Upstream Solutions

Introduction

Delaware faces urgent and growing challenges in behavioral health, with rising rates of substance use disorders (SUD) and mental health conditions leading to adverse impacts on individuals, families, and communities. These increases come after a decade of major declines in tobacco use and modest declines in other substance use in Delaware. In addition to the public health crisis of COVID-19, the pandemic disrupted social, economic, and healthcare systems, significantly affecting the delivery of services and coordination among providers, particularly in the realm of substance use prevention. According to data collected for the National Survey of Drug Use and Health (NSDUH), SUD affects over 17% of individuals aged 12 and older, with rates nearing 30% among young adults aged 18–25. Nearly one in five adults in Delaware has experienced a mental illness, and almost 18% of youth aged 12–17 have had a major depressive episode.¹

The need for an effective prevention strategy in Delaware is especially urgent given the ongoing opioid epidemic plaguing Delaware families and communities, and the increasing normalization of marijuana use, particularly among youth and young adults, following Delaware’s 2015 decriminalization and 2023 legalization of recreational use for those 21 and older. As marijuana becomes more widely accepted, the perception of risk has declined, with over half of 12th graders in Delaware reporting lifetime marijuana use and 39% of all high school students doing the same.² Early initiation is a strong predictor of long-term substance use problems, and most adults in SUD treatment report beginning use during adolescence, reinforcing the critical importance of targeting youth and young adults with focused prevention strategies.

These realities, combined with national data showing increased co-occurring mental health and substance use disorders underscore the critical role prevention has in implementing a comprehensive approach that recognizes multiple opportunities to address behavioral health problems and highlights the urgency to implement effective, science-based prevention strategies before the behavioral health crisis deepens further.

Prevention Science

Prevention science plays a vital role in addressing the intertwined public health challenges of addiction and mental health. Broadly speaking, prevention science is oriented toward promoting health and well-being. At the forefront of prevention science, practitioners focus on strategies, practices, policies, and programs designed to intervene before a problem or condition emerges or worsens to reduce adverse outcomes. At the core of prevention science, practitioners focus on the development of evidence-based strategies that reduce risk factors and enhance protective factors to improve the health and well-being of individuals, families, and communities, and the promotion of health equity and the reduction of disparities. This approach offers a data-driven, cost-effective framework that proactively fosters resilient individuals, families, and communities before they require intensive treatment.

For the past 50 years, prevention science has drawn from a diverse range of disciplines including the behavioral, social, psychological, and neurosciences. Practitioners are skilled in approaches that support science-based strategies to understand the origins of social problems at the individual, community, and societal levels (e.g., substance use, mental health, juvenile delinquency, criminal behavior, violence, trauma, human trafficking, and poverty).³ By drawing on multiple disciplines, including epidemiology, psychology, sociology, and education, prevention science develops interventions that are targeted, effective, and measurable. Its goal is not only to prevent the onset of mental health challenges and substance use, but to promote the health and resilience of entire populations.

Prevention science fosters social capital and health equity, two essential components for sustainable communities. It focuses on reducing modifiable risk factors and enhancing protective factors across biological, psychological, familial, community, and societal levels. Prevention science uses an upstream approach to addressing problems, which can reduce costs by halting or redirecting collateral consequences of outdated, downstream, reactionary approaches.⁴ Unlike treatment, which often responds to harm after it has occurred, prevention science is proactive, evidence-based, and aimed at sustaining wellness and equity over time. By focusing on the root cause of social problems, prevention science aims to improve the well-being of individuals and communities through approaches that identify risk factors and build resiliency by increasing protective factors, all while continuing to assess and evaluate the efficiency and effectiveness of the programs.

Prevention science is not only morally compelling but fiscally responsible. Evidence shows that every dollar spent on effective prevention yields multiple dollars in societal savings from reduced healthcare costs to decreased criminal justice involvement and increased educational attainment.

Approach to Prevention

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. DSAMH is the lead agency in Delaware and is dedicated to addressing substance use prevention, treatment, and recovery. DSAMH collaborates with other state agencies, schools, community-based organizations, healthcare providers, and other key stakeholders, ensuring that all Delawareans across the lifespan have the opportunity to live healthy, fulfilling lives.

