Connecting Science and Practice: The Impact of Gambling ... · Department of Community & Behavior...

Connecting Science and Practice:Connecting Science and Practice:The Impact of Gambling Research The Impact of Gambling Research

on Clinicianson Clinicians

Anne Helene Skinstad, PhDAnne Helene Skinstad, PhDMartin Goransson, MPHMartin Goransson, MPH

Department of Community and Behavior HealthDepartment of Community and Behavior HealthPrairielands Addiction Technology Transfer CenterPrairielands Addiction Technology Transfer Center

The University of Iowa College of Public HealthThe University of Iowa College of Public Health

Presented at the 2006 Midwest Conference on Problem Presented at the 2006 Midwest Conference on Problem Gambling and Substance Abuse. Gambling and Substance Abuse.

August 17, 2006 Kansas City, MOAugust 17, 2006 Kansas City, MO

Department of Community & Behavior Health Prairielands Addiction Technology Transfer Center

Connecting Science and PracticeConnecting Science and Practice

Institute of MedicineInstitute of Medicine Report (IOM): Report (IOM): Bridging the Gap between Research and Practice Bridging the Gap between Research and Practice (1998)(1998)

From Bench to TrenchFrom Bench to Trench (Rawson, 2003). (Rawson, 2003). Goals of the IOM report:Goals of the IOM report:

Reduce the barrier between research and Reduce the barrier between research and practicepractice

Reduce the time between an innovation and Reduce the time between an innovation and adoption of the innovation into practiceadoption of the innovation into practice

Increase communication between researchers and Increase communication between researchers and practitioners: practitioners: From Trench to BenchFrom Trench to Bench


Connecting Science and PracticeConnecting Science and Practice A number of programs were initiated after A number of programs were initiated after the IOM report. Examples include:the IOM report. Examples include:

Substance Abuse and Mental Health Service Substance Abuse and Mental Health Service Administration (SAMHSA): Administration (SAMHSA): Practice -Improvement CollaborativePractice -Improvement Collaborative

National Institute on Drug Abuse (NIDA): National Institute on Drug Abuse (NIDA): Clinical Trials Network: Clinical Trials Network:

Problem gambling: Problem gambling: Not yet a research homeNot yet a research home


Connecting Science and PracticeConnecting Science and Practice Development of a plan for connecting Science to Development of a plan for connecting Science to

Practice requires clarity in a number of areas, Practice requires clarity in a number of areas, including:including: Research in assessment and treatment of problem Research in assessment and treatment of problem gamblinggambling

Reno modelReno model

Knowledge about the workforceKnowledge about the workforce CharacteristicsCharacteristics Training needsTraining needs

Technology transfer of empirically supported Technology transfer of empirically supported innovationsinnovations

Where does technology transfer fit into the RENO model?Where does technology transfer fit into the RENO model? Summary Summary


RESEARCH ON ASSESSMENT AND RESEARCH ON ASSESSMENT AND TREATMENT OF PROBLEM GAMBLINGTREATMENT OF PROBLEM GAMBLING


The Reno Model The Reno Model [3][3]

Lack of Conceptual ClarityLack of Conceptual Clarity

Absence of ConsensusAbsence of Consensus

Two Key Barriers to Advancing Two Key Barriers to Advancing Responsible GamblingResponsible Gambling


Lack of Conceptual ClarityLack of Conceptual Clarity [3][3]

Multitude of Terms and DefinitionsMultitude of Terms and Definitions Problem GamblerProblem Gambler At-risk GamblerAt-risk Gambler Compulsive GamblerCompulsive Gambler Probable Pathological GamblerProbable Pathological Gambler Pathological Gambler Pathological Gambler



The South Oaks Gambling Screen The South Oaks Gambling Screen (SOGS) (SOGS) [4][4]

Most widely used instrument in Most widely used instrument in treatment studiestreatment studies

Not a diagnostic instrumentNot a diagnostic instrument

The lack of uniformity hinders The lack of uniformity hinders effective knowledge transfereffective knowledge transfer



