January 11-13, 2010 Miami Beach, Florida

The Science of Rewards Using Rewards in the Criminal Justice System J Steps Meeting January 11-13, 2010 Miami Beach, Florida

Drug Addiction and Its Treatment Intersection between drug abuse/addiction and the criminal justice system NIDA research on the CJ-involved drug abuser The neurobiology of addiction What drug abuse treatment works and what doesn t Where do we go from here? J-Steps: 2

Need for Research on Offenders with Drug Problems Re-entry entry of drug-disordered disordered offenders into society poses multiple challenges Over 83% of state prisoners and 78% of federal prisoners have a history of substance abuse Less than 20% received treatment in prison About 700,000 offenders are released from prison every year; up to 12 million from jails More than a third (37%) of parolees in 2005 were drug offenders (up from 11% in 1985) Parole supervision increasingly focuses on surveillance over rehabilitation J-Steps: 3

Individuals in Community Supervision, Jails/Prisons, and Drug Courts (2007) Adult Drug Courts = 1,174 Juvenile Drug Courts = 455 Correctional Supervision Prison/Jail Drug Courts Total Estimated number with drug problem* * E t t 53% f t t l f i f Ch dl t l (JAMA 2009) d t 43% f t t l f b ti * Est at 53% of total for prisoners, from Chandler et al (JAMA, 2009), and at 43% of total for probationers, from Brittingham et al. (SAMHSA/OAS, 1999). Drug Court data are from Huddleston et al (BJA/NDCI, 2008). Prison/jail/community supervision data are from Glaze & Bonczar (BJS, 2008).

U.S. Adult Offender Population Recent drug use by ~50% of violent offenders (BJS, 2006) and 60 80% of child abuse/neglect (NIJ 1999) Corrections officials estimate 50 68% of inmates meet abuse/ dependence criteria (BJS 2005; 2006) 7 17% of prisoners meetingcriteria get treatment in jail or prison (BJS 2005; 2006) J-Steps: 5

Many offenders have a drug use disorder but few receive treatment Federal Prison State Prison 0% 20% 40% 60% 80% Treatment from a professional Other programs: education, self-help Drug dependence or abuse diagnosis Mumola & Karberg. Drug use and dependence, state and federal prisoners, 2004. BJS 2006 (rev 07) J-Steps: 6

Modality Differences Most individuals in community-based drug abuse treatment are criminal justice-involved. involved. 100 CJ Status and CJ Referral In DATOS 80 60 40 66 33 59 43 29 56 31 20 0 LTR ODF OMT Total 2 CJ Status CJ Referral Simpson et al. PAB, 1997 J-Steps: 7

Intersection between drug abuse / addiction and criminal behavior. Statistics: Dependence/abuse in CJS relationship of drug use to crime link between drug use and offending problem of relapse and return to the criminal justice system J-Steps: 9

Level of NIDA Support for Research on Drug Abuse and Criminal Justice In 2008, NIDA supported about 120 research grants (across all divisions and branches) that looked at the drug-involved offender population. This comprised about 5% of the NIDA extramural research budget. The total amount supported was over $47 million. About half of the research on drug-involved offenders is in NIDA s Services Research Branch. J-Steps: 10

NIDA Research on Drug Abuse and Criminal Justice Criminal justice portfolio topics: Improving the effectiveness of pharmacological and behavioral treatment interventions for drug-involved offenders Reducing risky behavior that can lead to HIV or other infectious disease in criminal justice populations Re-entry for drug-involved d offenders linkage to treatment t t and other services Sub-populations p adolescents, women, and HIV-infected individuals Drug treatment courts and other integrated approaches Research on transfer of effective interventions to usual practice Criminal Justice Drug Abuse Treatment Studies (CJ-DATS) J-Steps: 11

Time in treatment very short treatment does not produce lasting behavioral change. Treatment is a process and it can be broken into stages. There are pharmacological and behavioral interventions that can benefit the behavioral change process. System factors are important in determining whether treatment is successful. J-Steps: 12

What do we know about drug abuse and addiction? J-Steps: 13

Advances in Science Have Revolutionized Our Fundamental Views of Drug Abuse and Addiction J-Steps: 14

Your Brain on Drugs Source: Breiter & Rosen, Ann N Y Acad Sci 1999

The Brains of Addicts Are Different From the Brains of Non-Addicts And Those Differences Are An Essential Element of Addiction J-Steps: 16

