A Pilot Study of Virtual Reality Cue Exposure and Mindfulness-Based Coping to Decrease Opioid Craving Among Latinx Heroin Users

Background:

Opioid use disorder (OUD) remains a significant public health concern.  OUD presents considerable public health risks such as HIV, Hepatitis C, and overdose. Although medication assisted therapies (MAT) such as methadone and buprenephorine have been proven effective in decreasing substance craving and withdrawal symptoms, these interventions alone do not address the environmental associations and contextual factors that often maintain heroin use and OUD. Mindfulness-based virtual reality-based cue exposure therapy (MBVR-CET) is a novel intervention approach addressing contextually specific craving, a key factor in substance relapse. Through repeated exposure to substance use cues in a safe and controlled environment, craving is elicited. Through repeated exposure, the association between substance cues, craving, and substance use is weakened.  Our intervention approach also incorporated mindfulness-based coping skills to further assist in breaking the associations between mood states, environmental context and craving.

Methods:

For the MBVR-CET feasibility pilot, seven Latinx individuals ages 18-65 reporting current heroin use on multiple days weekly were street recruited to participate in a one session intervention where participants were immersed in a virtual substance use environment.  Using a one arm repeated measures design, participants were repeatedly exposed to heroin use cues designed to elicit heroin craving, then were taught brief mindfulness-based coping skills. For the randomized controlled portion of the study, a target N=50 will be recruited and randomized to MBVR-CET or a relapse prevention video education control condition. While in the virtual environments, participants were assessed for multiple physiological indicators of cue-reactivity. Participants were also asked to self-report their levels of heroin craving at intervals consistent with presentation of substance use cues.  At the end of each session, participants completed standard measures of usability, acceptability, presence, immersion and then engaged in a brief qualitative interview to determine if the substance use environments were contextually appropriate and realistic

Results: 

Exposure to virtual heroin cues was found to elicit high levels of heroin craving in participants when compared to baseline, t (6) = -2.50, p = 047, d = .94. Trends in data for the physiological reactivity measures indicate that repeated exposure to virtual heroin cues, coupled with mindfulness based coping leads to a return to levels of physiological reactivity of seen at baseline. Results of the repeated measures ANOVA further indicate that mindfulness-based coping  was associated with significant decreases in self-reported craving between initial presentation of craving cues and the end of mindfulness-based skill practice, Wilks Lambda = .013,  F (3,18) = 9.40, p = .001, n_p² = .58.  Maulchy’s test x² (5) = 8.50, p = .138 did not indicate any violation of sphericity.

Conclusions and Implications:

Although preliminary, this pilot provides initial data supporting the use of a combined virtual reality cue exposure protocol coupled with mindfulness based coping skills to decrease physiological reactivity and self-reported craving in a sample of Latinx heroin users.  This intervention approach has potential for use in a variety of community-based substance use treatment programs, including residential, outpatient community care and IOPs, as VR technology continues to become more portable and affordable.