Systematic content analysis of patient evaluations of START NOW psychotherapy reveals practical strategies for improving the treatment of opioid use disorder

In the United States, opioid use is pervasive with 10.1 million people (or 3.7% of the population) aged 12 or older in 2019 misusing opioids in the past year [1]. According to data from the 2019 National Survey on Drug Use and Health, access to addiction treatment is limited, and only 18.1% of people aged 12 or older with a past year opioid use disorder (OUD) received medication-assisted treatment (MAT) in the past year for opioid misuse [2]. This is according to the Substance Abuse and Mental Health Services Administration (SAMHSA), which estimates that about 1.6 million people 12 or older qualify for the diagnosis of OUD based on the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition [2].

The treatment of OUD is complicated by the fact that many patients have psychiatric comorbidities, psychosocial challenges such as a history of incarceration, and socioeconomic challenges such as unemployment and homelessness [3‐7]. Moreover, opioid misuse is not only related to other substance use but also associated with increased rates of comorbid depression and anxiety disorders [8‐10]. For example, one study found that 47.1% of individuals with prescription opioid dependence were also diagnosed with comorbid mood or anxiety disorders [10].

Prevalence data from SAMHSA’s 2019 report provides further evidence that substance use is more frequent in adults (> 18 years old) with diagnosed mental illness [2, 11, 12]. Specifically, in the United States, 13.8% with serious mental illness and 8.8% with any mental illness misused opioids in the past year compared to 2.5% in adults without mental illness [2]. Because of these impairing, widespread, and numerous comorbidities, many groups of clinicians have suggested that, at the very least, access to screening and treatment of these comorbidities in individuals with OUD is important for improving overall health and likely opioid treatment success [6, 11, 13]. From our experience and perspective, there is a need for integrated, comprehensive interventions—that take into account all co-existing comorbidities—in order to effectively treat OUD.

In our office-based opioid treatment setting, we propose that medication-assisted treatment should be paired with a more holistic psychotherapy [14]. Therefore, we suggest that such a comprehensive intervention is a modified version of START NOW targeted specifically towards the substance use patient population. START NOW is a skills-based psychotherapy that was originally implemented and studied in the Connecticut Correctional Health Research Program with support from a National Institute of Justice grant (NIJ 2002-IJ-CX-K009) [15].

START NOW is a free, manual-guided skills training psychotherapy that integrates cognitive behavior therapy, motivational interviewing, trauma-informed care, and elements of cognitive neuro-rehabilitation [15]. Entirely available in the public domain, START NOW was originally designed for low-resource settings and as a psychotherapy for incarcerated individuals who present with mood dysregulation, impulsivity, aggression, and interpersonal discord. A retrospective cohort analysis of 850 patients in state prison demonstrated a significantly reduced risk of disciplinary infractions and future psychiatric inpatient days with a dose response effect [16, 17]. Furthermore, START NOW has been associated with reduced risk of criminal recidivism in an evaluation of a specialized alternative-to-incarceration program for individuals with serious mental illness and co-occurring substance use disorder [18].

Our primary research question is: what are patients’ opinions about START NOW therapy and office-based opioid treatment (OBOT)? This article provides a detailed analysis on patient evaluations of START NOW psychotherapy. For this study, START NOW has been modified for the substance use disorder patient population and is currently being studied in a clinical trial for its effectiveness in treating OUD when paired with buprenorphine/naloxone medication-assisted treatment. At our institution (Carilion Clinic, Roanoke, VA) and with the resources available to us, the treatment of opioid use disorder is near-exclusively offered in the form of buprenorphine/naloxone MAT in the setting of outpatient OBOT. Group therapy, along with urine drug screens and buprenorphine/naloxone distribution, occurs once a week for a majority of patients. Therefore, this study seeks to explore how we can maximize the benefit of psychotherapy administered to our patients. Specifically, we plan on using this collected feedback to possibly modify START NOW and improve its delivery so that it is more effective and culturally appropriate for the OUD patient population. In our opinion, MAT OBOT programs may not always be appropriate treatment for every patient; for example, such limitations include but are not limited to variability in effectiveness of psychotherapy administered, patients who may benefit from inpatient treatment rather than outpatient services, and patients who may benefit from more frequent follow-up than weekly sessions [19, 20]. Nonetheless, MAT OBOT programs have been shown to be effective for treating OUD and are deserving of further study [21‐24].

In regards to the START NOW Satisfaction Questionnaire, box-and-whisker plots suggests that participants’ opinions about START NOW improve with increased participation. But due to the small sample size and format of the study, our research lacks statistically significant proof of this trend. The heat-map analysis of SNAP demonstrates several characteristics of our participants but ultimately lacks statistical relevance as it only captures one data point.

