A Look at Substance Use Diversion Programs in the Delaware Criminal Justice System Using the Sequential Intercept Model

Abstract

This commentary describes approaches by Delaware health and justice practitioners that divert justice-involved individuals presenting with substance use disorder (SUD) symptoms out of the criminal justice system and enhance connections to treatment and supportive services. It applies the Sequential Intercept Model (SIM) used by the U.S. Substance Abuse and Mental Health Services Administration (SAMHSA) to discern opportunities for intervention at various stages of criminal processing. Examples of deflection/diversion programs at six of the SIM points are presented. Such cross-system collaborations are helping to redefine criminal justice reform and pathways of care after contact with the criminal justice system.

Introduction

Evolving substance use problems in Delaware’s communities are fundamentally transforming criminal justice processing practices in the State. Since 2019, Delaware has consistently ranked among the top five states with the highest drug overdose mortality rates. The State experienced a 69% increase in overdose deaths from 2016 to 2021.¹ Drug poisoning deaths remain high despite declines in fatalities (338 in 2024 versus 527 in 2023) that reflect national patterns.² According to internal drug monitoring data, between 2023 and 2024, Delaware’s fatal drug overdoses fell 36% (527 vs. 338).³ Nonfatal suspected overdose rates have been more stable, impacting 2.7 per 10,000 individuals as of 2022.³ Substance use contributes to disproportionate rates of contact with the criminal justice system. An estimated 9% of people with a substance use disorder (SUD) diagnosis will experience arrest in a given year.⁴ A recent systematic review estimates that 37% of men and 48% of women who entered U.S. jails and prisons met the diagnostic criteria for a drug use disorder.⁵

The Sequential Intercept Model

The Sequential Intercept Model (SIM) is a linear model of movement through the criminal justice system.⁶ It features six “intercepts” of criminal processing called Intercepts 0-5. Individuals may not necessarily engage with every point due to the nature of their justice contact, though, and may cycle through points due to recurrent interactions with law enforcement, courts, probation, or corrections. The overarching goal is deflection, or diversion, of individuals presenting with substance use or mental health disorder symptoms out of the justice system and toward treatment and supportive services in communities. We detail each stage in the following.

• Intercept 0 is the first stage of the SIM, representing community-level interactions before contact with the justice system occurs. It features 911 dispatch, crisis line or crisis intervention team, and law enforcement-based pre-arrest efforts that prioritize treatment or service referral before an arrest can take place.

• Intercept 1 refers to arrest diversion or arrest deflection initiatives. Once police or emergency personnel are deployed, Intercept 1 responses prioritize referrals or hand-offs to community services in lieu of taking an individual into custody, setting formal charges, or placing them into jail until their initial court appearance.

• Intercepts 2 and 3 pertain to detention and court processing decisions. The former determines whether someone should be released to the community and under what conditions, as well as whether they should face criminal charges. An emphasis is placed on diversion to community-based services through coordination by members of the court, clinicians, and social workers soon after booking or shortly before their initial court appearance. The latter characterizes diversion initiatives that occur after someone’s pretrial detention. It likewise includes programs to ensure people have access to appropriate care while waiting in jail for their cases to work their way through the courts or after being sentenced to incarceration following adjudication. Jail/prison health care and access to medication are legally required to ensure people remain in stable health during their stay.

• The last two intercepts characterize the coordination of treatment and care as part of the transitions out of the justice system and into the community. Intercept 4 involves efforts that provide treatment and supportive programming following an individual’s incarceration. Programs help to coordinate care plans, access to recovery programs and medication, and other supports that encourage reintegration into communities after someone has been released from jail or prison. Intercept 5 provides a role for community-based supervision (e.g., probation) that decreases offenses or violations of sentencing conditions that result in jail or prison stays as a consequence.

