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 is 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 gonna 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 gonna 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 gonna come up in the conversation.

And then the slide deck and the 'injects' guide the discussion itself. So, those are gonna 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.