HSS26016-COMPSUBAPS-attD.pdf

Delaware Behavioral

Health Prevention

Strategy and Plan Safe and Healthy Delawareans across the Lifespan

The Delaware Division of Substance Abuse and Mental Health

April, 2024

For more information about this report please contact Dr. Amy Herb; National Prevention Network Coordinator for Delaware at amy.herb@delaware.gov mailto:amy.herb@delaware.gov

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Delaware Behavioral Health Prevention Strategy and Plan Safe and Healthy Delawareans across the Lifespan

Section I: Delaware Behavioral Health Prevention Strategy and Plan

Introduction, Background, and Overview

Introduction

The Division of Substance Abuse and Mental Health (DSAMH) is one of the nine divisions within

Delaware’s Department of Health and Social Services (DHSS) and is the single state agency (SSA) for the State of Delaware. DSAMH’s mission is to promote health and recovery by ensuring that

Delawareans have access to quality prevention and treatment for mental health, substance use, and gambling conditions. As the SSA, DSAMH is the lead agency in Delaware and is responsible for managing federal funds dedicated to addressing substance use prevention, treatment, and recovery.

Delaware operates a bifurcated system for behavioral health services. DSAMH administers behavioral health services for adults (individuals 18 years of age or older), and the Department of

Services for Children, Youth, and their Families (DSCYF), Division of Prevention and Behavioral

Health Services (DPBHS) administers behavioral health services for youth (individuals up to age

18). To ensure Delawareans are safe and healthy across the lifespan, DSAMH collaborates with

DPBHS in the planning and implementation of substance use and mental health prevention services.

Delaware is committed to fostering healthy and resilient individuals, families, and communities through a systemic, collaborative, and comprehensive Behavioral Health Prevention Strategy and

Plan. Behavioral health challenges, including mental health conditions and substance use disorders, can greatly impede everyday functioning, including job or school performance, relationships, health, parenting, and enjoyment of everyday activities.1 Delaware aims to establish a science-based, proactive prevention framework that addresses behavioral health risks early, recognizing that by identifying and addressing these challenges early, with an upstream approach, the adverse s on individuals, families, and communities can be mitigated by increasing protective factors and promoting well-being throughout the state.

This Behavioral Health Prevention Strategy and Plan takes a multi-faceted approach aimed at addressing the state’s prevention landscape by promoting mental health literacy, raising behavioral health awareness, providing health education and support services, and enhancing the capacity of the prevention workforce to deliver effective prevention services to empower individuals to make healthy choices around substances, to seek help, and support recovery. By prioritizing prevention, education, and community engagement, this plan aims to empower individuals, families, and communities with the tools and resources necessary to manage behavioral health challenges through supportive networks. Collaboration among state agencies, schools, community-based organizations, healthcare providers, and other key stakeholders is central to the success of this plan, ensuring that all Delawareans have the opportunity to live healthy, fulfilling lives.

Substance Use Prevention, Treatment and Recovery Services Block Grant

The Substance Abuse and Mental Health Services Administration (SAMHSA) allocates federal funds through DSAMH to address behavioral health needs, with a focus on prevention, intervention, treatment, and recovery support. This includes the Substance Use Prevention, 1 Mental Health and Substance Use Disorders: Impairment in Functioning-Behavioral Health; NCBI; 2012

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Treatment, and Recovery Services Block Grant (SUPTRS), Community Mental Health Services

Block Grants (MHBG), and Opioid-Specific State Grants. Additionally, as the SSA, DSAMH promotes quality and effectiveness through planning, ensuring accountability, reporting data, coordinating with state governments, and collaborating with the provider community.

DSAMH has been the recipient of the SUPTRS Block Grant since the Federal Fiscal Year (FFY)

1992. In alignment with the statutory regulations, DSAMH is charged with the development, implementation, maintenance, and oversight of a State Behavioral Health Assessment and Plan for prevention, intervention, treatment, and recovery supports, the administration of state and federal funding to carry out the plan, and development of standards for the certification and approval of prevention and treatment programs.

DSAMH utilizes the majority of these funds to support a statewide substance use treatment system that provides services such as detoxification, inpatient, outpatient, and recovery services with a focus on the priority populations: pregnant women and women with dependent children, and persons who inject drugs. Additionally, DSAMH uses the SUPTRS Block Grant to carry out substance use primary prevention services. DSAMH allocates no less than 20% of the total

SUPTRS award annually for primary prevention strategies directed at individuals not identified as needing treatment services. Delaware is committed to addressing prevention services across the lifespan; as such, DSAMH collaborates with DPBHS in the planning and implementation of substance use and mental health prevention services.

One component of the SUPTRS State Behavioral Health Assessment and Plan is the development of a comprehensive primary prevention program that includes activities and services provided in a variety of settings, targeted to both the general population and sub-groups that are at high risk for substance use. Delaware’s small geographic size provides advantages to developing, strengthening, and sustaining prevention efforts across the State that are relevant to multiple communities and target populations.