Examples of SIM Model Intervention in Delaware

Pre-Arrest Diversion at Intercepts 0 and 1

The possibility of intervention before arrest has inspired numerous law enforcement agencies to start unique deflection initiatives. One of the earliest programs in Delaware– Hero Help in New Castle County– represents part of the State’s earliest efforts to address substance use issues through treatment referral amid growing overdose death rates in the 2010s. Developed in 2016, the Hero Help program was designed to give Delaware residents aged 18 and older without convictions or serious offenses or major pending charges the opportunity to receive immediate treatment with a local provider.^7,8 Individuals could enter the program through voluntary self-referrals, in lieu of arrest, or by officer recommendation. With grant support from the University of Baltimore’s Combating Opioid Overdoses through Community-Level Intervention (COOCLI) Initiative, Hero Help hired a full-time civilian coordinator embedded in the police department. This coordinator led efforts to connect participants to direct (i.e., detox) and indirect services (e.g., housing, transportation, mental health) and manage care plans. Likewise, the coordinator actively led outreach campaigns and invited people to the Hero Help program as a follow-up to a non-fatal overdose. Funding from the Bureau of Justice Assistance expanded Hero Help’s team to include a mental health professional, case manager, nurse, and child victim advocate.⁹

The Hero Help program has demonstrable impacts. At the individual level, the addition of a coordinator increased detox completion rates from 56% to 77% and next-level care acceptance rates from 51% to 76%.¹⁰ Arrests decreased, too.¹⁰ At the community level, the program may have contributed to decreases in aggregated overdose rates in the jurisdiction that the New Castle County Division of Police serves. According to a Center for Drug and Health Studies study that compared forecasted and actual overdose rates, the expansion of the Hero Help team led to a decrease of 7.5 nonfatal and 1.85 fatal overdoses per month. Such reductions in overdoses contributed to a cost-savings of $21.5 million per month, based on Centers for Disease Control calculations¹¹ of the costs of Opioid Use Disorder and other health economic data.¹²

Other early intercept interventions have emerged across Delaware. The Angel program in Dover was developed at the same time as Hero Help. Under this initiative, sworn officers and volunteers known as Angels would connect people with SUD to a local treatment provider for intake and clinical evaluation for needs.¹³ At present, the Delaware Comprehensive Opioid, Stimulant, and Substance Abuse (COSSAP) Saving Lives Initiative has multiple models of deflection, with sites in diverse locales, such as New Castle City, Seaford/Laurel, Georgetown, and Newark.

The Division of Substance Abuse and Mental Health (DSAMH) has also embedded behavioral health clinicians and peer support specialists in all Delaware State Police troops statewide.¹⁴ Individuals who have contact with the Delaware State Police due to underlying substance use disorders are offered the opportunity to access behavioral health treatment services in lieu of their criminal charges progressing. Program metrics compiled by DSAMH indicate that9,599 referrals have been made by Delaware State Police to the program since the program’s launch in 2021.Thirty-five percent of these individuals have accepted the program, with 2,201 people accepting the referral to addiction or psychiatric treatment.

SUD Programs in Delaware’s Correctional Institutions at Intercepts 2 through 5

Amid robust early-stage diversion opportunities, efforts to address substance use are also being undertaken towards the later stages of the SIM. As of June 30, 2024, 6% of individuals incarcerated in Delaware’s Level 5 institutions had a lead criminal charge that involved drugs.¹⁵ This finding is based on screenings of all people incarcerated in Delaware, regardless of charge type. The Delaware Department of Correction (DOC) operates nine inpatient SUD programs for its incarcerated populations. As a unified correctional system, DOC operates both jails and prisons for the State. Individuals who are incarcerated before adjudication (i.e., pretrial detention populations) are housed in the same prison facilities, but remain in distinct areas from those who are incarcerated after conviction (i.e., sentenced populations). Sentencing in Delaware is also differentiated by level, with Level 4 being work release/home confinement and Level 5 being incarceration.

