The Penn State Center for Security Research and Education (CSRE), in collaboration with Penn State Homeland Security Programs and the Pennsylvania Emergency Management Agency (PEMA), held a tabletop exercise that addressed first-responder and whole-community response and resilience to the ongoing opioid crisis. The exercise, which took place Sept. 24, 2019, at PEMA headquarters in Harrisburg, Pa., also was supported by the Governor’s Office for Homeland Security and the Pennsylvania Department of Health’s Bureau of Public Health Preparedness. The Dickinson School of Law and Immaculata University were academic contributors. This article summarizes the main outcome in the current COVID-19 context.
The Opioid Crisis Emergency Nested in the COVID-19 Pandemic
The exercise and its results and recommendations have gained additional importance in the context of the evolving COVID-19 pandemic. Pennsylvania is among those states that have seen an increased number of opioid-related deaths since the onset of the COVID-19 pandemic, along with ongoing concerns for people struggling with substance abuse issues (see issue brief by the American Medical Association – AMA). Since Pennsylvania’s Public Health Department has no statutory authority to declare a public health emergency, on Jan. 10, 2018, Governor Tom Wolf issued an Opioid Crisis Emergency Proclamation that has since been renewed, by amendments pursuing the related legal provisions in 90-day segments. The global COVID-19 pandemic exacerbated the opioid epidemic as it worsened substance use problems overall, according to the Centers for Disease Control and Prevention (CDC). Before COVID-19, illegal fentanyl, which is a synthetic opioid, was one of the highest mortality factors in those who abused narcotics in the U.S.
Multidisciplinary Tabletop Exercise at the Pennsylvania Emergency Management Agency (PEMA)
In the tabletop exercise, more than 50 experts participated, involving local and state first-responder agencies as well as further whole-community representatives in a discussion about effectuating comprehensive response to overdose incidents. In addition to state and local law enforcement agencies, emergency medical technicians, public health and healthcare professionals, and academia, a particular focus included contributions from non-traditional partners such as faith-based organizations, medical facilities, local businesses, social service agencies such as the American Red Cross, local public transportation departments, faith-based organizations, or area colleges and universities. Particularly in a resilience context, the whole community is an integrated equal partner within a systemic approach as part of the National Preparedness Goal of homeland security. Participants hence were recruited to represent a variety of domains, contexts, and communities.
Pennsylvania’s Opioid Command Center developed a statewide Strategic Plan 2020-2023. This plan is based in part on, and includes some, questions discussed and answers found at the tabletop exercise – for example, the road to long-term recovery.
The exercise was based on a scenario (in a one- to two-year timeframe) that was developed by a mixed multidisciplinary expert group from practice and academia, under the guidance of the Pennsylvania Department of Health’s Bureau of Public Health Preparedness. The scenario envisioned plausible response challenges stemming from a sudden increase in opioid overdoses throughout a weekend, in conjunction with a severe winter weather event. In the COVID-19 era, concurrent disaster emergencies have become an operational planning standard. The tabletop exercise scenario had already included the assumption that the opioid outbreak falls within a meteorological emergency, presenting responders with additional challenges.
The scenario is assumed to affect approximately 150 people and materialize in the lower Susquehanna Valley, a sub-basin that cuts across 10 Pennsylvania counties, over the compressed timeframe of one weekend. The longer scenario description begins with the following core assumptions: The Lower Susquehanna Valley is experiencing a crisis developed from the belief that a new opioid is being exposed to the region known as carfentanyl. Carfentanyl is an opioid roughly 100 times stronger than fentanyl and roughly 1,000 times stronger than heroin. The determination of this exact drug proclaimed as the drug causing the outbreak is unknown, as it has not been analyzed in the laboratory. While first responders are not sure of the drug, a public outbreak has occurred, and administrators must identify how to control the outbreak.
The exercise was run in three modules:
- Module 1: Immediate life sustainment efforts during the weekend (Scenario days 1-2)
- Module 2: Mid-term response efforts within the community (Scenario days 3-14)
- Module 3: Longer-term response efforts within the community (Scenario days 15+)
Selected Main Exercise Results
The Commonwealth of Pennsylvania’s constitution and public health law results in a distributed and dispersed public health administration structure in which coordination is the priority. As well, this requires forward-looking, scenario-based workforce education and training. Several protocols coexist in Pennsylvania for different aspects of opioid emergency response. The scenario should be considered in a broader context and the response is planned to utilize available services that can support coordination of care and management. Practically, a variety of responders will attend all 911 calls as the scenario unfolds. All would contribute supplies, but none would or could act decisively toward unified coordination. Participants highlighted the need to therefore closely practice National Incident Management System (NIMS) principles in situations of new/unforeseen crises as depicted in the exercise scenario, as they guide how personnel work across the whole community in responding to incidents.