Because Their Brains have been Re-Wired by Drug Use J-Steps: 17

Cocaine Craving: Population (cocaine users, controls) x Film (cocaine) Cingulate Signal Inte ensity (AU) Cocaine Film Ant Cing IFG Controls Cocaine Users Garavan et al Am J Psych 2000

Cocaine Craving: Population (cocaine users, controls) x Film (cocaine, erotic) Cingulate Signal Inte ensity (AU) Cocaine Film Erotic Film Ant Cing IFG Controls Cocaine Users Garavan et al Am J Psych 2000

Circuits Involved in Drug Abuse and Addiction INHIBITORY CONTROL PFC OFC SCC ACG NAcc Hipp VP REWARD MOTIVATION/ DRIVE Amyg MEMORY/ LEARNING J-Steps: 20

Nuclear Circuitry Mediating the Activation of Goal-Directed Behavior Medial dorsal thalamus Ventral pallidum Nucleus accumbens core Prefrontal cortex Enter basal ganglia motor generator Dopamine Ventral tegmental area Basolateral amygdala Hippocampus Glutamate Extended amygdala GABA Central amygdala a nucleus, bed nucleus of the stria GABA/Neuropeptide terminalis nucleus accumbens shell Cannabinoid receptors??? Adapted from Kalivas and Volkow, Am J Psychiatry 162:8, Aug 2005

Reward Processing in the Brain Schultz, Nat Rvw Neuro 2000 J-Steps: 22

We Know That In combination with many other transmitter systems, and despite their many differences, most abused substances enhance dopamine activities J-Steps: 23

Dopamine Pathways striatum frontal cortex hippocampus substantia nigra/vta Functions reward (motivation) pleasure, euphoria motor function (fine tuning) compulsion perseveration nucleus accumbens

Dopamine Response Prediction of Future Rewards Simple Acquisition Learning Ludvig et al., Neural Computation, 2008 J-Steps: 25

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Natural Rewards Elevate Dopamine Levels Output of Basal DA O % o 200 150 100 50 0 Empty FOOD Box Feeding NAc shell 0 60 120 180 Time (min) ine) on (% Basel Concentratio DA C 200 150 100 Sample Number Scr Female 1 Present SEX Scr 1 2 3 4 5 6 7 8 910 11 Mounts Intromissions Ejaculations Scr Female 2 Present 11 12 13 14 15 16 17 15 10 5 0 Copulation Frequency Source: Di Chiara et al. Source: Fiorino and Phillips

Effects of Drugs on Dopamine Release l Release % of Basal 1100 1000 900 800 700 600 500 400 300 200 100 0 Accumbens AMPHETAMINE DA DOPAC HVA 0 1 2 3 4 5 hr Time After Amphetamine % of Basal Release 400 300 200 100 0 Accumbens COCAINE DA DOPAC HVA 0 1 2 3 4 5 hr Time After Cocaine al Release % of Basa 250 200 150 100 NICOTINE Accumbens Caudate Release % of Basal 200 Release250 150 100 Accumbens MORPHINE Dose (mg/kg) 0.5 1.0 25 2.5 10 0 0 1 2 3 hr Time After Nicotine 0 0 1 2 3 4 5hr Time After Morphine Di Chiara and Imperato

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Prolonged Drug Use Changes The Brain In Fundamental and Long-Lasting Lasting Ways J-Steps: 32

Effect of Cocaine Abuse on Dopamine D2 Receptors normal subject cocaine abuser (1 month post) cocaine abuser (4 months post)

Brain Dopamine Receptors Comparison Subject Cocaine Abuser (1 month after) Cocaine Abuser (4 months after) J-Steps: 34

Brain Glucose Metabolism Comparison Subject Cocaine Abuser (1 week) Cocaine Abuser (3 months) J-Steps: 35

Brain Glucose Metabolism in Cocaine Abusers (n = 20) and Controls (n = 23) CG 60 romol/100g g/min 55 50 45 micr 00g/min icromol/10 mi 40 60 55 50 45 40 CG Controls Abusers P<001 OFC 0.01 Controls Abusers P < 0.005

Dopamine D2 Receptors are Lower in Addiction Cocaine DADA DA DA DA DA DA DA DA DA DA DA Meth Reward Circuits Non-Drug Abuser Alcohol DADA DA DA DA DA Heroin Control Addicted Reward Circuits Drug Abuser