Three of DOC’s SUD programs target pretrial populations, allowing people to access therapeutic communities, or specialized housing units focused on group-based healing, while waiting for the resolution of their cases. Its 6 for 1 program was first developed in 2002 for men incarcerated in Howard R. Young Correctional Institution, until it was expanded to include women housed in Baylor Women's Correctional Institution in 2013. The program’s name initially reflected receiving one day of credit time for every six days of therapy, but now encompasses the program operating seven days a week, with six days of therapy and one day of reflection.¹⁶

In 2020, DOC introduced the Road to Recovery (R2R) program for its sentenced populations. R2R is based on the therapeutic community model and incorporates cognitive behavioral therapy into its curriculum. Therapy is group-based. As former DOC Commissioner Claire DeMatteis observed, “it's more of a dormitory-style setting” where R2R participants “have classes together, counseling together, they rec together, and they eat together, and they help one another through the process.”¹⁷ A counselor leads CBT group sessions targeting one’s thinking and ways of changing their thought processes when similar situations arise. The program includes individual counseling sessions, peer-led treatment sessions, self-help groups, and interactive journaling exercises.

R2R features three tracks. Track 1 is a residential program with 30-35 hours weekly for 9 to 12 months for Level 5 and 25-30 hours for 6-9 months at Level 4. Track 2 is an intensive outpatient care program with 9-15 hours weekly for 4 to 6 months at Levels 4 and 5. Track 3 is an outpatient program with 9 hours weekly for 3 to 6 months at Levels 4 and 5. An assessment tool called the Addiction Severity Index (ASI) is used in conjunction with drug screens and multidisciplinary clinical reviews by DOC, helps to determine individual needs as well as placement within R2R. The program permits participants to also take “electives,” addressing trauma, anger management, co-occurring disorders, and relationships.¹⁸ A preliminary report on cognitive behavioral therapy interventions by the Center for Drug and Health Studies suggests that participation in R2R diminishes arrest rates at the 6-month and 1-year marks relative to a control group without programming.¹⁹

Since 2017, DOC has introduced medication-assisted treatment programming for opioid use disorder (MOUD) in its facilities. DOC can continue medications given to individuals in the community prior to their incarceration as well as prescribe medications at intake. Currently, DOC administers daily forms of Methadone and Buprenorphine through a nurse and long-acting injections of Buprenorphine and Naltrexone. Individuals who are identified as having OUD may access medication regardless of their participation in a DOC SUD program. Individuals with OUD in the general population also have the opportunity to engage in one MOUD/SUD group session and a one-on-one mental health session per month.

MAT is a key strategy for reentry as well. Before individuals with OUD are released from prison, plans are developed in the three months before release to continue medication and treatment within the community. Post-release plans depend on the type of medication as well as the needs of the individual. To illustrate, newly released individuals who were prescribed methadone receive a warm handoff to a community provider for an immediate appointment, those prescribed oral Buprenorphine receive a week’s supply before seeing a community provider, and those with long-acting medications receive an injection a month before release. The goal is to provide a continuum of care to prevent recidivism, improve treatment linkage, and encourage successful transitions to the community.

Conclusion

Substance use problems require appropriate care and robust interventions within the criminal justice system. The SIM is a useful framework to locate opportunities where treatment initiation and engagement, service integration and linkages, diversion from jail and prison, and crime prevention can all occur. Examples of SUD-focused programmatic developments in Delaware underscore the importance of justice and health-system collaborations. These partnerships rely on referral networks, case management, therapy, supportive clinicians, and other social services. Criminal justice institutions– police, courts, jails, and prisons– will be differentially positioned to develop SUD responses in their communities, largely due to disparities in resources and available behavioral health services. The task of addressing SUD may feel overwhelming to criminal justice agencies. Still, thriving health and justice partnerships combined with evidence of deflection program effectiveness in Delaware are changing the narrative about what criminal justice reform and the treatment of justice-involved persons presenting with SUD can look like.