To better serve Delaware, DSAMH and its state and other partners set out to develop this comprehensive Behavioral Health Prevention Strategy and Plan to build the prevention capacity in the state, address the prevention needs of individuals, families, and communities, and enhance the prevention infrastructure in the state. As DSAMH and other state agencies refine their funding priorities for Fiscal Years 2025 – 2030, prevention-related and oriented activities will be required to align with this strategic plan, DSAMH’s guiding principles, and prevention performance goals and indicators to qualify for funding.

Delaware’s Prevention Infrastructure and Behavioral Health Treatment System

Delaware has a well-established system of support to address challenges related to behavioral health, including prevention, early intervention, treatment, and recovery support, which is overseen by DSAMH and DPBHS.

Delaware’s prevention infrastructure has improved significantly over the past five years. In particular, DSAMH and DPBHS collaborate closely with state agencies and divisions, including:

• DHSS’ Division of Public Health (DPH), Division of Social Services (DSS), Division of

Medicaid and Medical Assistance (DMMA), and the Division of Developmental Disability

Services (DDS)

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• Delaware Department of Education (DDOE)

• Delaware School Board

• Delaware Alcohol and Tobacco Enforcement (DATE)

• Delaware Department of Labor (DOL)

• Delaware State Housing Authority (DSHA)

In collaboration with DPBHS and other state agencies, DSAMH has created a statewide prevention infrastructure upon which this strategy builds, which includes surveillance, data collection, and analysis, coordination of a strategic vision, as well as coordination of funding for state and community level grants, and direct subrecipients to enable prevention programs and activities for populations across Delaware.

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Section II: Delaware Behavioral Health Prevention Strategy and Plan

Delaware’s Approach to Prevention

Behavioral Health Continuum of Care Model

Delaware’s prevention approach aligns with the Substance Abuse and Mental Health Services

Administration’s (SAMHSA) Behavioral Health Continuum of Care Model, derived from an

Institute of Medicine report. This comprehensive approach to behavioral health recognizes the multiple opportunities to address behavioral health problems. 2 Utilizing this model framework supports DSAMH’s mission to promote health and recovery by ensuring that Delawareans have access to quality prevention and treatment for mental health, substance use, and gambling conditions.

The model encompasses four components:

• Promotion: Strategies designed to create environments and conditions that support behavioral health and the ability of individuals to withstand challenges.

• Prevention: Strategies delivered prior to the onset of a mental health condition, or substance use disorder.

• Treatment: Services for individuals who are diagnosed with a behavioral health disorder such as a mental health condition, or substance use disorder

• Recovery: Services support individuals’ compliance with long-term treatment and aftercare to reduce relapse, reoccurrence, and/or further adverse outcomes.

Equally important to the behavioral health treatment and recovery services system is Delaware’s approach and adoption of behavioral health promotion and primary, secondary, and tertiary prevention strategies. Delaware defines prevention broadly and comprehensively, with a particular focus on identifying the individual, environmental, and social determinants of health, and then implementing prevention efforts and strategies targeted toward reducing risks by building resilience and establishing supportive environments.

Based on this model, Delaware’s approach to preventing behavioral health challenges and outcomes focuses on strategies that target populations with different levels of risk. Specifically, Delaware prevention programs use the Institute of Medicine Model, which classifies preventive interventions according to the targeted population. The IOM population classifications are:

• Universal: The general public or a whole population group that has not been identified on the basis of individual risk

• Selective: Individuals or a subgroup of the population whose risk of developing a disorder is significantly higher than average

2 The Institute of Medicine’s Continuum of Care

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• Indicated: Individuals in high-risk environments who have minimal but detectable signs or symptoms foreshadowing disorder or have biological markers indicating predispositions for the disorder but do not yet meet diagnostic levels

This plan adapts and builds upon Delaware’s previous prevention strategic plan, published in 2010, and refines strategies implemented in several grant programs, specifically the SUPTRS Block

Grant administered by SAMHSA's Center for Substance Abuse Treatment’s (CSAT) State

Systems Partnership Branch (SSPB), in collaboration with the Center for Substance Abuse

Prevention’s (CSAP) Division of Primary Prevention (DPP), which provides the backbone for

Delaware’s prevention and treatment infrastructure, and SAMHSA’s Strategic Prevention

Framework. Additionally, this strategy will provide a strategic vision for Delaware efforts and funding, with the goal of intentionally aligning current and future prevention activities.

Increasing Protective Factors and Reducing Risk Factors

Although behavioral health challenges can vary substantially from mental health conditions and substance use, research demonstrates that some common elements are effective in preventing or mitigating the effects of these issues. Researchers and health advocates have identified several risk and protective factors associated with substance use, many of which develop during childhood.