Multitude of Treatment outcome Multitude of Treatment outcome measuresmeasures Over 30 different outcome measures used Over 30 different outcome measures used in the clinical trials and treatment in the clinical trials and treatment outcome literature outcome literature [5][5]

Measures and definitions of Measures and definitions of effectivenesseffectiveness AbstinenceAbstinence Pre-Post statistical differencePre-Post statistical difference Clinically significant differences Clinically significant differences [6][6]


Best PracticesBest Practices


Clearly: MaybeClearly: Maybe [7][7]

Best Practice implementation Best Practice implementation urgent to ensure efficacious urgent to ensure efficacious treatment and start the processtreatment and start the process

It is detrimental to treatment to It is detrimental to treatment to limit treatment options at this limit treatment options at this point, lacking more clinical datapoint, lacking more clinical data


Cognitive InterventionsCognitive Interventions [8,9][8,9]

Strongest Empirical SupportStrongest Empirical Support Cognitive CorrectionCognitive Correction Chance and Randomness clarificationChance and Randomness clarification Problem SolvingProblem Solving Social SkillsSocial Skills


Medical TreatmentMedical Treatment [10,11,24][10,11,24]

Encouraging EvidenceEncouraging Evidence SSRI’sSSRI’s Nalmefene, NaltrexoneNalmefene, Naltrexone Mood StabilizersMood Stabilizers

Remaining ProblemsRemaining Problems Placebo responsePlacebo response Co-occurrence (what is being treated)Co-occurrence (what is being treated) LongevityLongevity


Brief Interventions and Self HelpBrief Interventions and Self Help Brief intervention with college Brief intervention with college students students [12][12] Built on MI and CBT principles Built on MI and CBT principles High recruitment, completion, and follow-up High recruitment, completion, and follow-up ratesrates

Self help manuals Self help manuals [13][13] Promising results with 84% of participants Promising results with 84% of participants reporting reduced gambling behavior at 12 reporting reduced gambling behavior at 12 monthsmonths

Gambler’s Anonymous in combination with Gambler’s Anonymous in combination with professional treatment professional treatment [14][14] Most commonly used treatment methodMost commonly used treatment method Number of GA meetings attended significantly Number of GA meetings attended significantly and independently associated with gambling and independently associated with gambling abstinenceabstinence


WORKFORCE ISSUESWORKFORCE ISSUES


Workforce IssuesWorkforce Issues More research on the gambling treatment More research on the gambling treatment workforce needed to improve outcomes and workforce needed to improve outcomes and quality of services quality of services [21,22][21,22]

181 psychologists employed by the Veterans 181 psychologists employed by the Veterans Administration surveyed in 2001. Administration surveyed in 2001. Over 60% had not received any training on Over 60% had not received any training on assessment or treatment of gambling disorders assessment or treatment of gambling disorders during their graduate training, internship or during their graduate training, internship or post-graduate training. post-graduate training.

Almost half of the respondents had never Almost half of the respondents had never attended or had the opportunity to attend a attended or had the opportunity to attend a continuing education seminar or workshop on continuing education seminar or workshop on pathological or problem gambling %psychologists pathological or problem gambling %psychologists receive training receive training [23].[23].


Workforce Issues Workforce Issues Opportunity for researchers and providers Opportunity for researchers and providers to collaborateto collaborate Opportunity for clinicians to improve practicesOpportunity for clinicians to improve practices Opportunity for researchers to access Opportunity for researchers to access populations and conduct community based populations and conduct community based clinical research clinical research

Investing in and understanding the Investing in and understanding the gambling treatment workforce benefits gambling treatment workforce benefits research and treatment outcomes research and treatment outcomes

Now is the time to start collaborating as Now is the time to start collaborating as more and more research is coming out and more and more research is coming out and gambling is our understanding of gambling gambling is our understanding of gambling is improving fast.is improving fast.