Dopamine Transporters in Methamphetamine Abusers 2.4 Normal Control Dop pamine Transporte ers (Bma ax/kd) 2.2 2.0 1.8 16 1.6 1.4 1.2 1.0 Normal Controls Meth Abusers Methamphetamine Abuser p < 0.0002 Methamphetamine abusers have significant reductions in dopamine transporters. BNL - UCLA - SUNY NIDA - ONDCP - DOE

Dopamine Transporters in Methamphetamine Abusers Dopam mine Trans sporter Bmax/Kd 2.0 1.8 1.6 1.4 1.2 1.0 7 8 9 10 11 12 13 Time Gait (seconds) 2.0 1.8 1.6 1.4 1.2 1.0 16 14 12 10 8 6 4 Delayed Recall (words remembered) Motor Task Loss of dopamine transporters in the meth abusers may result in slowing of motor reactions. Memory Task Loss of dopamine transporters in the meth abusers may result in memory impairment. BNL/UCLA/SUNY NIDA, ONDCP, DOE

Implication: Brain changes resulting from prolonged use of drugs may be reflected in compromised cognitive functioning Is there recovery?

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[C-11]d-threo-methylphenidate Normal Control DAT Recovery with prolonged abstinence from methamphetamine Methamphetamine Abuser (1 month detoxification) Methamphetamine Abuser (14 month abstinent) Source: Volkow, N.D. et al., Journal of Neuroscience, 21(23), pp. 9414-9418, December 1, 2001.

Genetic Variation Predicts Naltrexone Treatment Response for Alcohol Dependence apse) 1.0 0.9 rvival (Tim me to Rel 0.8 0.7 06 0.6 0.5 0.4 Naltrexone/ Asp40 Allele (A/G, G/G) (n=23) Naltrexone/ Asn40 Allele (A/A) (n=48) Placebo/ Asp40 Allele (A/G, G/G) (n=18) Cumu ulative Su 0.3 0.2 01 0.1 0.0 0 14 28 42 56 70 84 Days Placebo/ Asn40 Allele (A/A) (n=41) Oslin DW et al., Neuropsychopharmacology 28, 1546-1552, 2003.

DA Receptor Levels and Respone to MP unpleasant response 2.5 0 pleasant response Subjects with low receptor levels found MP pleasant while those with high levels found MP unpleasant

www.drugabuse.gov NIDA NATIONAL INSTITUTE ON DRUG ABUSE Publications can be obtained through the National Clearinghouse for Alcohol and Drug Information 1-800-729-6686

1. Drug addiction is a brain disease that affects behavior.

What do we know about drug abuse treatment? What works and what doesn t? J-Steps: 47

3. Treatment must last long enough to produce stable behavioral changes. % DATOS: Outcomes - Yr 1 Post Discharge 100 < 90 Days 90+ Days 80 60 55 53 54 40 20 28 19 15 9 24 0 Cocaine (Any Use) * UA+ (Any Drug) * Alcohol (Daily Use) * Any Jail* *p<.001 N=342; Simpson, Joe, & Brown, 1997, PAB

Weekly Cocaine Use in Year 1 Follow Up by Length of Stay in DATOS 90 80 70 60 50 40 30 20 10 0 42 29 26 33 30 26 19 24 10 % in STI (n=605) % in ODF (n=458) % in LTR (n=542) 1-60 61-90 91-150 151-180 181-270 >270 18 16 10 8 Number of Days in Treatment J-Steps: 49

Evidence-Based Practice J-Steps: 50

4. Assessment is the first step in treatment. Nature/extent of drug gp problem Strengths: Family support Employment history Motivation Threats to recovery: Criminal behavior Mental health Physical health Family Influences Employment Homelessness HIV/AIDS CJ-DATS INTAKE SITE: CLIENT ID: DATE: (Core Measures) ) 11 xxx 05/16/03 AGE 41 EDUCATION 09 GENDER RACE/ETHNICITY MARITAL STATUS COCAINE HEROIN/OPIATES MARIJUANA Male OTHER ILLEGAL DRUGS ALCOHOL Mexican American Separated MULTIPLE (3+) DRUG USE LEGAL STATUS??? LEGALLY MANDATED??? HI NEED FOR TREATMENT??? HI PRESSURE FOR TREATMENT??? CLIENT PROBLEM PROFILE NO YES HIV/SEX RISKS PEERS/FRIENDS S FAMILY PSYCHOLOGICAL HEALTH UNEMPLOYMENT HIV/NEEDLE USE RISKS CRIMINAL INVOLVEMENT HIV/AIDS Low Mod High Extreme Client PROBLEM INDEX (Range 0-14) 8 1-4 5-7 8-10 11-14 Joe, Simpson, Greener, & Rowan-Szal, in press (Psychological Reports) NO YES