Understanding and identifying these factors is essential for effective prevention, as it enables the early implementation of interventions that can significantly decrease the chances of substance use in the future. In the absence of protective factors, certain conditions, experiences, and societal factors can combine to put individuals and communities at increased risk for behavioral challenges, including but not limited to behavioral health concerns. 3

These risk factors include:

• Genetic predisposition

• Child abuse

• Trauma

• Familial substance abuse

• Norms favorable to drug and alcohol use, including substance-abusing peers

• Social isolation or alienation

• Lack of employment opportunities

• Prenatal exposure

Overarchingly, prevention efforts enhance protective factors and reduce risk factors at the individual, relationship, community, and societal levels. These efforts must be comprehensive and complementary rather than conducted in isolation. In other words, interventions at each of these levels are necessary, but insufficient when undertaken in isolation. 4

For optimal behavioral health, protective factors include:

3 Smith, J., & Johnson, M. (2023). Understanding risk and protective factors for substance use. Journal of

Behavioral Health, 10(2), 45-58. https://doi.org/xxxxxx 4 Smith, J., & Johnson, M. (2023). Understanding risk and protective factors for substance use. Journal of

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• Positive Social Connections: This includes prevention efforts aimed at building strong relationships with family, friends, and community members who can provide emotional support and reduce feelings of isolation.

• Healthy Social and Emotional Skills: This includes providing skills-based education on prevention efforts to develop skills such as empathy, emotional regulation, and effective communication, which can enhance resilience and coping mechanisms.

• Engagement in School and Community Activities: This includes fostering communities and schools that encourage and promote participation in educational and community-based programs. These programs can foster a sense of purpose and belonging, contributing to positive mental health outcomes.

• Access to Mental Health Care: This includes addressing community needs and enhancing access to and awareness of mental health services and support systems that can aid in early identification and treatment of mental health issues, promoting recovery and well-being.

Connectedness to and positive relationships with individuals, family, friends, community, and social institutions.

Delaware Prevention Approaches and Strategies

Mental health and substance use are intricately connected, with overlapping and interacting risk and protective factors for both. In addition, some mental health conditions, such as anxiety and depression, can predispose individuals to substance use. Likewise, substance use can exacerbate mental health conditions; for example, substance use can increase the risk of suicide. As such, prevention efforts must also include a range of complementary and comprehensive approaches.5

Efforts should include systems-level interventions that reduce and mitigate the risks of negative environmental exposures or experiences, which occur across all communities and affect all ages and settings where citizens live, learn, work, and access healthcare. Systems practices, such as having a prepared workforce and support system for individuals, can create more connected and resilient communities.

SAMHSA describes six broad categories of effective substance use prevention strategies that target whole communities, families, and individuals and can be interpreted more broadly to encompass most efforts to enhance relationships, individual development, and community resilience:6 Delaware uses and builds upon these six broad categories in their behavioral health strategies for all ages, where citizens live, learn, work, and access health care.

• Information dissemination provides knowledge and increases awareness of the nature and extent of alcohol and other drug use, use, and addiction, as well as their effects on individuals, families, and communities. It also provides knowledge and increases awareness of available prevention and treatment programs and services. It is characterized by one-way communication from the information source to the audience, with limited contact between the two.

5 Smith, J., & Johnson, M. (2023). Understanding risk and protective factors for substance use. Journal of

6 Substance Abuse and Mental Health Administration. Focus on Prevention. HHS Publication No. (SMA) 10–4120.

Rockville, MD: Center for Substance Abuse Prevention, Substance Abuse and Mental Health Services

Administration, Revised 2017. Available at: https://store.samhsa.gov/system/files/sma10-4120.pdf. Accessed

January 3, 2019.

https://store.samhsa.gov/system/files/sma10-4120.pdf

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• Education builds skills through structured learning processes. Critical life and social skills include decision making, peer resistance, coping with stress, problem solving, interpersonal communication, and systematic and judgmental capabilities. There is more interaction between facilitators and participants than there is for information dissemination, including evidence-informed and evidence-based programs.

• Alternatives provide opportunities for target populations to participate in activities that exclude alcohol and other drugs. The purpose is to discourage the use of alcohol and other drugs by providing alternative, healthy activities.

• Problem Identification and Referral aims to identify individuals who have indulged in illegal or age-inappropriate use of tobacco or alcohol and individuals who have indulged in the first use of illicit drugs. The goal is to assess if their behavior can be reversed through education. This strategy does not include any activity designed to determine if a person needs treatment.

• Community-based Process provides ongoing networking activities and technical assistance to community groups or agencies. It encompasses neighborhood-based, grassroots empowerment models using action planning and collaborative systems planning.

• Environmental establishes or changes written and unwritten community standards, codes, and attitudes. It intends to influence the general population's use of alcohol and other drugs.

Prevention Along the Continuum

Although this strategic vision will primarily focus on enhancing protective factors and avoiding the adoption of risk behaviors, Delaware views prevention as a continuum; even if individuals or populations have engaged in risky behaviors or have been diagnosed with a mental health condition and/or substance use disorder. While Delaware supports an upstream approach through primary prevention efforts, the state increasingly recognizes the importance of a comprehensive approach to behavioral health, including the implementation of secondary and tertiary prevention strategies. These strategies focus on early intervention to reduce the severity and impact of mental health and substance use disorders, and to manage the impact of chronic behavioral health conditions, aiming to prevent worsening outcomes and improve the quality of life for individuals already experiencing significant mental health conditions or substance use disorders.

Coordination and Strategic Vision

In late 2023, to address the state's fragmented prevention infrastructure and service delivery drift, resources were used from DSAMH’s Substance Use Prevention, Treatment, and Recovery

Services Block Grant to leverage the State Epidemiological Outcomes Workgroup (SEOW) to conduct a State Prevention Portfolio to explore the current landscape of prevention in Delaware.

