1116: How “Tabletop in a Box” Helps Communities Respond to Overdose Spikes

JOHN SHEEHAN: 

This is Public Health Review Morning Edition for Thursday, April 30, 2026. I'm John Sheehan with news from the Association of State and Territorial Health Officials.

When overdose cases suddenly spike, every second counts. Today, Jessica Pough, ASTHO's director of overdose preparedness and response, talks about a new tool designed to help communities prepare before crisis hits. The "Overdose Spike Preparedness Exercise: Tabletop in a Box," gives state and local agencies a structured, customizable way to simulate real-world overdose surge scenarios.

JESSICA POUGH:

Yeah, so this is a resource that ASTHO created that is intended to assist state and local jurisdictions in their planning and preparedness for overdose spikes through the implementation of an Overdose Spike Preparedness Exercise. And when we're talking about spikes, we sort of broadly define that as when the total number of suspected overdoses for a defined geographic area exceeds a predetermined threshold for a specific time. And so, these are emergency events. They require a coordinated response among a slew of agencies and partners. And the purpose for the exercise is to be able to practice response scenarios with all of those partners who might be called upon to respond during a real-life spike. And so, this resource is intended to support states and jurisdictions in their planning for that exercise.

SHEEHAN: 

Gotcha, so there's a sudden rise in overdose cases, and what do you do? And could you connect the dots for us, the necessity of looping in so many agencies, so many partners?

POUGH:

Yeah, so during spikes, these are moments when jurisdictions are being asked to respond rather quickly and often, sometimes with incomplete information. And so, at a high level, this resource is really about helping communities practice for those moments. During a spike, teams are being asked to make real time decisions around things like spike detection, messaging to the partners, messaging to the public, and just how to prioritize outreach when resources might be limited. And so, what we've seen is without some sort of formalized, shared structure in place, those decisions can feel a bit fragmented, maybe even overwhelming. And so, a big part of ASTHO's preparedness approach is helping jurisdictions think through those decision points ahead of time and build out a more consistent, intentional approach to response. And so, the exercises are really the mechanism for how that gets tested. It's one thing to outline a process, but actually walking through it helps you be able to see where there's ambiguity, maybe where assumptions don't quite hold up. And so, the "Exercise in a Box" gives jurisdictions a structured way to do that by bringing their partners together to walk through that realistic scenario and really pressure test how they will respond.

SHEEHAN: 

Sure. And could you talk a little bit more about the complexity of such events and why it's so necessary to do that planning well ahead of time?

POUGH:

Yeah. One thing that we hear consistently from states is that the response is only as strong as what's been worked through ahead of time, right? So, during a spike, like I mentioned, things are evolving rather quickly. You might be seeing the increases in overdoses, but in the background, still trying to understand what's driving it, maybe how widespread it is. And that uncertainty can really make it difficult to know when to act or even what actions to take. And so, what the exercise does is it gives teams a chance to be able to work through those gray areas in advance. And so, instead of reactivating in the moment, teams are activated. They already thought through when and how to activate their response. And that really helps partners be able to move with more clarity, more confidence when something real does happen.

SHEEHAN: 

And could you talk out the process of connecting with partners and sort of the process necessary to get everyone on the same page?

POUGH:

Yeah. The partnerships [are] a huge part of this work. Overdose spike, really, overdose spike response really spans multiple sectors. So, you're talking about public health, EMS, health care providers, and systems. So, that includes hospitals and emergency departments. You're talking about behavioral health providers, community-based groups, public safety. I can go on and on. And each of those partners is interacting with the spike in a different way. So, for example, EMS and emergency departments might be the first to actually see an increase in overdoses and flag that something unusual is happening. Public health can then look at that alongside the surveillance data to help confirm whether it's a true spike. And then, at the same time, you've got your ‘boots on the ground’ partners, those community-based organizations, those behavioral health organizations, who might be hearing directly from people about changes in the drug supply or increased risk in a specific area, which is information that may not show up in data right away. So, it's good to have that lens. And then you have partners like public safety and communications teams who are thinking through things like, "Do we issue a public alert? How do we get information out quickly and accurately? And how do we make sure it reaches the right audiences?" And so, the challenge of, really the opportunity is, just bringing those different inputs together to be able to form a shared understanding of what's happening, what actions to take next. And like I said, the exercise creates space for that. It helps partners see how their piece of the pie sort of contributes to the bigger picture and how decisions like where to focus outreach or when to escalate a response are shaped across those sectors.

SHEEHAN: 

Yeah, and of course, there's not one kind of overdose. The exercise includes variations on those scenarios. Can you tell us a little bit more about that?