5. Tailoring services to needs is critical for treatment to be successful. Financial Services Core Housing & Treatment Transportation Behavioral Core Treatment Therapy Medical Services Intake Processing/ Assessment Treatment Plan Mental Health Substance Use Counseling Vocational Child Care Clinical and Case Management Pharmacotherapy Continuing i Care Self-Help/Peer Support Groups Educational Family Services AIDS/HIV Services Legal Services

Elements of Drug Treatment Motiv Early Early Engagement Recovery Patient Attributes at Intake Therapeutic Relationship Relationship Behavioral Compliance Retention Drug Use Crime Program Participation Psychological Improvement Social Adj Months 1-3 Posttreatment J-Steps: 53

Treatment Process Model Sequence of Recovery Stages Motiv Patient Attributes at Intake Early Engagement Program Participation Early Recovery Behavioral Change Therapeutic Psychosocial Relationship eato Change Retention/ Transition Sufficient Retention Drug Use Crime Social Relations Posttreatment Simpson & Joe, 1993 (Pt); Joe, Simpson, & Rowan-Szal (2001, PS) J-Steps: 54

Contingency Management ( Token Rewards ) Motiv Patient Attributes at Intake Early Engagement Program Participation Early Recovery Behavioral Change Retention/ Transition Supportive Networks Therapeutic Relationship Psychological Improvement Sufficient Retention Drug Use Crime Social Adj Months 1-3 Posttreatment Rowan-Szal et al., 1994 (JSAT); 1997 (JMA); Griffith, Rowan-Szal et al., 2000 (DAD) J-Steps: 55

Counseling Enhancements ( Cognitive Mapping ) Motiv Patient Attributes at Intake Early Engagement Program Participation Early Recovery Behavioral Change Retention/ Transition Supportive Networks Therapeutic Relationship Psychological Improvement Sufficient Retention Drug Use Crime Social Adj Months 1-3 Posttreatment Dansereau et al., 1993 (JCP), 1995 (PAB); Joe et al., 1997 (JNMD); Pitre et al., 1998 (JSAT) J-Steps: 56

Specialized Interventions (Manualized Skills-Based Counseling) Motiv Patient Attributes at Intake Early Engagement Program Participation Early Recovery Behavioral Change Retention/ Transition Supportive Networks Therapeutic Relationship Psychological Improvement Sufficient Retention Drug Use Crime Social Adj Months 1-3 Posttreatment Dansereau et al., 1993 (JCP), 1995 (PAB); Joe et al., 1997 (JNMD); Pitre et al., 1998 (JSAT) J-Steps: 57

Motivational Enhancement (MET) Motiv Patient Attributes at Intake Early Engagement Program Participation Early Recovery Behavioral Change Retention/ Transition Supportive Networks Therapeutic Relationship Psychological Improvement Sufficient Retention Drug Use Crime Social Adj Months 1-3 Principles of Drug Addiction Treatment: A Research Based Guide (NIDA, 2000) Posttreatment J-Steps: 58

Elements of Effectiveness Drug Treatment Induction Enhanced Counseling Social Networks Personal Health Services Motiv Patient Attributes at Intake Counselor Attributes & Skills Program Characteristics Early Early Engagement Recovery Therapeutic Relationship Program Participation Months 1-3 Behavioral Strategies Behavioral Compliance Psychological Improvement Social Skills Training Stabilization Treatment Retention Supportive Networks Drug Use Crime Social Adj Posttreatment Social Support Services (From D. D. Simpson et al.)

