Sensory-Rich Technology Helps Substance Users Confront Triggers, Control Cravings

You enter a barren house that harbors a slew of public health hazards. Peeling wallboard and blackish mold taint the bathroom. A young man sits on the dingy floor next to the toilet, smoking crack cocaine.

Your heart races. Your mind becomes fixated on the familiar popping noise of the crack pipe. You feel a powerful urge to use.

At that moment comes a reassuring voice: “You’re doing great, keep going.”

It’s your therapist, guiding you through a virtual crack house that feels remarkably real on your headset. From the safety of the clinic, you move about the 3-D avatars and rate your cravings as they rise and fall. When the urge to use subsides, the therapist plays a novel tone: beep boop boop. beep boop boop. Your brain starts to associate the tone with learning not to use drugs – a reminder that you don’t have to give in to temptation.

More people are facing their fears – and changing deep-rooted behaviors – by engaging with virtual reality environments.

“I think virtual reality may be able to help people get better, faster,” says Zachary Rosenthal, Ph.D., Clinical Director of the Cognitive Behavioral Research & Treatment Program at Duke University.

Rosenthal and his team pioneered the crack house simulation, with technical support from a software company and funding from the National Institute on Drug Abuse.

It’s one of many cyber worlds that could help people improve their mental health and confront such problems as drug and alcohol dependence, crippling phobias and post-traumatic stress disorder (PTSD).

People with a fear of flying, for example, could work through their anxieties on a virtual plane – an idea that’s shown success in clinical trials. A binge drinker might confront cravings at a virtual bar, authentically crafted down to the person’s favorite brand of hard liquor.

Some users get so immersed in the experience, in fact, that they grab at the air for a virtual beer or other computer-generated image. Researchers can even stimulate the senses with “smell machines” that send a whiff of marijuana or cigarette smoke into cyberspace.

“We went to actual crack houses,” Rosenthal says of developing the virtual cocaine intervention. “We wanted to get into the world to see what it actually looked like.” The Duke team sent video footage of North Carolina drug enclaves to its technology partner, Psychology Software Tools, and collaborated on storyboards and 3-D simulations.

The ultimate goal is to help users learn coping skills in a controlled, life-like environment – so they can better transfer those skills to real high-risk situations.

Next Generation Tool to Advance Addiction Care

Despite its ability to mimic daily life, virtual reality does not replace the expertise of a therapist, researchers say. The technology is still being tested with substance users and is seen as a complement to traditional treatments such as cognitive behavioral therapy.

“I believe virtual reality has great potential to help those receiving treatment for substance use disorders,” says Amy Traylor, Ph.D., assistant professor of social work at the University of Alabama, where she operates a virtual reality lab. “While it is not a stand-alone intervention, virtual reality may one day be used be used to enhance current treatments and provide assessment information.”

Rosenthal pairs virtual reality sessions with “extinction reminders” – the unique beep boop boop tones played when drug cravings wane and healthier responses are learned. It’s similar to the famous “Pavlov’s Dogs” experiments in which dogs learned to associate a bell (a neutral stimulus) with food – eventually drooling at the sound of a bell, even when no food was present.

Participants in the crack cocaine trial associated the unique tones – which they received on their cell phones between clinic visits – with the memory of the therapeutic experience. Hearing the tones reminded users that they were able to “ride out” their cravings in the virtual crack house, until the urge to use drugs was gone.

“Virtual reality allows us to train the person’s brain to respond differently,” Rosenthal notes. “The point of our intervention is to elicit cravings and extinguish cravings . . . what we’re finding is that these phone calls do seem to decrease cravings better than control phone calls (with no unique tones).”

A recovering cocaine user who participated in the trial told MTV News: “When I have a craving and I hear the tone, I think to myself, ‘I do not have to do this.’”

Tailored to Your Triggers

One limitation of typical addiction treatment is the clinic’s neutral setting. Clients role play coping skills in an environment that lacks the “cues” to trigger real life cravings – interacting with drinkers at a party, for example, or watching a drug deal unfold at a convenience store.