POUGH:

Right, exactly. So, the scenario and injects are really what makes the exercise feel real. So, you'll start with a situation like an increase in overdoses in a specific area, and then you're able to use injects to actually layer in new information as things might unfold. So, for example, one inject might introduce a new or unfamiliar substance that's being detected in the drug supply. And then that in turn is gonna raise questions and discussion around potency, risk, how quickly that information would be shared with partners and the public when that happens. Another example is that you might shift the context a little bit. So, thinking about rural communities experiencing a spike where there may be fewer services, maybe you have a longer response time, and that's going to change how teams think about outreach and resource deployment. So, the situation keeps evolving, and each inject is sort of designed to add a new layer that participants have to work through. And that really just forces teams to be able to adjust in real time, revisit some of the earlier decision points, rethink some of those assumptions, and figure out what's new, next based on new information. And I think that that's where a lot of the value comes in because it reflects the reality that these situations don't unfold in a straight line. Teams need to be able to adapt as new details emerge.

SHEEHAN: 

And you encourage local agencies to sort of bring their own experience into it because as much as you can sort of prepare a template, you're never going to know the intricacies of a certain community. What kind of differences could we be talking about?

POUGH:

Yeah, that's exactly right. One thing that we were really intentional about is making sure that this isn't one size fits all. So, we didn't want to be too prescriptive with the resource. Spikes can look very different, like you mentioned, depending on the community. It also depends on what jurisdictions want to be better prepared for. So, how that exercise looks will depend on that. And so, for example, you might have one jurisdiction who wants to tailor the exercise around how they detect and validate a spike. And so, that would focus on what data sources they rely on, what thresholds would actually  trigger action. Another might focus more on the communications piece. So, they might be looking to have a conversation around how they're coordinating internal messaging, deciding when to issue a public alert, and how they're ensuring that information is consistent across partners. And then you might see another team sort of customize their exercise based on partner engagement. So, maybe there's a specific local organization that you don't typically work with that you'd like to engage, and want to use the exercise as a way to clarify expectations and rules with them. And so, we just really encourage jurisdictions to adapt based on what they want to get out of it. Also, where they see gaps in their current processes. And again, I think that that level of customization is what makes it meaningful because it's not just a generic scenario. It's something that is intended to reflect their system and actually functions how they want and strengthen it.

SHEEHAN: 

Yeah. And in terms of the resource itself, it includes slides, PDFs, and sort of these downloadable resources. How do agencies put the whole thing together and implement for their own use?

POUGH:

Yeah, so there are a lot of moving pieces, but they are all very practical and intentional. It's designed to walk teams through the full process. So, from planning to follow-up. So, you start with some of those planning tools that you mentioned, the partner list, the agenda, and that's gonna help teams think intentionally about who needs to be in the room or maybe at the virtual table. And so you're looking at, are the right data partners there, or community organizations represented? Maybe we need to invite communication staff involved if messaging is going to come up in the conversation. And then the slide deck and the injects guide the discussion itself. So, those are going to help facilitators actually move the group through those key decision-making points. So, things like, "How are we recognizing this as a spike? Who needs to be notified? What actions should we be prioritizing within the first 24 hours, first 48 hours?" And then comes the action planning template which is really about capturing what comes out of that conversation. So, that might include things like, "Do we need clearer criteria for when to activate a response? Or do we need to strengthen how we're sharing information across partners?" Or maybe there's gaps in who we've engaged as a partner or who we've invited to the table, and that needs to be addressed. So, instead of the exercise being a one-time discussion, it really creates a set of concrete next steps that teams can actually move forward with.

SHEEHAN:

And Jessica, that gets back to the importance of planning, that I think the case you made earlier. How can agencies learn more and who should think about putting this in place?

POUGH:

Yeah, I mean, I'll start with making the case for why folks should be exploring this resource. And that's because it creates space for this kind of thinking, which can be hard to prioritize otherwise. Truth is, a lot of jurisdictions are actively responding to overdoses every day, but they don't always have the opportunity or need to be able to step back with their partners and reflect on how their response functions as a system. So, to answer your second question, who should be exploring the resource? Anyone responding to overdose spikes, anyone coordinating that response. I think I sort of laid out that the onus is on all of these different sectors. They each have a different piece of the pie, a different view, and a different capability in response. But this gives them a way to do that in a structured and practical way. And ultimately, I think it's about being better positioned to respond when something changes, so that teams can move more quickly, make more informed decisions, and actually use their resources in the most effective way possible.

SHEEHAN: 

Well, Jessica Pough, thanks so much.

POUGH:

Thank you.

SHEEHAN: 

Jessica Pough is ASTHO's director of overdose preparedness and response.

Join ASTHO for part two of the ASTHO Policy Institute Lunch and Learn webinar series focused on strengthening public health surveillance and reporting systems through policy work and the implications for STIs and infectious diseases. As part of ASTHO's Policy Institute, this webinar will explore key challenges within current reporting systems, including duplication, interoperability gaps, administrative burden, and how these barriers impact STI data quality, timeliness, and action. Find the link to register in the show notes.

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This has been Public Health Review Morning Edition. I'm John Sheehan for the Association of State and Territorial Health Officials.