Addressing issues related to addictive behaviors and diagnoses
Virtual reality (VR) is an interactive, computer-generated experience through the use of specialized equipment within a simulated environment where a user has a 360° view and can move around and interact with an artificial world (Slater & Sanchez-Vives, 2016). In VR, a head-mounted device (HMD) delivers two computer-generated images, one for each eye. These images form a stereo pair created through computer coding according to what each eye would see in the three-dimensional (3D) virtual scene. One of the two displays is placed in front of each eye in a frame that captures the position and orientation of the user's head and gaze direction. When the user moves his/her head, information is transmitted to the computer, which recomputes the images and sends the resulting signals to the displays, creating the effect of being in an alternate life-sized environment with a 360°, 3D view (Slater & Sanchez-Vives, 2016). Three-dimensional, tracked hand devices enable users to effect changes within the VR environment, including pointing, picking up, or using tools or objects. The technical goal of VR is to replace real sense perceptions with computer-generated perceptions. VR offers enough cues for the perceptual system to hypothesize, sense, feel, and respond to a simulated environment as it would a real environment (Slater & Sanchez-Vives, 2016).
Several VR systems are available to the public that can include the headset only, or there are more advanced systems that include hand controls and external sensors. Currently, the most advanced systems require the HMD to be tethered by cable to a personal computer (PC). There are advanced specifications for the PC to run these VR systems, including an upgraded graphics card, a fast processor, and the capability to store and process a large amount of data (Greenwald, 2019). Users purchase and download VR applications (apps) in areas such as gaming, music, history, movies, and travel (Oculus, n.d.). Some apps are free, but most require a one-time payment ranging from a few dollars to $30 (Knoop, 2018). Although VR is primarily used for gaming, education, and other forms of entertainment, there are potential uses in mental health treatment, including substance use disorders (SUDs).
Effect of VR on the Brain
The effect of VR on neurobiology and brain functioning is still an emerging field of science. In a recent meta-analysis, researchers were able to find five neuroimaging studies that determined that VR increases activity in the left superior temporal gyrus and right superior frontal gyrus more than exposure to two-dimensional (2D) images (Landowska, Roberts, & Eachus, 2017). In addition, VR was noted to decrease activity in the amygdala (i.e., the brain's fear and anxiety center) and anterior cingulate cortex and increase activity in the lateral prefrontal cortex. The authors concluded that VR is useful in regulating emotion and fear inhibition, including reducing substance use cravings (Landowska et al., 2017).
Many mental health disorders, including anxiety, posttraumatic stress disorder, and SUDs share a component of difficulty or distress in interacting with the environment. VR can help treat these disorders by enabling individuals to experience problematic situations within a virtual world to master new skills to overcome these situations. Simulations in VR can be graded in difficulty and experienced over time to produce changes and improvements (Freeman et al., 2017). In addition, because VR activates brain regions, it has potential use as an alternative to substance use.
VR as a Method to Reduce Cravings
Individuals with SUDs are often triggered by memories and environments related to substance use. These triggers are thought to cause a surge in dopamine, which results in cravings to use (Hone-Blanchet, Wensing, & Fecteau, 2014). VR has been studied to simulate cues, through cue exposure therapy (CET), that lead to cravings that drive substance use (Freeman et al., 2017). During CET, patients are exposed to triggers to use, such as environments that feature substances or people using substances, to condition a response other than using a substance (Hone-Blanchet et al., 2014). In one older study, researchers concluded that VR CET triggered stronger cravings than 2D images (Lee et al., 2003). Participants in another study were exposed to CET through VR and underwent brain imaging before and after each VR treatment. Findings of this study included that there was over-activity in the basal ganglia with CET before VR, and afterwards there was decreased activity in the basal ganglia, suggesting stabilization of the cue response (Son et al., 2015).
VR can also be used to deliver exposure therapy (VRET), in which multiple VR exposures trigger environments for substance use for the purpose of extinction or desensitization of those triggers. Researchers conducted a meta-analysis of studies using VRET for alcohol and nicotine dependence and concluded that there is evidence that VRET is effective in reducing cravings in individuals with alcohol and nicotine use disorders, but that more rigorous studies are needed due to potential methodological and bias issues (Trahan, Maynard, Smith, Farina, & Khoo, 2019).
VR for Stress and Anxiety in Patients with SUDs
Co-occurring mental health disorders, including depression and anxiety, are common in individuals with substance use disorders (National Institute on Drug Abuse [NIDA], 2018a). One strategy to manage stress and other mental health disorders is mindfulness. There are many forms of mindfulness, including meditation focusing on awareness of the moment and emphasizing what one senses and feels without interpretation or judgment. Other forms of mindfulness center on focusing on a word or mantra, breathing methods, and guided imagery, all of which can be used to relax the body and mind and help reduce stress (Mayo Clinic, 2018). Benefits of mindfulness practices include reductions in stress, depression, anxiety, and pain (Goldberg et al., 2018). In addition, mindfulness has been shown to decrease the size and activity of the amygdala and increase activity in the prefrontal cortex, anterior cingulate cortex, and insular cortex (Hatchard et al., 2017). Researchers who conducted a meta-analysis on the effect of mindfulness on SUDs found that mindfulness is effective in reducing the frequency and severity of substance use and decreases cravings and stress (Li, Howard, Garland, McGovern, & Lazar, 2017).
