The Use of Virtual Reality in Craving Assessment and Cue-Exposure Therapy in Substance Use Disorders

Craving is recognized as an important diagnosis criterion for substance use disorders (SUDs) and a predictive factor of relapse. Various methods to study craving exist; however, suppressing craving to successfully promote abstinence remains an unmet clinical need in SUDs. One reason is that social and environmental contexts recalling drug and alcohol consumption in the everyday life of patients suffering from SUDs often initiate craving and provoke relapse. Current behavioral therapies for SUDs use the cue-exposure approach to suppress salience of social and environmental contexts that may induce craving. They facilitate learning and cognitive reinforcement of new behavior and entrain craving suppression in the presence of cues related to drug and alcohol consumption. Unfortunately, craving often overweighs behavioral training especially in real social and environmental contexts with peer pressure encouraging the use of substance, such as parties and bars. In this perspective, virtual reality (VR) is gaining interest in the development of cue-reactivity paradigms and practices new skills in treatment. VR enhances ecological validity of traditional craving-induction measurement. In this review, we discuss results from (1) studies using VR and alternative virtual agents in the induction of craving and (2) studies combining cue-exposure therapy with VR in the promotion of abstinence from drugs and alcohol use. They used virtual environments, displaying alcohol and drugs to SUD patients. Moreover, some environments included avatars. Hence, some studies have focused on the social interactions that are associated with drug-seeking behaviors and peer pressure. Findings indicate that VR can successfully increase craving. Studies combining cue–exposure therapy with virtual environment, however, reported mitigated success so far

Smoking-related cue reactivity in a virtual reality setting: association between craving and EEG measures

BACKGROUND: Cue-reactivity is the array of responses that smokers exhibit when exposed to conditioned and contextual stimuli previously associated to substance use. The difficulty to experimentally recreate the complexity of smokers' spatial experience and context requires more ecological models. Virtual reality (VR) creates a state of immersion close to reality allowing controlled assessments of behavioral responses. To date, no studies investigated brain activation associated to smoking cue-reactivity in VR using electroencephalography (EEG).AIMS: To investigate whether a VR cue-reactivity paradigm (a) may increase smoking craving, (b) is feasible with EEG recording, and (c) induces craving levels associated to EEG desynchronization.METHODS: Smokers (N=20) and non-smokers (N=20) were exposed to neutral and smoking-related VR scenarios, without and with smoking conditioned stimuli, respectively. EEG was recorded from occipital and parietal leads throughout the sessions to assess alpha band desynchronization. Smoking and food craving and presence visual analogue scales (VAS) were assessed during the session.RESULTS: To be smoker, but not non-smoker, significantly influenced smoking craving VAS induced by smoking cue VR but not by neutral VR. No significant food craving changes was observed during the VR sessions. The new finding was that EEG alpha band power in posterior leads was significantly increased by the smoking context scenario only in smokers, and that the degree of smoking (i.e., heavy vs. light) was significantly associated to this neurophysiological measure.CONCLUSIONS: This study demonstrated, for the first time, the feasibility of EEG recording in a VR setting, suggesting that EEG desynchronization may be a neurophysiological marker of smoking cue-reactivity

A validation study to trigger nicotine craving in virtual reality

We built a virtual beer garden that contained various smoking cues (both verbal and non-verbal) using a motion capture system to record the realistic smoking behaviour related animations. Our 3-min long VR experience was optimized for Oculus Quest 2 with the hand tracking function enabled. We conducted a pilot study with 13 non-treatment-seeking nicotine-dependent cigarette smokers. The preliminary results indicate that this VR experience led to high levels of presence, and that there is a significant increase of nicotine craving - but only for those who reported a high level of immersion

Virtual Reality for Neuroarchitecture: Cue Reactivity in Built Spaces

Domestic and urban environments are associated to our life experiences and behaviors. These environments may acquire an emotional and motivational value and, in turn, shape our behaviors. Although there is a well-established knowledge of the effects of built space features on perception, feelings, and affective responses (Ulrich, 1991), only a limited attention has been however paid to physical space-induced motivated behaviors. There is still a strong attitude to consider the control of motivated behaviors as a matter of individual desires, free will, moral choices, executive control, etc.—and not as the interaction between environment and personality, genetics, and brain mechanisms. Recently, there has been a convergent agreement from architects, designers, psychologists, and neuroscientists about the multifactorial nature of the reciprocal interaction between humans and built space, and how it could impact on well-being psychological distress and risky behaviors (Sternberg, 2009). The emerging interdisciplinary field of “neuroarchitecture” developed conceptual paradigms and empirical frameworks based on the interaction between brain and built spaces (see Academy of Neuroscience for Architecture; www.anfarch.org). Within this framework, we would like to propose the “Cue Reactivity” phenomenon as a paradigmatic example of such as interaction. Cue reactivity (C-R) is the adaptive response to salient information in the environment (Niaura et al., 1988). Salient information is that associated to drugs, sex, palatable food, and to a variety of natural and non-natural rewards (such as gambling, shopping, etc.). Drug C-R manifests itself as an array of responses to stimuli previously associated to drug effect. The detrimental consequence of C-R is relapse to drug-seeking and drug-taking (Rohsenow et al., 1991). On the other hand, C-R is an evolutionary phenotype of the interaction with the environment: in fact, spatial context rich of reward-related cues may stimulate both positive and risky motivated behaviors. In this Opinion paper, we will show that identification and design of specific physical space features may affect mental health, and that indoor and furniture of drinking venues are associated to alcohol use. Based on what we know about C-R, and on the effects of built spaces on psychological and behavioral processes, we think that more research is now possible to plan and design research-based “C-R-free situations.” For instance, investigations on outdoor and indoor features associated to C-R may help to develop “motivational safer built environments.” The complexity of real world investigations is not however easily modeled in the laboratory, but technologies like virtual reality may offer the possibility to increase subject's presence in a spatial context simulation and, in the meantime, the control of the experimental parameters (García-Rodríguez et al., 2012). For these reasons, we propose virtual reality as a methodological approach in-between naturalistic and experimental lab setting for a better understanding of built space features affecting C-R.The “5per mille 2012” research grant by the Italian Cancer League (Lega Italiana Lotta per i Tumori, LILT) supported the study (PI: CC) and research grant for GB. LILT also supported CC and SF with educational grants