A Survey of the Pathological Gambling A Survey of the Pathological Gambling Treatment Workforce: Who They Are and Treatment Workforce: Who They Are and

How Better We Can Help ThemHow Better We Can Help Them 18 month grant awarded by the 18 month grant awarded by the Institute for Research on Institute for Research on Pathological Gambling and Related Pathological Gambling and Related DisordersDisorders

First national gambling treatment First national gambling treatment workforce survey in the U.S. (or workforce survey in the U.S. (or elsewhere).elsewhere).

Project start: August, 2006. Project start: August, 2006. Anticipated date of completion: Anticipated date of completion: December, 2007.December, 2007.


Project aimsProject aims Specific Aim #1:Specific Aim #1: Develop, pretest, and validate an Develop, pretest, and validate an

instrument to measure the characteristics, instrument to measure the characteristics, attitudes, and training needs of the problem attitudes, and training needs of the problem gambling workforce.gambling workforce.

Specific Aim #2Specific Aim #2:: Administer the validated Administer the validated instrument to a purposive sample of gambling and instrument to a purposive sample of gambling and substance abuse treatment providers in seven ATTC substance abuse treatment providers in seven ATTC regions (a minimum of 12 states) that cover the regions (a minimum of 12 states) that cover the major geographic regions of the US.major geographic regions of the US.

Specific Aim #3:Specific Aim #3: Convene an expert panel Convene an expert panel consisting of ATTC directors and internationally consisting of ATTC directors and internationally recognized gambling researchers to amass a set of recognized gambling researchers to amass a set of recommendations to enable the development of an recommendations to enable the development of an evidence-based curriculum firmly based on our evidence-based curriculum firmly based on our findings. findings.


Bringing Research Findings to the Bringing Research Findings to the WorkforceWorkforce [15,16][15,16]

Scientific advances are under-Scientific advances are under-utilized by the addictions fieldutilized by the addictions field

Gambling presents opportunities and Gambling presents opportunities and challenges in this regardchallenges in this regard New field with ability to influence practiceNew field with ability to influence practice Early gambling research “hard to sell” compared Early gambling research “hard to sell” compared to other addictions to other addictions


Characteristics of the WorkforceCharacteristics of the Workforce

What do we know about the What do we know about the characteristics of the workforcecharacteristics of the workforce

Educational backgroundEducational background Knowledge about basic counseling skillsKnowledge about basic counseling skills Knowledge about assessment and planning an Knowledge about assessment and planning an assessment strategiesassessment strategies

Knowledge about empirically supported Knowledge about empirically supported therapeutic strategiestherapeutic strategies

AgeAge GenderGender


Additional WorkforceAdditional Workforce Working situationsWorking situations Community based substance abuse Community based substance abuse treatment centerstreatment centers Inpatient treatment centersInpatient treatment centers Outpatient treatment centersOutpatient treatment centers

Community-based mental health centersCommunity-based mental health centers Inpatient mental health unitsInpatient mental health units

Independent private practicesIndependent private practices Front line health care practicesFront line health care practices


Other Workforce IssuesOther Workforce Issues

Supervision issuesSupervision issues Administrative supervisionAdministrative supervision Clinical supervisionClinical supervision


STRATEGIES FOR TECHNOLOGY STRATEGIES FOR TECHNOLOGY TRANSFERTRANSFER

CONNECTING SCIENCE AND PRACTICECONNECTING SCIENCE AND PRACTICE


The ATTC Network: Serving the The ATTC Network: Serving the Field since 1993Field since 1993 [1][1]

The Addiction Technology Transfer The Addiction Technology Transfer centercenter is dedicated to identifying and is dedicated to identifying and advancing opportunities for improving advancing opportunities for improving addiction treatmentaddiction treatment

Our missionOur mission is to unify science, is to unify science, education, and services to transform the education, and services to transform the lives of individuals and families affected lives of individuals and families affected by alcohol and other drug addictionby alcohol and other drug addiction