Based on some of the qualitative data collected, we believe that our study reveals practical strategies for improving the treatment of OUD, which may be helpful to other clinicians and researchers. This data is ultimately subjective as these are select quotes from audio-transcripts. Our conclusions are summarized in Table 5, which are described again below with additional supporting evidence from other published manuscripts. We categorize our conclusions into three domains: content strategies for new psychotherapies, implementation strategies, and other observations.

With regards to content strategies, analysis of our SNAP data reveals self-reported behavioral tendencies of our participants (Fig. 4). Other researchers have identified behaviors, such as impulsivity and failure to plan for the future, that may be the most pertinent for psychotherapy to target in order to most effectively curb maladaptive behaviors contributory to substance misuse behavior [31, 32]. Comments from the focus groups also suggest that targeting impulsivity and failure to plan for the future is useful (Table 5). Audio-recorded data indicates that patients strongly want psychotherapy vignettes and examples that are culturally-relatable and appropriate (Table 5) [33, 34]. Furthermore, certain topics—self-care skills and building positive relationships—were very favorably received and thus should be emphasized (Table 5) [35].

Unlike previous qualitative evaluations, ours is unique because of START NOW’s inherent emphasis on building skills. We suggest that skill building may be the future with regards to improving psychotherapies. In START NOW, the two most practiced skills are “Focusing” and the “ABC System for Functional Analysis of Behavior,” both of which were favorably reviewed (Table 4). In general, the goal of the focusing exercises is to increase the likelihood that participants are proactive rather than reactive and impulsive. The ABC system provides a systematic method for participants to think about their actions and the consequences, to reduce and eliminate maladaptive behaviors, and to reinforce positive behaviors.

With regards to implementation strategies, patient evaluations suggest that all psychotherapy group leaders should be extremely well trained. Participants strongly preferred lessons to be delivered from experienced clinicians (as opposed to medical residents) (Table 5). Despite this, we believe that this opinion can be eliminated with residents who are well-trained in OUD, START NOW psychotherapy, and MAT OBOT [36]. We recommend intensive training with role-playing as the gold standard for preparing psychotherapy leaders. Due to participant preferences or personal disabilities, writing down responses in the workbooks should be optional (Table 5). We believe that this may enhance overall participation and engagement [33]. Participants strongly preferred having their own START NOW workbook to own, personalize, and take home. Likewise, real life practice exercises (or homework) should be encouraged but not mandatory as patients prefer increased autonomy and a nonjudgmental environment (Table 5) [37].

Other observations and conclusions from our study suggest that initial skepticism towards START NOW improves with subsequent participation with more START NOW sessions (Fig. 2, Table 5). We believe that this is an encouraging finding for other clinicians implementing new psychotherapies, which may be met with initial resistance. Overall, clinicians were viewed very favorably, even during poorly-received psychotherapy sessions, stressing the importance of strong physician-patient relationships (Tables 4 & 5). This underscores the importance of every clinician needing to build rapport and trust with their patients [37]. We believe that this is especially important despite limited time during content-rich psychotherapies such as START NOW. With regards to content delivery, participants preferred to be treated as a more mature audience with content to be delivered in a less pedantic tone (Table 5). We believe that all these recommendations may help START NOW be more accommodating and effective for treating patients with OUD.

As with other qualitative research studies, our data analysis lacks the statistical analysis and rigor expected in quantitative research. Another limitation of our study is the fact that participants completed paper surveys anonymously, and no identifiers were stated during the audio-recorded focus groups; as a result, participant characteristics and opinions cannot be correlated between the paper survey data and the audio-recorded data from the focus groups. Therefore, paper survey data and audio-recorded data is treated independently from one another. The results of SNAP are of limited utility because we only collected SNAP results at a single time point rather than at each group therapy session, for example, which would have allowed us to look at trends.

Future directions include modifying START NOW as described above and improving its delivery. Ultimately, we suggest that there needs to be a randomized controlled trial to evaluate the efficacy of START NOW psychotherapy for treating OUD. Such a study may also attempt to compare START NOW Satisfaction Questionnaire and SNAP results before and after treatment. We hope our experiences and conclusions with implementing a psychotherapy for OUD in low resource settings is useful for other clinicians and researchers trying to do the same.

As described in detail in the previous section, we believe that the results of this study may guide the development and implementation of other forms of psychotherapy to ultimately improve the treatment of opioid use disorder. Our research also allows us to validate most aspects of START NOW psychotherapy modified for treating substance use disorders and revealed areas for improvement. Our study also suggests a favorable outlook of START NOW with increased participation, suggesting that the initial skepticism to this program can be overcome to allow for effective implementation. The fact that START NOW was well-received by participants is encouraging for future clinical trials exploring its effectiveness as a psychotherapy for individuals with opioid use disorder.