DSAMH has adopted a “No Wrong Door” policy to ensure all individuals, at any time, can access an array of behavioral health services. This policy embeds a philosophy across the agency that emphasizes every staff person within the agency participates in assuring the availability of services for individuals in need. Individuals can contact or go to any of the staff within an agency to find the information, direct service, or referral they need, and be assisted no matter where they enter the system.

Delaware uses SAMHSA’s Strategic Prevention Framework (SPF) as the process and basis for this prevention strategy.⁵ The SPF is based on a comprehensive model for planning, implementation, and evaluation of prevention practices and programs, and outlines five key steps, detailed below, including:

• Assess Needs: Profile population needs, resources, and readiness to address needs and gaps in service delivery.

• Build Capacity: Identify, enhance, or build competency and resources for state and community partners to sufficiently detect and address identified needs.

• Plan: Develop an iterative, responsive, and practical strategic and implementation plan for prevention policies, practices, and programs.

• Implement: Implement evidence-based prevention policies, practices, and programs

• Evaluate: Systematically monitor, assess, and adjust all prevention policies, practices, and programs.

Institute of Medicine’s 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 (IOM) report (figure 1).⁶ This comprehensive approach to behavioral health recognizes the multiple opportunities to address behavioral health problems. 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.

Figure 1.

SAMHSA Behavioral Health Continuum of Care Model

The IOM’s risk-based classification enhances the effectiveness, precision, and scalability of prevention efforts. By applying this framework, DSAMH can strategically allocate resources, match interventions to the appropriate population, and maximize impact by addressing needs at every stage of risk. This model also supports coordination across providers, promotes health equity, and helps ensure that no group, whether at low or high risk, is overlooked.

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 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

• 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

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.

Risk and Protective 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. SAMHSA defines risk factors as the “conditions in people’s lives that make them more or less likely to use alcohol, tobacco, or illicit drugs.”⁷ These factors are characteristics at the biological, psychological, family, community, or cultural level and are associated with a higher likelihood of problem outcomes. These include characteristics such as 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, and prenatal exposure.

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 reduce the likelihood of substance use in the future. In the absence of protective factors, certain conditions, experiences, and societal factors can combine to increase the risk for behavioral challenges in individuals and communities, including but not limited to behavioral health concerns.

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. Characteristic at the biological, psychological, family, or community (including peers and culture) level that is associated with a lower likelihood of problem outcomes or that reduces the negative impact of a risk factor on problem outcomes.

For optimal behavioral health, protective factors include:

• 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.

To achieve effective outcomes in primary prevention, it is critical to understand the risk and protective factors that contribute to local behavioral health challenges. Prevention practitioners do not directly reduce rates of SUD or other behavioral health issues; rather, they influence these outcomes by targeting the underlying factors that drive them. Once a community identifies its priority problem behaviors—such as cannabis use or binge drinking—it must then determine which risk and protective factors most strongly influence those behaviors. With this understanding, communities can select and implement evidence-based programs, policies, and practices designed to address those factors and, in turn, reduce the occurrence of the targeted behaviors.⁷

Delaware’s Behavioral Health Prevention Strategy and Plan

In late 2023, to address the state's fragmented prevention infrastructure and service delivery drift impacted by the increase in the incidence and prevalence of substance abuse and the public health crisis of COVID-19, DSAMH leveraged the State Epidemiological Outcomes Workgroup (SEOW) to produce 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.

Concurrently, a cross-sector body of prevention stakeholders began to convene to develop a coordinated statewide behavioral health prevention strategy. The convoy of stakeholders assessed the state’s prevention landscape and identified the following objectives to serve as the foundation for the 2025 – 2030 Delaware Behavioral Health Prevention Strategy and Plan. These objectives included:

• 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.