Virtual Reality-Based Treatment Approaches in the Field of Substance Use Disorders

Purpose: Substance use disorders (SUD) are burdening chronic conditions characterized by high relapse rates despite severe negative consequences. Substance-related cues that elicit craving by means of automatic physiological and behavioural responses have long been suggested to predict relapse. One major mechanism contributing to relapse behaviour are cue-induced behavioural approach tendencies towards the addictive agent. Recently, there has been an emerging interest in virtual reality (VR)-based approaches to assess and modify craving and its related responses. This review aims at elucidating (1) VR techniques applied in the field of SUD, (2) VR as an induction/assessment tool for biopsychological correlates of craving and (3) VR-based therapeutic approaches. Findings: There is an emerging number of studies focusing on different substances of abuse incorporating VR in craving induction/assessment as well as therapy. Despite some limitations as missing of randomized controlled clinical trials with large samples and missing data on the long-term effects of VR treatment, the VR approach showed consistent results in eliciting and reducing craving across different substances. Summary: This review suggests virtual reality as a promising tool for the assessment and treatment of craving among individuals with substance use disorders. Because of its ecological validity, VR unifies the benefits of a laboratory setting with the advantages of a realistic environment. Further studies with large samples and randomized controlled clinical trials using more homogenous VR techniques as well as assessment of objective biophysiological craving markers are required

A virtual reality study on postretrieval extinction of smoking memory reconsolidation in smokers

Exposure to smoking-related stimuli may induce the reconsolidation of smoking-related memories in smokers. Research has proposed that extinction applied after the retrieval of a smoking memory may inhibit reconsolidation and prevent craving. The aim of this study was to test the effect of postretrieval extinction (PRE) on the reconsolidation of smoking memory by using a virtual reality (VR) simulation in smokers. On the day 1 session, the study exposed 46 smokers to a neutral and then to a smoking VR scenario under a fixed-block protocol. On day 2, the study randomized participants into three groups (G) and exposed them to a 15-s VR immersion in smoking (G1, G3) or neutral (G2) scenario for memory retrieval. After 15 min, the study exposed G1 and G2 to a VR PRE during the temporal window of memory vulnerability, whereas the study exposed G3 to extinction immediately after retrieval. On day 3, the study exposed all groups to neutral and smoking scenarios similar to day 1. All groups significantly increased craving for cigarettes after exposure to the smoking scenario on day 1 (p 0.01). On day 3, VR PRE after a 15-second VR smoking memory retrieval was able to inhibit reconsolidation in G1, but not in G3 exposed to PRE before the window of vulnerability, or in G2 not exposed to the smoking memory retrieval. These findings show the superiority of VR PRE after smoking memory retrieval compared to a standard extinction procedure

Peak provoked craving after smoking cessation

Peak provoked craving (PPC) is an alternative approach to cue-induced craving that focuses on the highest craving level experienced during the exposure to drug-related cues. The main objective of this study was to assess the effect of abstinence on PPC in smokers and to determine whether PPC is altered by continuous abstinence. Results showed reductions on PPC levels only 24 hours after achieving abstinence and craving levels remain significantly lower after 7 days of abstinence

Cue Reactivity in Non-Smoking Electronic Cigarette Users

Electronic cigarettes (ECIGs) are among the most popular nicotine products in the United States, particularly among youth and young adults. Many individuals who use ECIGs report an interest in quitting or unsuccessful quit attempts. In addition to nicotine dependence, one factor that may contribute to continued ECIG use is an individual’s response to ECIG-related environmental stimuli, or cues. Existing research demonstrates that exposure to ECIG cues increases craving for ECIGs among cigarette smokers, including those without previous ECIG experience. The purpose of this study was to examine effects of ECIG cue exposure in experienced ECIG users with minimal smoking history, thus eliminating the potential confound of pre-existing nicotine dependence and cue reactivity from cigarettes. Experienced ECIG users (N = 34) who were never established cigarette smokers (≤ 100 cigarettes lifetime) completed two within-subject cue exposure conditions that differed only by pictorial cue type: ECIG or neutral. Participants experienced two bouts of cue exposure per session, completing subjective measures of ECIG craving and mood before and after each bout. After both cue exposures, participants completed hypothetical delay-discounting and behavioral economic tasks. Two different versions of these tasks were completed, with ECIG use quantified in either puffs or minutes of use. Mixed-effects models and paired-samples t-tests assessed effects of cue type on these outcomes. Ratings of desire to vape (Questionnaire on Vaping Urges-Brief Factor 1, ECIG Schuh-Stitzer) increased significantly from pre- to post-cue exposure for ECIG cues relative to neutral cues, p’s \u3c .05. A similar pattern was observed for negative mood (Positive and Negative Affect Schedule), p = .005. ECIG cue exposure did not significantly affect ECIG delay discounting or increase demand for ECIGs, p’s \u3e .05. Results are largely consistent with those reported for cigarette smokers. Findings may inform the regulation of ECIG product advertising, as exposure to ECIG-related cues may promote continued ECIG use