Are We Evaluating Treatment Correctly? Hypertension 1 2 3 1 Untreated disorder manifests itself at high level 2 Treatment reduces symptoms 3 Symptoms return when treat- ment is terminated proof of effectiveness of treatment Substance use disorder 1 2 3 1 Untreated disorder manifests itself at high level 2 Treatment reduces symptoms 3 Symptoms return when treat- ment is terminated does treatment work? McLellan (2002), Addiction, 97:249-251

Relapse Rates For Drug Dependence And Other Chronic Illnesses lapse Percent of Patients Who Re 75 50 25 0 60% 40 - Drug Dependence 30-50% Type I Diabetes 50-70% Hyper- tension 50-70% Asthma McLellan et al. (2000), JAMA J-Steps: 61

8. Treatment planning should involve treatment and criminal justice personnel. Public Health Approach - disease - treatment Public Safety Approach - illegal behavior - punish High Attrition High Recidivism

Integrated Public Health - Public Safety Strategy Community- based treatment Close supervision Blends functions of criminal justice and treatment systems to optimize outcomes Opportunity to avoid incarceration or criminal record Consequences for noncompliance are certain and immediate

10. A balance of rewards and sanctions can encourage pro-social behavior and treatment progress. Sanctions Rewards Reinforce positive behavior Use rewards (non-monetary) to recognize progress Catch people doing things right Graduated Consistent, predictable, fair Treatment not a sanction! Most likely to have desired effect the closer they follow the targeted behavior.

J-Steps: 65

What are the implications of new neuroscience findings for drug abuse treatment? J-Steps: 66

Non Addicted Brain Addicted Brain Control STOP Control Reward Drive Reward Drive GO Memory Memory

Treating the ADDICTED Brain REWARD CONTROL DRIVE Decrease the rewarding value of drugs MEMORY

Outpatient Study: Percent of Negative Urines After Depot Naltrexone Administration 80% Placebo 192 mg Dose 70% 384 mg Dose 60% 50% 40% 30% 20% 10% 0% 0 2 4 6 8 10 12 14 16 18 Visits it (2 per week) Comer et al. Arch Gen Psychiatry, 63, 210-218, 2006.

Disulfiram and Naltrexone for the Treatment of Co-occurring Cocaine and Alcohol Dependence Pct of cocaine+alcohol dependent patients with at least 3 consecutive weeks of abstinence from both cocaine and alcohol in an 11 week trial % Patients w/ 3 conse ecutive abstin nent wks 40% 35% 30% 25% 20% 15% 10% 5% 0% 15.0% 17.0% 17.3% 34.7% Placebo Disulfiram Naltrexone Disulfiram N=54 N=53 N=52 Naltrexone N=49 Source: Pettinati, HM et al., Addictive Behaviors, 33, pp. 651-667, 2008.

Treating the ADDICTED Brain REWARD CONTROL DRIVE Decrease the rewarding value of drugs REWARD CONTROL DRIVE Increase the rewarding value of non-drug reinforcers MEMORY MEMORY

Contingency Management for the Treatment of Methamphetamine Use Disorders Roll, J.M. et al., AJP 163(11) pp. 1993-1999, November 2006.

Treating the ADDICTED Brain REWARD CONTROL DRIVE Decrease the rewarding value of drugs REWARD CONTROL DRIVE Increase the rewarding value of non-drug reinforcers MEMORY MEMORY REWARD CONTROL DRIVE MEMORY Weaken learned positive associations with drugs and drug cues

Medications Biofeedback Coping Skills Desensitization Other behavioral strategies

Efficacious Behavioral Treatments for Drug Dependence COGNITIVE BEHAVIORAL THERAPY (cocaine dependence) also for benzodiazepine withdrawal in panic disorder patients COMMUNITY REINFORCEMENT APPROACH (CRA) WITH VOUCHERS (cocaine dependence) CONTINGENCY MANAGEMENT (WITHOUT CRA) (methadone- maintained opiate & cocaine abusers) LOWER-COST CONTINGENCY MANAGEMENT (cocaine dependent people in methadone-maintenance) BRIEF STRATEGIC FAMILY THERAPY (certain sub-populations of Hispanic adolescent polydrug abusers) MULTIDIMENSIONAL FAMILY THERAPY African-American polydrug- abusing adolescents) BEHAVIORAL COUPLES THERAPY (methadone-maintained opioidaddicted men; drug-abusing women) MOTIVATIONAL INTERVIEWING / MOTIVATIONAL ENHANCEMENT THERAPY

Right Lateral and Top Views of the Dynamic Sequence of Gray Matter Maturation over the Cortical Surface Gogtay et al. (2004) Proc. Natl. Acad. Sci.101, 8174-8179