The assessment included a community provider survey and content areas included communities served, services provided, and access to resources. Findings from this assessment described four main themes: financial resources, geographic area served, description of prevention services, and community perceptions of risk.

Participants indicated that most prevention efforts are focused on community information dissemination, community outreach, social activities, evidence-based prevention education in K-

12 schools, and youth-focused programming. The majority (64%) reported state funding was their foremost financial resource, and individual youth-focused programming was the most financially supported. Respondents also indicated a need for training on applied skills, data collection, and

Page 8 of 23 April 2025 advanced community engagement. Many providers reported facing challenges with maintaining communication and collaboration due to limited access to digital tools and platforms. While some agencies successfully adapted to remote work and virtual service delivery, others struggled with technological barriers, impacting their ability to maintain strong relationships with stakeholders, share data, and coordinate services effectively. 7

Concurrently, a cross-sector body of stakeholders began to convene the AAC Prevention

Subcommittee housed under the Addiction Action Committee (16 DE Code § 5198). The

Addiction Action Committee (AAC) is a legislative committee charged with developing and monitoring a coordinated and comprehensive approach to Delaware’s addiction epidemic. The

Prevention Subcommittee is co-chaired by DSAMH’s Prevention Coordinator (NPN).

Subcommittee members include the Division of Prevention and Behavioral Health, the Department of Education, the SEOW, DSAMH’s State Opioid Response Team, recipients of Drug-Free

Community Coalitions, SPF-PFS recipients, and other community-based prevention advocates.

The 2024 goals of the AAC Prevention Subcommittee were to:

• Provide input on the development of the Statewide Behavioral Health Prevention Strategy and Plan

• Assess the State's SUD Prevention Profile

• Enhance capacity and infrastructure across state SUD Prevention Partners

The AAC Prevention Subcommittee was charged with providing input for DSAMH’s Behavioral

Health Prevention Strategy and Plan. The AAC Prevention Subcommittee assessed the prevention landscape in Delaware and identified the following objectives: Increase protective factors through education, and development for individuals, families, and communities with evidence-informed prevention and early intervention strategies to prevent adverse outcomes of behavioral health challenges, the use and misuse of drugs, and the development of substance use disorders; increase the capacity to implement, data-driven decision-making; support educational institutions (K-12 and higher education) to increase their capacity to implement and deliver effective prevention programs and strategies focused on risk and protective factors; and increase the capacity of the prevention workforce to plan, implement, deliver, and evaluate quality prevention services to individuals, families, and communities.

This prevention strategy builds upon and provides a structure for other efforts in the state by aligning goals and objectives, providing a theoretical basis for current and future funding, and streamlining behavioral health-related prevention efforts and recommendations included in other state initiatives, such as:

• The Behavioral Health Consortium’s Three-Year Action Plan

• 2022 Division of Substance Abuse and Mental Health, Delaware’s Substance Use

Treatment System Needs Report

• Senate Committee Resolution 69 Task Force focused on expanding the health education curriculum

7 DSAMH internal reports and publications

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• 2024 Division of Prevention and Behavioral Health Services, Substance Use Treatment

System: Current state and recommendations for meeting the needs of Delaware’s youth with substance use challenges

• 2024 Department of Education Drug and Alcohol Education Curriculum Report

This prevention strategy will also encapsulate, streamline, and institutionalize prevention-related goals and objectives from different funded initiatives to ensure that all future efforts seek to address similar or identical prevention outcomes and use common metrics and indicators to define success.

These include:

• Substance Use Prevention, Treatment, and Recovery Services Block Grant

• Strategic Prevention Framework-Prescription Drugs (SPF-Rx)

• State Opioid Response

• Delaware Department of Education’s efforts related to the Behavioral Health Multi-Tier

System of Support

• Division of Public Health efforts

• Healthy Communities Delaware

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Section III: Delaware Behavioral Health Prevention Strategy and Plan

Understanding Delaware’s Behavioral Health System and Challenges

Introduction

Delaware, like most states, is witnessing an increase in the incidence and prevalence of substance abuse and its negative, often life-altering, impact on its residents. These increases come after a decade of major declines in tobacco use and modest declines in other substance use in Delaware.

The data is an indication of the need for renewed prevention efforts in the state. Although small in geographic size, the need for a comprehensive, statewide, formalized, and sustainable substance abuse prevention system across the lifespan is critical.

Assessing the Problem

As part of the SPF-PFS process with funding from SAMHSA, DSAMH provides funding to the

Center on Drug and Health Studies at the University of Delaware to convene statewide stakeholders in a Statewide Epidemiological Workgroup (SEOW). The SEOW collects and analyzes data on substance use, associated behaviors, and their consequences to establish and monitor indicators related to substance abuse prevention. The SEOW’s goals are to:

• To build monitoring and surveillance systems to identify, analyze, and profile data from state and local sources.

• To provide current benchmarks, trends, and patterns of substance consumption and its consequences.