Funded byFunded by the Substance Abuse and Mental the Substance Abuse and Mental Health Services Administration (SAMHSA) Health Services Administration (SAMHSA)


The ATTC NetworkThe ATTC Network Areas of EmphasisAreas of Emphasis

Enhancing cultural-appropriate Enhancing cultural-appropriate assessment and treatment strategies assessment and treatment strategies for substance abusefor substance abuse

Dissemination substance abuse Dissemination substance abuse assessment and treatment toolsassessment and treatment tools

Building a stronger and better Building a stronger and better workforceworkforce

Advancing knowledge adoptionAdvancing knowledge adoption Forging partnerships in order to Forging partnerships in order to facilitate adoptionfacilitate adoption


Prarielands ATTCPrarielands ATTC (PATTC) (PATTC) [2][2] Iowa, Minnesota, Nebraska, North Dakota, Iowa, Minnesota, Nebraska, North Dakota, and South Dakotaand South Dakota

PATTC heads the ATTC Network gambling PATTC heads the ATTC Network gambling initiativeinitiative

Lead Agent for the Annual Midwest Lead Agent for the Annual Midwest Conference on Problem Gambling and Conference on Problem Gambling and Substance AbuseSubstance Abuse


What does Technology TransferWhat does Technology Transfermean?mean?

Technology Transfer Technology Transfer is producer-oriented is producer-oriented

Diffusion is user-Diffusion is user-orientedoriented

Rogers 2004 (19)Rogers 2004 (19)


Technology Transfer Technology Transfer (Cont.)(Cont.)

Technology Transfer is Technology Transfer is more than a behavior more than a behavior change process. Both change process. Both cognition and behavior cognition and behavior must be impacted.must be impacted.

Brown (2000) (18)Brown (2000) (18)


Technology Transfer CycleTechnology Transfer Cycle [16][16]

N.A. Roget, University of Nevada, RenoP.K. Horvatich, Virginia Commonwealth University A.H. Skinstad, University of IowaS.A. Storti, Brown University 2004


Knowledge DisseminationKnowledge Dissemination Target groups:Target groups:

General publicGeneral public Professionals working in the Professionals working in the casinoscasinos EMERGE: Executive, Management, & EMERGE: Executive, Management, & Employee Responsible Gaming Education Employee Responsible Gaming Education


Knowledge DisseminationKnowledge Dissemination(Cont.)(Cont.)

Professional communitiesProfessional communities Pre-servicePre-service

Counseling professionCounseling profession PsychologistsPsychologists Social workers and othersSocial workers and others Health care professionals: Health care professionals: physicians, nurses, physician physicians, nurses, physician assistants and othersassistants and others

Post-service disseminationPost-service dissemination


Active Ingredients of Active Ingredients of Technology Transfer (TT)Technology Transfer (TT)

Roget (2002) (20) conducted a Roget (2002) (20) conducted a review of the technology review of the technology transfer literature and found transfer literature and found nine common themes regarding nine common themes regarding the processes of technology the processes of technology transfertransfer


Adoption of Adoption of New InnovationsNew Innovations

In order to facilitate adoption In order to facilitate adoption of new innovations, nine of new innovations, nine ingredients of Technology ingredients of Technology Transfer need to be included in Transfer need to be included in the effort. the effort.


The Nine Ingredients of The Nine Ingredients of Technology TransferTechnology Transfer

Influence & Involve Opinion LeadersInfluence & Involve Opinion Leaders Ensure & Accessibility SuitabilityEnsure & Accessibility Suitability Provide Multiple ExposuresProvide Multiple Exposures Increase Personal Contact with Increase Personal Contact with InnovationInnovation

Provide Positive RewardsProvide Positive Rewards Utilize Regeneration StrategiesUtilize Regeneration Strategies Enhance OwnershipEnhance Ownership Include Bottom-up PerspectivesInclude Bottom-up Perspectives Deal with ResistanceDeal with Resistance


Provide Multiple ExposuresProvide Multiple Exposures [16][16]

