Virtual reality as a treatment for alcohol use disorder

The abuse of substances is a major, global problem, although it is most
prominent in western, developed countries (WorldHealthOrganisation, 2018). It
is a problem in terms of the huge financial costs due to medical care,
criminality and loss of productivity (see for example: Bouchery et al., 2011).
Moreover, the enormous emotional burden suffered by addicted individuals and
their environment, cannot be expressed financially.

Relapse in substance use is a common problem among alcohol and drug addicts.
Therefore, many researchers have devoted themselves to developing new
interventions to treat addiction problems in order to reduce relapse (Marissen
et al., 2005). Substance abuse disorder (SUD) patients are known to have 50-80%
relapse into substance abuse after a period of abstinence. Craving almost
always precedes a relapse and is therefore seen as an important contributor to
the relapse in previous substance abuse (McKay, 1999).

In recent years, virtual reality (VR) has gained ground within mental health
care research, showing that the treatment of anxiety disorders with VR can be
successful (Freeman et al., 2017). However, whether VR can contribute to the
treatment of SUD is still largely unclear.

Lee et al. (2007) showed that craving decreased after 8 sessions of VR-CET in
which 8 participants were exposed to alcohol related context and cues in VR-CET
scenarios. Lee et al. (2007) therefore suggest that virtual reality may
increase the effectiveness of cue exposure therapy and contribute to a decrease
in craving for alcohol. In addition, they hypothesize that virtual reality may
not only be useful in treating alcohol dependence but can also serve as an
evaluation tool to identify high-risk patients (Lee et al., 2009). In addition,
research by Son et al. (2015) shows that virtual reality treatment in alcohol
addicts after 10 sessions contributes to a slowdown in brain metabolism,
suggesting a decrease in craving for alcohol. However, they conclude that
further studies into this form of therapy (VR CET) and the long-term effects of
this needs to be further investigated. In their systematic review of 8 alcohol
studies with VR Durl et al. (2018) conclude that although VR has shown positive
results in alcohol studies it remains underutilized, among other things because
of the high costs. They also conclude that further longitudinal empirical
research is needed as only one study thus far looked into longitudinal effects.
A meta-analysis (Ghita & Gutierrez-Maldonado, 2018) of thirteen studies in
which virtual reality was used as a diagnostic tool and for treating craving in
people familiar with alcohol abuse shows that virtual reality can be used to
provoke craving and that VR CET can be used to reduce craving.

The main goal of the study is to examine if cue-exposure therapy through
virtual reality (VR CET) can contribute to decreasing subjective craving in
patients who suffer from alcohol use disorder (AUD). Further, the questions
will be addressed whether; 1. VR CET results in a decrease in physiological
craving, 2. To what extent do physiological measurements of craving and
subjective craving correspond 3. And if it results in an increase of
self-efficacy.

Participants will be recruited in the day treatment department for Addiction
and Personality disorders of Antes, located in Rotterdam. They will be
interviewed and asked to fill in questionnaires. During their virtual reality
treatment participants will be monitored physiologically. Records will be kept
of moment of discharge from treatment, as well as the reason for discharge. The
outcomes of routine (drug) urine analyses will be recorded alongside of
self-report on relapse in drug use. Three months after initial assessment,
participants will be interviewed again to investigate the level of experienced
craving in the last month and the use of addictive substances in the last three
months.

During the VR CET participants will receive an hour of VR CET twice a week for
5 subsequent weeks, 10 hours in total. The regular CBT protocol for addiction
care will be used as a guideline, in which the following components will be
addressed: 1. Handling risk situations, 2. Dealing with craving, 3. Refusing
alcohol in social situations. During VR CET these parts will be addressed with
the use of virtual reality to practice these skills in a virtual world.

The participants will be exposed to a relatively new developed virtual reality
cue-exposure treatment (VR CET) in the period after detoxification. Positive
treatment outcomes of virtual reality in the field of anxiety disorders are
known and first results of addiction studies show that AUD patients had a
decreased brain metabolism that implies a regulating effect on the limbic
system and reduces alcohol craving after 10 sessions of virtual reality therapy
(Son et al., 2015). Despite several positive results further research in the
field of virtual reality and substance use disorders is needed, because
treatment through virtual reality is not yet solidly proven to be effective in
the treatment of alcohol use disorders. Therefore, t further research is needed
on VR therapy focused on craving in AUD. During the VR CET patients will be
exposed to alcohol related stimuli. This might cause a (temporary) increase of
craving or in the most adverse situation even increase chances of relapse in
alcohol abuse. However, in case of increased craving participants will be
actively treated with regards to regulating their craving through stimulus
respons prevention techniques. They will be offered the same relapse prevention
as during standard cognitive behavioral treatment, in which attention will be
paid to self-control measures, an emergency plan and insight into the pattern
that precedes relapse.