• To create data-guided products that inform prevention planning and policies.

• To train agencies and communities in understanding, using, and presenting data to effectively support prevention efforts.

The SEOW facilitator team publishes an annual profile that highlights the most recently available data and features special topics, such as populations that experience disproportionate risk for substance use or related behaviors. The most recent edition, the 2024 Delaware Epidemiological

Profile, is available along with all SEOW data products, from the Center for Drug and Health

Studies Epidemiological Reports and Products web page. The publication draws upon data from over 30 data sources. The team also produces an executive summary, slides, and infographics of key findings for each module of the annual profile, all downloadable and for public use to support grant applications, planning, training, outreach, evaluation, and other aspects of treatment and prevention programming throughout the state.

The following are among the data sources monitored to identify priorities for and to track goals and objectives of, the state’s behavioral health prevention strategy, including but not limited to:

• College Risk Behaviors Survey is an annual survey administered during the spring semester to a random sample of full-time, undergraduate, University of Delaware and

Wesley College Students.

• Delaware School Survey is an annual survey of 5th, 8th, and 11th grade public school students in Delaware.

• Youth Risk Behavior Survey is a biannual survey of youth in public high schools. The

Youth Risk Behavior Surveillance System measures behaviors that fall into six categories:

1. Behaviors that result in unintentional injuries and violence

2. Tobacco use

3. Alcohol and other drug use

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4. Sexual behaviors that result in HIV infection, other sexually transmitted diseases, and unintended pregnancies

5. Dietary behaviors

6. 6. Physical activity

• National Survey on Drug Use and Health provides annual national- and state-level data on tobacco, alcohol, and drug use, mental health, and other health-related issues in the

United States.

• Behavioral Risk Factor Surveillance System (BRFSS) is a system of telephone surveys that collects state data about U.S. residents regarding their health-related risk behaviors, chronic health conditions, and use of preventive services. BRFSS now collects data in all 50 states as well as the District of Columbia and three U.S. territories.

• Youth Tobacco Survey is conducted by Delaware's Tobacco Prevention and Control

Program in public middle and high schools on even-numbered years. The YTS provides data for planning, implementation, and evaluation of effective programs to prevent and reduce tobacco use in Delaware. The survey is administered anonymously to a random sample of students from grades 6-12 in all school districts.

• National Health Interview Survey collects data on a broad range of health topics, such as tracking health status, healthcare access, and progress toward achieving national health objectives, through personal household interviews.

• Kids Count is a national and state-by-state effort by the Annie E. Casey Foundation to track the well-being of children in the United States. Kids County in Delaware is a project of the

Center for Community Research & Service, and is a collaborative effort of over forty organizations to enrich local and state discussion concerning ways to secure better lives for all children by providing policymakers and citizens with benchmarks of child well-being.

• DSAMH and other state agency internal data.

Delaware Background Demographics

Delaware is the second-smallest state in the U.S. For the first time, in July 2021, the estimated population topped 1 million people residing among its three counties, representing a 10% increase in the past decade (U.S. Census Bureau, n.d.). The northern part of the state (New Castle County) is more densely populated than the two southern counties (Kent and Sussex), which are predominantly rural. Although Delaware is a small state, it lacks an equitable distribution of health providers, and all three counties are considered Medically Underserved Areas (MUA) under criteria defined by the Health Resources and Services Administration. All of Delaware’s counties lack sufficient behavioral health service providers. Below are additional details related to

Delaware’s demographics.

One of the smallest and least populated states, Delaware has 1,031,890 residents distributed across three counties, New Castle County (population 575,494), Kent County (population 186,946), and mostly rural Sussex County (population 255,956). The largest city is Wilmington, with a population of 73,881.8 Although Delaware is a small state, it lacks an equitable distribution of health providers. All of Sussex County is considered a MUA under criteria defined by the Health

Resources and Services Administration, while New Castle and Kent are considered under the

8 Delaware Population Consortium, Population Projection Series, 2024 https://www.aecf.org/

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Governor’s Exception rule.9 Delaware counties lack sufficient behavioral health service providers around the state.

Delaware’s population is predominantly White (67.6%), followed by Black/African American

(24.1%), Asian (4.4%), American Indian and Alaska Native (0.7%), Native Hawaiian or other

Pacific Islander (0.1%), and two or more races (3.1%). 10.3% reported Hispanic/Latino origin.

Sussex County has a growing Latino and Haitian Creole population, where agricultural and service industries drive demographic shifts. 14.8% of Delaware residents speak languages other than

English at home, with the most common languages being Spanish, Chinese, and Haitian Creole.

Delaware’s LGB+ population is 7.5% of adults, higher than the national average of 5.5%. 10

In 2022, there were 211,259 youth living in Delaware under the age of 18. 58.3% of Delaware's youth lived in New Castle County, 20.3% lived in Kent County, and 21.4% lived in Sussex County.

15-17% of Delaware children were living in poverty. Additionally, 19% of children in Delaware from 2019 – 2020 have experienced two or more Adverse Childhood Experiences.

In 2022, the state had a graduation rate of only 86%, and 4% dropped out of school each year.