Expose adopters to the new technology Expose adopters to the new technology in various modesin various modes WorkshopsWorkshops ConferencesConferences Online educationOnline education CD-ROM materialsCD-ROM materials


Increase Personal Contact Increase Personal Contact with Innovationwith Innovation [16][16]

Onsite technical consulting with Onsite technical consulting with innovatorinnovator

Toll-free telephone consultingToll-free telephone consulting


Positive Rewards (Incentives) Positive Rewards (Incentives) [16][16]

““The single most poorly The single most poorly understood element of the understood element of the research-practice formula is the research-practice formula is the need for treatment programs to be need for treatment programs to be adequately compensated for their adequately compensated for their participation in research-participation in research-practice activities” [17 p. 776).practice activities” [17 p. 776). Time is moneyTime is money Space, supplies, and phones cost Space, supplies, and phones cost moneymoney

New treatments create expenses [17]New treatments create expenses [17]


Enhance Ownership Enhance Ownership [16][16]

Clinical guides/manualsClinical guides/manuals Literature reviews and Literature reviews and meeting with other users of meeting with other users of the technologythe technology

Provide credible evidence Provide credible evidence that the technology is that the technology is workingworking


Include Bottom-up PerspectivesInclude Bottom-up Perspectives [16][16]

Front line staff are members of Front line staff are members of the change teamthe change team

Find ways to integrate research Find ways to integrate research findings into everyday clinical findings into everyday clinical experienceexperience

What works for whom and where?What works for whom and where? How to maximize adoption? How to maximize adoption? Be creative and follow up. Be creative and follow up.


Deal with ResistanceDeal with Resistance [15,16][15,16]

Change is stressfulChange is stressful Emphasize payoffs of changeEmphasize payoffs of change Include everyone, change cannot Include everyone, change cannot be successfully imposedbe successfully imposed

Roll with resistance and realize Roll with resistance and realize that some resistance is that some resistance is legitimate and needs to be legitimate and needs to be addressedaddressed


SummarySummary


SummarySummary The field of assessment and treatment The field of assessment and treatment of problem gambling presents unique of problem gambling presents unique opportunitiesopportunities New area of researchNew area of research New area for dissemination and adoptionNew area for dissemination and adoption

Adopt strategies for effective Adopt strategies for effective dissemination and adoption from other dissemination and adoption from other fieldsfields

Build consensus on what technologies to Build consensus on what technologies to disseminatedisseminate

Decide on use of dissemination or Decide on use of dissemination or adoption strategiesadoption strategies


SummarySummary Support more research on problem gamblingSupport more research on problem gambling

Age and gender differenceAge and gender difference Cultural differencesCultural differences

Support more research on issues important for Support more research on issues important for workforce development workforce development

Support research on training needsSupport research on training needs

Support curriculum infusion in:Support curriculum infusion in: Pre-service education of health care Pre-service education of health care professionalsprofessionals

Continuing education of health care Continuing education of health care professionalsprofessionals

Evaluate our educational effortsEvaluate our educational efforts


Thank youThank you Special Thank You to Nancy Roget, Special Thank You to Nancy Roget, MS. from the Mountain West ATTC for MS. from the Mountain West ATTC for her important contributions to this her important contributions to this presentationpresentation

Thank You also to Candace Peters, Thank You also to Candace Peters, MA. and Jane Li, MS., both from the MA. and Jane Li, MS., both from the Prairielands ATTC for their Prairielands ATTC for their contributions to this presentationcontributions to this presentation


ReferencesReferences1.1. National Addiction Technology Transfer Center (2005) Retrieved 11-09-2005 from National Addiction Technology Transfer Center (2005) Retrieved 11-09-2005 from

http://www.nattc.org/http://www.nattc.org/2.2. Prarielands Addiction Technology Transfer Center (2005) Retrieved 11-09-2005 from Prarielands Addiction Technology Transfer Center (2005) Retrieved 11-09-2005 from

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