“There aren’t the sights, sounds and smells present that they associate with use,” says Traylor.

“It’s kind of like practicing a speech in an empty room . . . you can practice and start to feel comfortable and confident in yourself, but once the room fills with people, the environment is changed and that might create a level of anxiety for you that makes you completely forget everything you’ve practiced.”

Since it could be dangerous, impractical and unethical to expose a client to actual drug use, that’s where virtual reality can help, Traylor says.

The patient is transported, in a safe and supervised setting, to realistic scenarios “that may trigger the physical and psychological signs of craving,” she says. “This way, they could actively practice skills to reduce cravings, anxiety, or other unpleasant feelings in the type of environment in which they might be expected to need those skills.”

A major benefit of virtual reality is its vast potential to customize and reproduce addiction cues that have special meaning for the user.

“We tailor each virtual world to that participant’s drug use history,” Rosenthal says. “For example, I remember having a patient who said, ‘I never use in abandoned crack houses, it’s disgusting . . . I typically go to a motel.’ So in our virtual world, we have both a motel and an abandoned crack house.”

Clinicians can also change and layer the intensity of the cues in the virtual space. “For some people, all it takes (to spark a craving) is to see the drug paraphernalia on the kitchen table,” Rosenthal says. At the highest intensity level, virtual avatars might be playing cards and watching television inside an apartment, when a drug dealer knocks on the door and the group begins smoking crack.

“We can tailor the environment to the person to an extent, and we can bring that person to the same environment and reproduce it over and over again, and extinguish the conditioned response (craving) to the same stimuli,” Rosenthal says.

That ability to replicate a high-risk scenario makes virtual reality a helpful assessment tool in addiction treatment, Traylor says.

“Because the virtual reality environments can be the same from one session to another, clinicians can see how their clients’ craving levels change when exposed to the exact same environment,” she notes. “Conducting these assessments also allows clients the opportunity to identify triggers and environments that they had not previously realized were leading them to crave.”

A Learning Curve

Evidence is emerging that shows virtual reality’s promise as a platform for behavior change.

While more controlled studies are needed, the current research indicates the technology is effective in treating social phobias and PTSD. Virtual reality has also been shown to boost confidence for people in recovery from addiction, as they apply coping skills learned in the virtual world to their everyday lives.

Patrick Bordnick, Ph.D., a pioneer in the field (and Traylor’s mentor), conducted research on how virtual reality impacts cravings for alcohol, marijuana and cigarettes. His 10-week study of 46 adult smokers found that rates of smoking and craving for nicotine were “significantly lower” among participants exposed to virtual reality treatment and nicotine replacement therapy (i.e., gum, patches) vs. those who received only nicotine replacement therapy. Self confidence and coping skills were also significantly higher for the virtual reality group.

Bordnick also demonstrated that virtual environments can trigger addiction cravings and increase attention to cues (a pre-requisite for learning to control alcohol and drug cravings).

One study exposed 40 people with alcohol use disorders to virtual reality worlds that contain drinking cues (i.e., a sports bar). Their cravings increased in those settings, and participants said the environments were realistic and compelling. When marijuana users were exposed to virtual settings with drug cues (i.e., a party room where people were smoking marijuana), they experienced “significantly higher” cravings than participants who entered virtual worlds with neutral settings (a digital art gallery with nature videos).

Given the urgency of America’s addiction epidemic – 143 drug overdose deaths occur each day – virtual reality could have a positive impact. But most clinicians are not yet familiar with the technology, and research is lacking on its effectiveness for large groups of people.

“A significant limitation of virtual reality is that it’s complicated technology that has a cost to it and a learning curve,” Rosenthal says. “Counselors across this country may not be ready to begin using virtual reality in their daily practice.”

Rosenthal hopes to publish his virtual crack house study; he says the research shows a small but statistically significant decrease in cocaine cravings among the participants.

“I think virtual environments have enormous potential to be used as a way to know whether someone’s getting better,” he says, “as well as a platform to help people change.”

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