From 2019 – 2020, 6% of Delaware children had a parent who was ever incarcerated in their lifetime. Economically, in 2023, Delaware had a median household income of around $82,855.

10.5% of the population are persons in poverty. The state’s small size and strategic location along the I-95 corridor contribute to its economic connectivity with neighboring states but also contribute to facilitating the movement of illicit substances, making Delaware particularly vulnerable to drug distribution networks, and accessibility of illicit drugs.11

Table 1: Delaware Demographic Profile

(Source: U.S. Census Bureau QuickFacts: Delaware unless otherwise noted)

Overall population size

Delaware has 1,031,890 total residents, with 575,494 in New Castle

County, 255,956 in Sussex County, and 186,946 in Kent County. All three counties in Delaware are considered a Medically Underserved

Area (MUA, HRSA).

Race/ethnicity Delaware’s population is predominantly White (68%), followed by

23.8% Black/African American, 4.4% Asian, 0.7% American Indian and Alaska Native, 4.9% other race, and 3.0% two or more races.

10.3% reported Hispanic/Latino origin.

LGB+ Delaware’s LGB+ population is 7.5% of adults. This is significantly higher than the national average of 5.5% (UCLA School of Law, Williams Institute. 2023).

9 MUA is determined by HRSA’s criteria, which include have too few primary care providers, high infant mortality, high poverty, or a high elderly population.

10 University of Delaware Center for Community Research and Service, 2023 Kids Count in Delaware Focus on Impact of

COVID-19, 2023

11 United States Census Bureau, Delaware, 2023

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Language 13.9% of Delaware residents speak languages other than English at home, with the most common languages being Spanish, Chinese, and

Haitian-Creole.

Age 5.3% are 0-5; 20.4% are 6-17; 53.5% 18-64 and 20.8% 65 and older.

Socioeconomic

Status

The median household income is $79,325, the per capita income is

$42,180 and the poverty rate is 9.4%.

Without Health

Insurance

6.9% of the population doesn’t have health insurance.

Medicaid

Enrollment

In January 2024, a total of 285,691 individuals in Delaware were enrolled in Medicaid, with 227,140 enrolled in a managed care organization (MCO); 16,080 in an MCO-plus; 42,471 in fee-for-service; and 43,449 disenrolled due to unwinding (Delaware Division of Medicaid and Medical Assistance [DMMA], 2024).

Chronic Conditions Delaware ranks 28th as 11.4% of adults have had three or more of the following chronic health conditions: arthritis, asthma, chronic kidney disease, chronic obstructive pulmonary disease, cardiovascular disease

(heart disease, heart attack or stroke), cancer (excluding non-melanoma skin cancer), depression or diabetes (America’s Health Rankings, United Health Foundation).

Prevalence of Substance Use and Mental Health Behaviors and Conditions

Although small in its geographic size, the need for a comprehensive, statewide, formalized, and sustainable substance use prevention system across the lifespan is critical. Delaware is divided into four sub-state planning areas designated by SAMHSA’s Office of Applied Studies: the city of

Wilmington, the remainder of New Castle County, and Kent and Sussex Counties.

As reported in the Delaware Substance Use Disorder Among Delaware Medicaid Clients: Annual

Prevalence Report 2014-2019, published in February 2022, the trend of Delaware Medicaid clients with any type of SUD is increasing. The statewide prevalence of SUD among Medicaid clients increased steadily from 10.6% to 14.7% from 2014 to 2019. While men had higher rates of SUD overall, the rate of increase among men and women was very similar, with men increasing from

12.6% to 16.0% and women from 9.0% to 13.2%.

With respect to age, SUD prevalence rates were highest (and steadily increasing) among clients aged 30 to 39, 40 to 49, and 50 to 59. While the oldest clients in the analysis (aged 60 or higher) had lower rates than these age groups, rates of SUD were increasing among older adults as well.

Age groups showing a decline in SUD prevalence over the time period examined included 12 to

21‐year‐old clients, and, from 2018 to 2019, a slight decrease among 22 to 29-year-old clients was also observed. It should be noted that the true prevalence rate among clients over the age of 65 may be different from these estimates because Medicaid would not cover most older Delawareans.

To further this effort, the SEOW completed a needs assessment, which, with the support of community stakeholders and additional data and information, will determine state prevention priorities and guide decision-makers in how to allocate resources, develop policies, and implement

Page 14 of 23 April 2025 evidence-based programs and policies designed to reduce risk factors for substance abuse in our state.

The rate of a mental health condition was higher among clients with SUD‐related claims than for the Delaware Medicaid population overall. In 2019, 64.2% of clients with SUD also had at least one diagnosis related to a mental health condition. Anxiety and depression were the most common types of mental health diagnoses among Delaware Medicaid enrollees with SUD. The share of clients with SUD who were diagnosed with anxiety increased from 34.6% in 2016 to nearly 50% in 2019. One in five clients with SUD had diagnoses related to bipolar disorder.

The National Survey of Drug Use and Health (NSDUH) is another source of data on substance use and mental health. According to the most recently available, self-reported NSDUH data, the overall 2022-2023 prevalence estimate for SUD in the past year is 17.88% among Delaware respondents aged 12 and over. Prevalence is highest (28.86%) among the 18-25 year old group.