Delaware has begun to address these objectives to build a comprehensive, collaborative, data-driven, and sustainable prevention infrastructure, committed to fostering healthy and resilient individuals, families, and communities. This infrastructure is grounded in reducing risk factors, strengthening protective factors, building resilience, and promoting well-being. Since 2023, guided by Prevention Science and the Strategic Prevention Framework, a committee composed of state officials, education and research institutions, and community-based prevention providers has met regularly to develop a multi-faceted approach. Some of the initiatives that have begun including:

• Formalized the role and membership of the Delaware Addiction Action Committee (AAC) Prevention Subcommittee housed as a subcommittee of the AAC (16 DE Code § 5198), which is a legislative committee charged with developing and monitoring a coordinated and comprehensive approach to Delaware’s addiction epidemic. This subcommittee will be charged with ensuring coordination to meeting the objectives of the State Behavioral Health Prevention Strategy and Plan.

• Assessed the prevention landscape in Delaware to develop a comprehensive Statewide Behavioral Health Prevention Strategy and Plan

• Established a plan for a statewide cannabis prevention peer to peer media campaign using the grassroots hashtag #MyReasonWhyDE

• Developed a Statewide Cannabis Prevention Workgroup to align strategies across agencies and providers.

• Supported the restructuring of the Delaware Prevention Partners, a coalition of prevention providers, to build capacity across the prevention workforce through training and collaboration to increase competencies in evidence-based planning, implementation, delivery and evaluation of prevention services.

• Since the restructuring, the DPP has expanded reach and information sharing through a network of over 60 prevention professionals and social media; hosted monthly prevention provider sharing and collaboration sessions; established a quarterly prevention workforce training series, Prevention Professionals Have Power; organized and hosted the largest annual Delaware Prevention Day at Legislative Hall; and hosted Delaware’s largest Community Service and Prevention project, The Party.

• Supported the expanded capacity within the Delaware Department of Education to include a dedicated prevention specialist in each county to coordinate substance use prevention education across public and charter schools and to build partnerships between community providers and coalitions with K-12 schools.

The future and ongoing efforts to addressing the Delaware prevention landscape include:

• Expansion of the integrations of the SEOW with the collection and assessment of substance abuse consumption and consequence patterns at the state and local levels will be conducted and disseminated.

• Increase substance use prevention education efforts in K-12 schools to ensure coordination and efficiency of mandated substance use prevention education under regulation 551 and increase social and emotional learning.

• Provide technical assistance and capacity building across community-based organizations and prevention coalitions.

• Identify strategies and implementation plans to build the capacity across the state to address gaps and needs, and identify training and technical assistance integration for prevention subrecipients, prevention providers, and prevention coalitions

• Establishment of a youth coalition (for young people games 16 –25) to provide youth voice and advocacy to the state’s prevention efforts.

• Continued support for expansion of the DPP through the development of a state technical assistance and training plan, and events to foster collaboration and networking

• The development of a dedicated repository of prevention resources and evidence-based programming on the Help is Here website.

• Increase capacity across the state for the #MyReasonWhyDE peer to peer prevention campaign through a train-the-trainer series in the curriculum.

• Provide ongoing support for secondary, tertiary, and harm reduction prevention efforts to reach those who may need more intense intervention services.

• Expand integration of substance use screening tools in primary health care and community-based settings.

• Monitor and evaluate the effectiveness of programs and services utilizing outcome measures to inform decision-making for prevention services throughout Delaware.

• Ensure cultural competency through all substance abuse prevention programs, policies, and practices to reduce health disparities among diverse populations related to substance abuse.

• Meet regularly with Delaware’s prevention stakeholders/partners through the AAC Prevention Workgroup to develop/monitor the Behavioral Health Prevention Strategy and Plan to ensure the mobilization of community resources and ongoing collaboration, thereby sustaining the desired outcomes of programs, policies, and practices developed through the plan.

Delaware stands at a critical crossroads, where proactive, evidence-based prevention strategies can chart a new course toward healthier individuals, stronger families, and more resilient communities. Guided by prevention science and empowered by cross-sector collaboration, the state is laying a robust foundation to address behavioral health challenges before they take root. As Delaware advances its 2025–2030 Behavioral Health Prevention Strategy and Plan, the commitment to a data-driven, equity-focused, and youth-engaged approach offers more than hope; it offers a blueprint for transformation. By investing in prevention today, Delaware is not only mitigating risk but cultivating a future where well-being is the norm, not the exception.