Physical coordination, sensory processing Maturation Starts at the Back of the Brain... and Moves to the Front Motivation Emotion Judgment Cerebellum Nucleus Accumbens Amygdala Note: Judgment is the last to develop! Prefrontal Cortex

Addiction Is a Developmental Disease starts in childhood and adolescence to develop dence age group t me depend % in each a first-tim 1.8 1.6 1.4 1.2 1.0 0.8 0.6 0.4 02 0.2 0.0 TOBACCO THC ALCOHOL 5 10 15 20 25 30 35 40 45 50 55 60 65 Age 70 75 Age at tobacco, at alcohol and at cannabis dependence, as per DSM IV National Epidemiologic Survey on Alcohol and Related Conditions, 2003

Interventions for Drug Abusing Offenders Not Effective Strong Evidence Some Evidence Research Needed Boot Camp Intensive Supervision Generic Case Management Residential Substance Abuse Treatment Contingency Management Medications Drug Courts Breaking the Cycle Diversion to Treatment Moral Reasoning Motivational Interviewing Reentry Serious & Violent Offender Reentry Initiative (SVORI) Cognitive- Behavioral Treatment t Strengths- Based Case Management

Common Myths About Drug Abuse Drug abuse equates to drug addiction Alcohol is not a drug Addiction is a moral weakness You have to hit rock bottom to recover You have to want treatment for it to be successful Drug abuse is more common among minorities J-Steps: 81

Common Myths About Drug Abuse Abstinence cures addiction. J-Steps: 82

To Review Addiction is: a chronic brain disease expressed as compulsive behavior expressed within a social context prone to relapse treatable J-Steps: 83

Criminal Justice Drug Abuse Treatment Studies

CJ-DATS Research Centers and CJ Partner Sites Research Center J-Steps: 85

CJ-DATS Research Mission To establish a national research network to test integrated system-level drug abuse approaches for offenders with drug problems To develop knowledge about the design and delivery of drug treatment services to improve offender outcomes To improve outcomes for offenders with substance use disorders by improving the integration of drug abuse treatment with other public health and public safety systems J-Steps: 86

Services and Systems Issues Coordination Criminal Justice Addictions Treatment Public Safety Supervision Monitor illegal behavior Monitor release conditions Re-entry entry services Health, Public Health Drug use Risk behaviors Recovery Support services Drug-Involved Offender J-Steps: 87

CJ-DATS 1 Studies Understanding systems Assessing offender problems Measuring progress in treatment Linking criminal justice and drug treatment Adolescent interventions HIV and hepatitis risk reduction J-Steps: 88

CJ-DATS 1 Products Screening and assessment tools Manualized interventions Evidence-based practices Publications and reports Promising research directions J-Steps: 89

(c) 2004, Robert Crumb. All Rights Reserved. Step n Out Catching People Doing Things Right c) 2004, Robert Crumb. All Rights Reserved. Coordinate Tmt with Parole Officer Emphasize social reinforcements Shape behavior, don t just punish Give attention to positive behavior Be fair & realistic about changes J-Steps: 90

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CJ-DATS 1 Products Special Journal Issues: The Prison Journal,, March 2007 Journal of Substance Abuse Treatment,, April 2007 Criminal Justice and Behavior,, September 2007 Behavioral Sciences and the Law, July/August 2008 Journal of Psychoactive Drugs,, December 2008 Drug and Alcohol Dependence, August 2009 J-Steps: 92

Summary CJ-DATS 1 developed interventions for re-entry entry based on prior research Case management Contingency management Implementation of interventions was difficult Systems issues prior disposition; coordination between systems; access to services (e.g., HCV) Personnel staff turnover; support for studies How does research inform sustainability? Moving research-based interventions into practice will require: More knowledge about implementation Support from all criminal justice levels to be sustainable J-Steps: 93

Implementing Evidence-Based Practices Although numerous studies address the efficacy and effectiveness ofhealthinterventions, less research addresses successfully implementing and sustaining interventions. As long as efficacy and effectiveness trials are considered complete without considering implementation in non research settings, the public health potential of the original investments will not be realized. Feldstein & Glasgow (2008) Feldstein AC, Glasgow RE. (2008). A practical, robust implementation and sustainability model (PRISM) for integrating research findings into practice. Joint Comm J on Quality and Patient Safety 34(4), 228-243. J-Steps: 94