Findings from the same survey indicate that the overall prevalence of past month alcohol use is

53.10%. More than one in five (22.89%) report binge drinking within the past month, with the highest prevalence among those aged 18-25 (29.53%). Past month illicit drug use (including marijuana) was reported by 16.88% of respondents overall, however, the rate is nearly double

(29.94%) among those aged 18-25. While nearly one in five respondents (19.75%) was classified as needing substance use treatment, only 4.41% reported receiving substance use treatment in the past year.

Additionally, between August 28, 2024, and February 28, 2025, schools reported 261 Class C drug offenses, of which 86.5% (226) were for Marijuana possession, and in total representing 50% of all the total reported school crimes (517) under the School Crimes Statute (14 Del. C. § 4112(c)).

Additionally, between July 10, 2024 and February 28, 2025, Delaware schools reported 1,139 drug offenses under (14 DE Admin. Code 601) of which 71.4% (814) were for tobacco possession and/or use. These offenses represented 14% of the total offenses (7,927) that were reported.12

According to the 2022-2023 NSDUH, more than one in five (21.90%) Delaware adults report having any mental illness, 5.52% serious mental illness, and 7.94% a co-occurring SUD and any mental illness in the past year. The adults aged 18 to 25 had the highest prevalence rates across these three measures. Overall, nearly one in 20 reported that they had serious thoughts of suicide in the past year; the prevalence is highest among the youngest age groups (13.23% among respondents aged 12-17 and 12.47% among those aged 18-25). Collectively, these data suggest the need for early intervention strategies.

Delaware’s small geographic size provides advantages to developing, strengthening, and sustaining coordinated prevention efforts across the state that are relevant to multiple communities and target populations. To better serve Delaware, DSAMH and its state and other partners set out to develop a comprehensive Strategic Plan to address the prevention needs and enhance the state’s prevention infrastructure. To further this effort, the SEOW, with the support of state and community stakeholders, will continue to track data indicators for DSAMH as it allocates resources, develops policies, and implements evidence-based programs designed to reduce risk factors and promote protective factors to improve behavioral health in Delaware.

12 DDOE internal summaries and data

Page 15 of 23 April 2025

Delaware Regulation 551: Comprehensive Health Education Program

Regulation 551 Comprehensive Health Education Programs has specific requirements for drug and alcohol prevention education which include mandatory hours of instruction for each grade.

Regulation 551 also requires schools to select programming that is evidence-based or promising practices when necessary. Regulation 551 is one of the largest education regulations in Delaware, with specific hours for Instruction, as well as hours related to topics/concepts.

In Delaware, Regulation 551, Comprehensive Health Education Programs, details the hours required for Drug and Alcohol Education for each grade.

• K – 4th Grade: 10 hours

• 5th – 12th Grade: 15 hours

There is a lack of consistent community-based approaches to prevention, with a significant disconnect between schools and community settings. The Delaware Department of Education

(DDOE) is responsible for adhering to Regulation 551, Comprehensive Health Education

Programs. Regulation 551 requires mandatory hours of tobacco, alcohol, and substance use education K-12. Oversight for the regulation falls on DDOE’s Health Education Unit, and there is not a sole point person assigned to coordinate prevention education across the 19 districts and 23 charter schools, all of which have local authority to determine curriculum and partnerships with community-based prevention organizations. This has resulted in a significant need to increase the capacity of K-12 to implement coordinated evidence-based prevention strategies between community providers and schools and increase the capacity of health educators to deliver effective prevention programs and strategies focused on risk and protective factors.

Adverse Childhood Experiences

Adverse childhood experiences (ACEs) are traumatic events such as abuse, neglect, homelessness, and living with family members who have severe mental health or substance use problems. Data illustrates the complex relationship between ACEs, trauma, toxic stress, mental health conditions, and substance use disorders. The interaction of these factors has the potential to change an individual’s ability to process and address challenges and stressors, as well as negatively impact long-term health status and outcomes with increased risk for a range of behavioral health conditions and chronic diseases. 13 14 Studies show that individuals with a higher number of ACEs are at more risk for other health conditions including MH, SUD, and Co-Occurring Disorders

(CODs), negative outcomes.

Although different instruments have some variations in which ACE indicators are included, several data sources suggest that rates of ACEs in Delaware are similar to those throughout the U.S. In

2019, the Delaware Division of Public Health first included the optional ACEs module in the

Delaware Behavioral Risk Factor Surveillance System (BRFSS) questionnaire. Findings indicate that approximately two out of three adults have experienced at least one ACE, and 43.3% have experienced two or more. An SEOW meeting highlighted the BRFSS findings: “Notable health outcomes associated with exposure to one or more ACE include: fair or poor health status among female respondents; current depression and current smoking among both female and male

13Relationship of Childhood Abuse and Household Dysfunction to Many of the Leading Causes of Death in Adults.

American Journal of Preventive Medicine. 1998, Volume 14: 245–258.