At the same time, participants agreed there was no cohesive perspective on the opioid crisis, and first responder cultures and associated worldviews and group perspectives also played a substantial role in evaluating the crisis and pondering response options. The command center approach can help establish a common operational picture. While the structure of the opioid crisis is similar to that of more traditional emergencies, the stress volume on responders will be higher and this may limit the effectiveness of existing preparedness. Towns may even experience a response lag in the first day or two because the overdose increase may not be sufficiently distinguishable for them, and they may require some time to identify the series of events as an unfolding opioid overdose crisis.
In crisis communication, public information officers need to discern what information to disseminate. In an operationally complex crisis, like the one in this scenario, joint statements should be issued as frequently as possible to deliver consensus status updates. Adequate crisis communication will also be a key area to address growing public concerns. It will be essential to address evolving physical and emotional fatigue on the responder side and foresee support from neighboring jurisdictions. The South Central Task Force would be available to help coordinate resources. It will therefore be decisive to have a legal mechanism for sharing resources statewide, including the distribution of medical supplies in the south-central and mountain regions.
Non-traditional partners could assume a variety of roles, already starting at the initial stage of the scenario. Each of them has particular but limited strengths, which will make a comprehensive coordinated approach a necessity. For example, the U.S. Medical Corps (a military branch of commissioned officers responsible for the medical care of active duty, guard, reserve, dependent, veteran, and retired personnel) has the necessary expert workforce; however, they lack the authority to take charge of the situation. Traditional emergency response and public safety agencies can reach out to private partners, yet they will not know exactly whom to contact in this particular situation. Privately owned hospitals are potential partners to stop patient diversion. Some members of the public carry naloxone, an opioid antagonist. It is possible to train them to be a part of the crisis response. Support from non-traditional partners, including relevant schools at academic institutions, will also be needed to ensure the availability of standard mental illness treatment as part of the opioid response.
Operational coordination will include the use of the public transportation system to mobilize patients during a mass-casualty incident, as well as expanding logistics operations to include private-sector assets. Non-traditional partners are further needed to obtain logistics supplies but managing the non-traditional partners can also increase crisis complexity. Participants, though, agreed that it is better to have overlapping efforts than a lack of effort. During COVID-19, we are witnessing those challenges materialize in a different public health preparedness context.
The longer-term impact on responder communities and resilience levels will be difficult to assess in an unprecedented scenario like this. The crisis experience will be traumatic for the community, in particular as resources for long-term intervention will be limited. Actionable resilience will be important to build by generating a culture where neighbors can be immediate first responders as well as actors in extended response and recovery as far as possible. This is also important in the light of the consideration that substantial numbers of professional and volunteer first responders may suffer from psychological conditions that require them to have longer mental health breaks or even undergo treatment. This mirrors currently discussed requirements for an extended sustained response to COVID-19. In addition to hometown security actors such as neighbors, the private sector would play a decisive role in the scenario, as existing employee assistance and counseling programs in the private sector will be important self-help resources, as will similar programs made available to public-sector employers.
The hotwash session at the conclusion of the tabletop exercise emphasized the vitality of horizontal and vertical collaborative efforts within and across the government and broader whole-community agencies involved in preparedness and response. Participants underscored the need for more predictive analytics to anticipate and prepare for overdose incident hotspots. Similarly, they pointed out that the field lacks verified data about Narcan® nasal spray, a naloxone brand that is indicated for emergency treatment because it is known to block the effects of opioids with deployment and usage among the Emergency Medical Services and law enforcement communities. Topics like this constitute areas where research by academic partners can make direct contributions to improve response capabilities. Considering the extended timeframe of the opioid crisis, they also advocated the application of principles of strategic crisis management to the practice of opioid crisis response and resilience, to educating future emergency managers, as well as to related research endeavors. As well, since the opioid crisis is part of the homeland security and public safety domain, it was pointed out that finding a plausible balance between safety, security, and civil liberties is of high relevance in scenario-based response planning to foster resilience.
Penn State: After Action Report: Tabletop Exercise on Opioid Crisis Response and Resilience, 2019, including the exercise manual and full-scale scenario description.
A peer-reviewed research article with the tabletop exercise’s approach, context, findings, and recommendations has been published in April 2021 the Journal of Homeland Security and Emergency Management: Alexander Siedschlag, Tiangeng Lu, Andrea Jerković, and Weston Kensinger: “Opioid Crisis Response and Resilience: Results and Perspectives from a Multi-Agency Tabletop Exercise at the Pennsylvania Emergency Management Agency.”