By finding ‘bright spots’ in the opioid crisis, VCU researchers are mapping a path to better outcomes

By Christopher Richmond

Fatal drug overdoses have been Virginia's leading cause of unnatural death since 2013, and researchers from Virginia Commonwealth University and the Virginia Department of Health say more than five Virginians die every day from an opioid drug overdose. Behind the statistics are parents, children and neighbors lost to the opioid crisis - a human tragedy felt in every zip code, leaving a wake of grief that no ledger can truly capture.

While the headlines often focus on the areas hit hardest, researchers are now looking in a new direction: toward the communities that are beating the odds.

Leading this search is Jacqueline Britz, M.D., an assistant professor in the VCU School of Medicine's Department of Family Medicine and Population Health, a primary care physician on Richmond's Southside, and co-director of the Ambulatory Care Outcomes Research Network, also known as ACORN, a cornerstone of primary care research, policy and practice in Virginia, which includes 526 primary care practices (27% of all primary care practices in the state).

With support from VCU's Wright Center for Clinical and Translational Research, and through her National Institutes of Health K12 Career Development Award through VCU's Building Interdisciplinary Research Careers in Women's Health (BIRCWH) Program, Britz and her team are pioneering a "bright spots" approach to the opioid crisis. Rather than focusing solely on "hot spots" - areas where mortality is highest - her team identifies "positive deviants": communities that are performing significantly better than expected despite facing the same economic and social risk factors as their neighbors.

Identifying success stories in the data

To find these communities, Britz's team utilized a rigorous data-driven methodology. By analyzing the Virginia All-Payer Claims Database - a massive repository of health care utilization and insurance claims data - her team created a statistical model to look beyond simple mortality rates. This effort was led by Roy Sabo, Ph.D., a professor in the Department of Biostatistics in the VCU School of Public Health and a Wright Center lead in charge of the Biostatistics, Epidemiology and Research Design core. The work includes a multidisciplinary team from VCU's School of Public Health including Adam Funk, Darya Niaki, Pharm.D., and Jong Hyung Lee, Ph.D., a senior data analyst in the VCU Department of Family Medicine and Population Health.

"By leveraging the Virginia All-Payer Claims Database and several other data sources, such as the American Community Survey, or Census, we were able to look beyond the raw mortality data to identify communities that were outperforming and underperforming their expected opioid mortality, based on measures we know relevant," Sabo said. "Further, we could look at this comparative performance longitudinally to identify areas that were consistently deviating positively from the norm over several years. This provides our team with those areas most likely to give us potential solutions to opioid abatement that were not found in our model, to help us find something truly novel."

Crucial to translating this data into real-world practice is Alex Krist, M.D., a professor in the Department of Family Medicine and Population Health and the Wright Center's lead for Community Engaged Research. As co-director of ACORN, and a practicing family physician, Krist ensures that research isn't just academic, it's actionable for clinicians on the front lines.

"A major strength of this project is bringing together the translational science, frontline primary care and community voices to identify what's working and move those solutions into action," Krist said.

Understanding how some communities are avoiding the worst of the opioid crisis

The focus on bright spots is rooted in a concept known as "Positive Deviance," a term popularized by Jerry and Monique Sternin. In the 1990s, the Sternins famously used this asset-based model to combat childhood malnutrition in Vietnam by looking for families who, despite living in poverty, had healthy children.

As Britz explained during a recent presentation, the Sternins were given only six months to make a difference. Instead of bringing in outside food, they looked for bright spots within the village.

"They found that some very low-income families with few resources had children who were healthy and well-nourished," Britz said. "They discovered these families were doing things differently - like adding small shrimps and crabs from the rice paddies to the children's food, or feeding them multiple smaller meals throughout the day. By identifying these positive deviants and having them lead workshops to teach their neighbors, solutions were driven by the community."

Britz is now applying this same lens to the opioid crisis, moving from a deficit-based model of "what is wrong" to an inquiry into "what is going right." Her team has a rigorous approach to identifying these bright spots, using a variety of socioecological, workforce and health care delivery measures. This model is informed by community input, engaging community partners across the state to critically review their data.

Once the hard work of identifying these geographic bright spots through data was complete, the real detective work began: digging deep into the community fabric to figure out exactly how these areas were achieving such different results.

"Solutions to many public health challenges already exist within communities," Britz explained during a recent presentation at the Wright Center. "Collaborating with communities to explore the community assets driving positive health outcomes can inform strategies for future impact." By interviewing local leaders and studying their operations, she aims to distill complex local successes into best practices that could be extrapolated and shared across the state.

Building a bridge to other communities

Making these connections is a powerful example of translational research in action.

"Translational research is fundamentally about moving insights gained from research to improving the health of the community more quickly," said F. Gerard Moeller, M.D., director of the Wright Center. "In the context of the opioid crisis, this means finding what is working on the ground and ensuring other communities have the blueprint to replicate it."

To facilitate this, Britz worked with the Wright Center to develop the Virginia Opioid Abatement Toolkit, a first-of-its-kind state-specific project funded by the Virginia Opioid Abatement Authority to develop an evidence-based guide for cities and counties in the use of opioid abatement funds. This public resource has already seen significant engagement, with nearly 3,000 visits and 1,300 active users in Virginia.

A key component of the toolkit work is to provide community support and consultation, including community needs assessments and qualitative research led by Marshall Brooks, Ph.D., and Marie Schoen, from the VCU Department of Family Medicine and Population Health, for communities such as Richmond and Chesterfield. These consultations are key to understanding community context, including community priorities, challenges, as well as solutions. Through partnership with communities, the VCU team provides additional resources and support for communities in implementing programs to reduce opioid mortality.

Tyler Burton, the toolkit manager, brings a unique dual perspective to the project. A former health department opioid response coordinator, Burton's background includes utilizing the Overdose Detection Mapping Application Program -a tool used to reactively map hot spots of overdose activity.

While ODMAP is a critical reactive tool for mapping where the crisis is at its worst, the Bright Spots project is proactive, focusing on where community-led solutions are working. Burton's dual perspective allows her to bridge the gap between knowing where the problem is most urgent and discovering where the answers are already taking root.

Burton emphasizes that while national data exists, it often creates a clutter of information that doesn't apply to the unique legal and social landscape of the state.

"A big goal of ours was to take out all the noise ... and create a one-stop-shop for everything Virginia-specific," she said.

The reach of the toolkit is the result of exhaustive boots-on-the-ground work. Burton and her team have joined over 100 national and community events, attended 67 city and county task force meetings, presented the toolkit and conducted numerous one-on-one consultations with localities.

"We want people to feel like they have a seat at the table, especially those in smaller communities who might not have the same level of resources," Burton said.

Britz's hope for the toolkit is that it becomes a catalyst for real-world change.

"Ideally, my dream is to engage communities that would otherwise not be applying for any opioid abatement funds ... for us to provide them with needs assessments and resources to say, 'Hey, you can do this,'" Britz said.

In quoting Monique Sternin, she said, "Unless you listen, listen, listen, you cannot achieve anything. No one knows better what a community needs than the community itself."

To access the Virginia Opioid Abatement toolkit, visit virginiaopioidtoolkit.org/.

The C. Kenneth and Dianne Wright Center for Clinical and Translational Research at VCU is part of a premier national network of institutions dedicated to accelerating the transformation of scientific discoveries into lifesaving treatments for patients. This research was partially supported by the National Center for Advancing Translational Sciences (UL1TR002001 and UM1TR004360).