14 Centers for Disease Control and Prevention. Adverse Childhood Experiences Journal Articles by Topic Area.

Available at: https://www.cdc.gov/violenceprevention/acestudy/journal.html. Accessed December 25, 2018.

Page 16 of 23 April 2025 respondents; and current heavy drinking among male respondents (Hussaini & Delaware Division of Public Health, 2021).”

Delaware youth also experience ACEs at rates similar to youth throughout the country. The

National Survey of Children’s Health (NSCH) provides prevalence rates of childhood health and wellbeing as reported by their parents. According to the 2022-2023 NSCH, 17% of Delaware youth have experienced one, and an additional 15.6% have experienced two or more household-based

ACEs.15 The Delaware School Survey includes questions regarding several ACEs as well as substance use behaviors. According to the 2023 survey, 23% of 8th and 11th graders report having experienced one ACE, 17% experienced two, and 31% experienced three or more. Across both age groups, students who reported exposure to ACEs were more likely to report substance use as well as feelings of anxiety and depression. Higher numbers of ACEs corresponded with higher rates of reported risk behaviors and mental health indicators. For example, 9% of 8th graders who had no exposure to ACEs reported recent feelings of anxiety compared to 21% of students with exposure to one ACE, 29% among students who experienced 2 ACEs, and 42% among 8th graders who experienced 3 or more ACEs. While 1 in 10 11th graders who reported no exposure to ACEs reported past year marijuana use, 20% who experienced 1 ACE reported past year marijuana use, 28% who experienced 2 or more ACEs reported such use, and 39% who experienced 3 or more

ACEs reported such use (Center for Drug and Health Studies, 2024). 16

Special Populations

Delaware’s data show that specific populations are at an increased risk for behavioral health challenges, including increased risk of dangerous substance use, such as binge drinking or prescription drug (opiates) use, suicidal ideation or attempts, and uncontrolled or unmonitored psychiatric conditions such as psychosis. Prevention strategies described in the next sections will address the needs of these target populations using a combination of universal, selective, and indicated approaches.

Adolescents and Young Adults

During adolescence, peer influence becomes more important. Positive peer influences can steer youth away from substance use and provide connections to social groups and engaging activities.

Schools can play an important role by having a positive school climate where students feel recognized and valued while reducing social and other stressors.

Youth often begin experimenting with substances during adolescence, with alcohol being the most commonly used. 10.7% of middle schoolers reported they had used alcohol before age 11 (up from

6.7% in 2021), according to the Delaware 2023 Youth Risk Behavior Survey, while 14.4% of high school students reported they had used alcohol before age 13. 17.9% of middle schoolers reported they ever drank alcohol (up from 15.5% in 2021), while 19.9% of high school students reported

15 The NSCH Household-based ACEs indicator is a composite measure including children who: have a parent or guardian who are divorced or separated, had served time in jail, or who had died; saw or heard parents or adults slap, hit, kick, or punch one another in the home; had lived with someone who was mentally ill, suicidal, or severely depressed; have lived with someone with a problem with alcohol or drugs. Of note, the NSCH does not include questions regarding child abuse or neglect. Additional Delaware data on ACEs and other indicators of child health and wellbeing gathered by the NSCH can be explored using the interactive Data Resource Center for Child &

Adolescent Health: https://www.childhealthdata.or 16 For a more detailed look at the association between ACE exposure and behavioral health, visit the SEOW module, ACEs and Other Trauma, of the 2024 Delaware Epidemiological Profile.

Page 17 of 23 April 2025 using alcohol within 30 days of taking the survey (compared to 20.2% in 2021). 9% of high school students reported binge drinking (had four or more drinks of alcohol in a row if they were female or five or more drinks of alcohol in a row if they were male, within a couple of hours, on at least

1 day during the 30 days before the survey).

When looking at the current use of tobacco products, results from the 2023 YRBS showed that electronic vapor products were the most frequently used tobacco products, with 6.9% of middle school students and 18.3% of high schoolers reporting using vapes within the past 30 days. 14.4% of middle school students reported trying a vape product, while 33.4% of high schoolers reported that they had tried vapes.

The percentages of middle school students who reported currently using prescription pain medicine without a prescription (3.9%) and high school rates of prescription medication use went from 8% in 2021 to 9.8% in 2023. The percentage of middle school students who said they currently use marijuana increased from 1.5% in 2021 to 4.2% in 2023 and from 15.9% to 18.2% for high school students during that same period. Current use of marijuana was higher for male students than female students and higher for Black students than other race and ethnic groups.

Adolescence is also a time of increased mental health concerns, such as depression and anxiety, suicidal ideation, and self-injurious behaviors. According to the 2022-2023 National Survey on

Children’s Health, 30.4% of parents report their child aged 12-17 has a mental, emotional, developmental, or behavioral health problem. The 2023 YRBS indicated that 74.8% of high school students reported they had ever felt sad, empty, hopeless, angry, or anxious. 18.9% of high school students felt sad or hopeless (almost every day for >=2 weeks in a row so that they stopped doing some usual activities, even during the 12 months before the survey), with 9.8% that seriously considered attempting suicide (during the 12 months before the survey). 5.5% reported a suicide attempt within the past 12 months of taking the survey.

Youth…