - Yes
- 8% - No
- 14% - Yes, but only at first
- 13% - Yes, but only gradually
- 23% - Sometimes
***Shaffer pointed out that the idea that new gambling opportunities lead to more gambling problems is considered conventional wisdom, but that there isn’t always science to back up this belief. This question will be examined more closely in the session following the opening plenary, titled Does Exposure to New Gambling Lead to Gambling Problems: A Case Study from Canada.

4. Does your state/provincial or regional government have an initiative to reduce gambling-related harms
- 78% - Yes
- 22% - No
***Shaffer noted that 10 years ago, never would have seen a response like this one, and said he would argue that it has to do with the science that has been published in this time.

5. For those who said yes, how would you rate those efforts?
- 5% - Excellent
- 37% - Good
- 35% - Fair
- 23% - Poor

6. Are older adults who gamble more vulnerable to developing a gambling problem than the general adult population?
- 29% - Yes
- 32% - No
- 40% - Sometimes

7. How many people in the U.S adult population had a severe past-year gambling problem in 1977?
- 27% - Zero to one percent
- 42% - One to two percent
- 20% - Three to five percent
- 4% - Six to eight percent
- 6% - Much higher
***Shaffer pointed out that research on the prevalence of a severe past-year gambling problem in 1977, before gaming proliferated into several new jurisdictions – shows the prevalence was 0.77 percent.

8. How many people in the U.S adult population had a severe past-year gambling problem between 2001 and 2003?
- 11% - Zero to one percent
- 35% - One to two percent
- 33% - Three to five percent
- 14% - Six to eight percent
- 7% - Much higher
***According to Shaffer, research shows that the prevalence rate for a severe past-year gambling problem during this time was actually 0.6 percent.

9. The rate of pathological gambling in the United States is closest to the rate of the following disorder?
- 25% - Schizophrenia (Prevalence rate: 1.1 percent)
- 26% - Excessive shopping (Prevalence rate: 1.0 percent)
- 17% - Kleptomania (Prevalence rate: 1.1 percent)
- 24% - Obsessive Compulsive Disorder (Prevalence rate: 1.0 percent)
- 7% - Marijuana use disorder (Prevalence rate: 1.45 percent)
***The prevalence rates to the right of the disorders were revealed to the participants after their answers were recorded. Shaffer pointed out that the prevalence rates for all of these disorders are all close to 1 percent, but that while the U.S. government provides significant funding and resources in all these areas (except for, perhaps, excessive shopping), the same resources are not afforded pathological gambling research and treatment.

Several of these questions will be examined throughout the conference. Be sure to check out our ongoing conference blog coverage to see how conventional wisdom is tested and what the latest research reveals.

Interview with Kathy Scanlan of the Massachusetts Council on Compulsive Gambling

Click here for the NCRG Blog Team interview with Kathy Scanlan, executive director of the Massachusetts Council on Compulsive Gambling, about her NCRG Conference experience. Scanlan also is moderating Reflection on 50 Years of Gamblers Anonymous, scheduled for tomorrow, Monday, Nov. 12, at 4:45 p.m.

NCRG Conference: Day 1 At-a-Glance

The 8th annual NCRG Conference on Gambling and Addiction kicks-off today at 1 p.m. Here’s a quick look at the sessions and special events taking place this afternoon.

Plenary Sessions:
1 – 2 p.m. – Welcome and Town Hall Meeting
Moderator:
Phil Satre, Chairman, National Center for Responsible Gaming, and Retired Chairman and CEO, Harrah’s Entertainment, Inc.
Presenter:
Howard J. Shaffer, Ph.D., C.A.S., Associate Professor of Psychology in the Department of Psychiatry, Harvard Medical School, and Director, Division on Addictions, Cambridge Health Alliance
Location:
Champagne 1/2

2 – 3 p.m. – Does Exposure to New Gambling Lead to Gambling Problems? A Case Study from Canada
Moderator:
Debi A. LaPlante, Ph.D., Instructor of Psychology in Psychiatry, Harvard Medical School
Presenter:
Robert Ladouceur, Ph.D., Professor of Psychology, Laval University
Location:
Champagne 1/2

3:30 – 4:30 p.m. – The Reality of Relapse and Recovery Among Disordered Gamblers
Moderator:
Ken C. Winters, Ph.D., Professor of Psychiatry and Director of the Center for Adolescent Substance Abuse Research, University of Minnesota
Presenter:
David C. Hodgins, Ph.D., Professor of Psychology, University of Calgary
Location:
Champagne 1/2

Track A: Scientific and Clinical
4:30 – 5:45 p.m. – Can Medication Manage Disordered Gambling Behavior? Newest Trends in Research
Moderator:
Ken C. Winters, Ph.D., Professor of Psychiatry and Director of the Center for Adolescent Substance Abuse Research, University of Minnesota
Presenter:
Jon E. Grant, M.D., J.D., M.P.H., Associate Professor of Psychiatry, University of Minnesota Medical Center
Location:
Champagne 1/2

Track B: Government and Industry
4:30 – 5:45 p.m. – Innovations in Public Policy: Gambling Court and the Iowa Gambling Treatment Program
Moderator:
Alan Feldman, Senior Vice President of Public Affairs, MGM MIRAGE
Presenters:
Judge Mark G. Farrell, Senior Justice, Amherst Town Court
Mark Vander Linden, M.S.W., Director of Iowa Gambling Treatment Program, Iowa Department of Public Health
Location:
Champagne 3/4

Special Events
6 – 7:30 p.m. – Poster Session and Scientific Achievement Award Presentation Reception
Location:
Concorde A

Spotlight on Research: Can Medication Manage Disordered Gambling Behavior? Newest Trends in Research

Research indicates a clear relationship between biological vulnerabilities and the development of a gambling disorder. For example, a vulnerability might be insufficient levels of chemicals – or neurotransmitters – in the brain that regulate mood and judgment. If the low mood is elevated by an activity like gambling, the person could develop a gambling problem. Furthermore, the simultaneous occurrence of depression and other psychiatric problems with a gambling disorder underlines the importance of exploring drug treatments for pathological gambling.

However, currently there is no treatment standard for disordered gambling and no medication has been approved by the FDA for treating the disorder.

Dr. Jon Grant, associate professor of psychiatry and co-director of the Impulse Control Disorders Clinic at the University of Minnesota Medical School, has done extensive research in this area. A review essay published in 2006 and co-authored by Dr. S.W. Kim examined the results of studies looking at three types of drugs used to treat pathological gambling – antidepressants, mood stabilizers, and opioid antagonists. Results from some of these controlled clinical trials are promising and could eventually lead to significant improvement in the lives of people struggling with a gambling disorder.

Grant will discuss this research and its important implications for treatment during the conference session Can Medication Manage Disordered Gambling Behavior? Newest Trends in Research, scheduled for 4:30 p.m. on Sunday, Nov. 11. To access Grant’s full study click here, or visit the Institute for Research on Pathological Gambling and Related Disorders’ NCRG Conference Resource Page. When prompted, please enter the case-sensitive password: institute.