VR has several apps to engage in mindfulness. In these apps, users experience calming environments, either stationary or floating, such as a sandy beach or green forest. In those environments, one can see tree leaves moving and swaying grass and hear sounds of birds or waves. In some apps, one actually sees birds flying or animals roaming (Greener Games, n.d.). These environments can often be manipulated to daytime or nighttime settings or include rain or snow. Some meditation VR apps also include a choice of music or guided meditation on topics such as peace and forgiveness (Guided Meditation VR, n.d.). In one study of the effect of using VR for mindfulness, participants used VR to experience drifting down a river in a calming atmosphere (Navarro-Haro et al., 2017). Afterwards, participants reported significantly less sadness, anger, and anxiety and a greater sense of relaxation. Researchers concluded that there is preliminary evidence of the feasibility and acceptability of using VR to practice mindfulness (Navarro-Haro et al., 2017).
Another method for treating stress and anxiety in patients with SUDs is exposure therapy. Exposure therapy takes place when a safe environment is created to expose patients to situations they want to avoid that lead to anxiety or stress. Exposure to those situations leads to desensitization of the emotional response and reduces fear and avoidance (American Psychological Association, 2019). Findings from an older study showed that patients preferred VR over real-world environments for exposure therapy (Garcia-Palacios, Botella, Hoffman, & Fabregat, 2007). In a recent meta-analysis of 20 VR studies using exposure therapy, researchers concluded that VR was significantly more effective in treating anxiety compared to real-life exposure (Carl et al., 2019). In another study, researchers evaluated mindfulness digital games and apps and determined that, although there is a lack of rigorous scientific evaluation, there is potential due to high accessibility and motivation through design (Sliwinski, Katsikitis, & Jones, 2015).
VR for Pain in Patients with SUDs
Pain is a symptom commonly experienced by patients with SUDs. In addition to pain related to withdrawal symptoms, researchers found that more than 60% of patients experienced chronic pain before or after they developed a SUD (Hser et al., 2017). Numerous studies have indicated that VR is effective for pain management when used for distraction. Researchers conducted a meta-analysis of evidence on VR using data from 14 studies and found that the typical research participant receiving VR distraction benefitted more than approximately 82% of control participants (Kenney & Milling, 2016). Kenney and Milling (2016) concluded that VR distraction is a highly effective pain intervention. In another study, researchers exposed 30 patients with chronic pain to 5 minutes in a VR experience in which they floated through and could interact with different environments, resulting in a 33% reduction in pain (Jones, Moore, & Choo, 2016).
VR for Job Training Skills in Patients with SUDs
Another use of VR for individuals with SUDs is using it as a safe environment to learn new skills. Individuals with SUDs have higher than average unemployment rates (Compton, Gfroerer, Conway, & Finger, 2014). In one small randomized controlled trial, researchers had one group of participants with SUDs complete 10 hours of virtual interviews and compared their employment outcomes with participants with SUDs with traditional job training. Findings from the study showed that participants who used VR to improve job-seeking skills were more likely than controls to attain a competitive position, had greater odds of attaining a competitive position by 6-month follow up compared to controls, and took less time to find a position (Smith et al., 2016).
Emerging Possibilities for VR with Patients with SUDs
Science is still emerging on other uses of VR in individuals with SUDs. Researchers at the University of Houston (2014) developed a VR lab with an adjacent control room where those using VR, including environments created to help individuals who use heroin, can be observed. In the Houston lab, guided by a therapist, patients enter VR environments where they are likely to relapse and can process their cravings and desire to use substances and learn new skills. Research is currently being conducted in that lab to determine the effectiveness of this method.
Researchers at Vanderbilt University are studying the use of VR to introduce new cues to help patients say no to substance use, manage their emotions, and use VR as an alternative to using substances (Wolf, 2018). In their lab, patients experience craving-provoking environments where substances are used to practice refusal skills. A more novel approach they are studying is the use of VR as an alternative to substance use for patients with SUDs when they experience stress, such as in detoxification or when experiencing cravings. Researchers propose that experiencing a drug-free, relaxing yet stimulating abstract universe, such as interacting with colorful, free-floating spheres while listening to uplifting music, can be used to regulate emotions by stimulating the release of neurotransmitters. Preliminary results of this VR strategy found that 29 of 30 patients studied reported that this type of VR use improved their mental outlook (Wolf, 2018). Another similar use of VR that has not yet been studied for use with patients with SUDs is music visualizer apps currently available to the public for VR, in which images, often psychedelic in nature, are generated and synchronized with music. These apps could also be used as alternatives to using substances or to reduce stress through brain activation.
VR for exercise also has potential use with patients with SUDs. Exercise increases dopamine levels and has been shown to have a positive effect on SUD treatment outcomes (Weinstock, Farney, Elrod, Henderson, & Weiss, 2017). Many exercise apps are available in VR, including boxing, dancing, and tennis. There is evidence that using VR for exercise can be an effective strategy to reduce depression and anxiety symptoms (Zeng, Pope, Lee & Gao, 2018). Further research is needed to determine the impact of exercise for use with patients SUDs.
Relapse or exacerbation rates for SUDs continue at 50%, which is similar to other chronic health disorders (NIDA, 2018b). New and novel treatment approaches are needed to help patients with SUDs. VR shows promise as a method to reduce cravings and help individuals say no to substance use in triggering environments. In addition, VR could be used to help treat pain, a common co-occurring symptom in patients with SUDs, to learn new life skills, and for exercise. Because VR activates the brain in ways that are similar to substance use, it is possible that VR could be used as an alternative to substance use. The science and technology of VR is still evolving but shows promise. Challenges and barriers to using VR with patients with SUDs include the cost of the systems, which is still prohibitive for many treatment facilities as well as individuals, and the lack of public availability of apps for use to treat SUDs.
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