Patrick Bordnick, MPH, PhD, Dean and Professor at the Tulane School of Social Work talks about how virtual reality can help with addiction.
Interview conducted by Ivanhoe Broadcast News in September 2018.
Tell me how you got involved in this project?
Dr. Bordnick: It all started back in graduate school when I was involved in a project on my dissertation looking at cocaine and alcohol craving. I remember interviewing a gentleman in a study for cocaine addiction and cocaine craving and getting the initial history and the person had told me they were clean for over ten years. I was fascinated that someone had been clean for ten years and now they were coming into this potential study to understand relapse. I kind of talked a little bit about what have they been doing and what has happened. They reiterated they had been clean for ten years and said one day they were at work and they had a hard time on the job and the next thing you know they found themselves driving into the neighborhood where they used to buy crack cocaine. And I said, well what happened next? And he said I’m sitting now two to three years later in front of you. I became fascinated to understand how do we empower people and someone who’s been clean for ten years or longer and then they relapse all of a sudden? There seems to be a critical piece missing or a skill set that this person doesn’t have and what can we do to help them with that? So that kind of started this project of how do we understand craving and why people relapse. And then what type of tools we can use to empower them to prevent relapse in the future.
Where did you see this project going from there?
Dr. Bordnick: Traditionally, in substance abuse when we want to understand drug craving or relapse, we would bring someone into a traditional clinic or laboratory setting and expose them to pictures of people using, videos or even drug paraphernalia, alcohol and such. We’d find out what was motivating them to use, we’d look at some of their reactivity like their skin conductivity, their breathing, or their heart rate. What we see is when someone is exposed to their drug of choice, their craving increases and the wanting of the drug increases as well as their body reacting in a certain way. I kept thinking about how we were doing this process and something always struck me as missing. And then one day, I was thinking about how we now teach people skills not to use which is called relapse prevention and teaching coping skills. So, we’d bring someone in to a clinical setting and we say okay, let’s pretend we’re in a bar together or we’re in a crack house and I’m your crack dealer, or a bartender or your friend. Then, we’d proceed to teach them assertiveness training, or ways to manage their coping. I kept thinking to myself, is the patient buying this? They’re sitting in a clinic or a lab setting, we’re not in a bar we’re not in a place where they would use cocaine, we’re not providing them the missing link here, we don’t have the context. So I started to think about how do we bring the real world in to the clinical space to better empower patients to teach them skills so when they’re in a real bar or a place where they use cocaine or have smoked cigarettes before that they’re more apt to recall the skills? Could we use videos, could we create a set, maybe a bar in the lab setting or the clinical setting? But it just became too cumbersome to think about how you would do that. I sort of stumbled one day searching for technology and technological ways to do this and I found virtual reality. I saw that it was being used initially to teach people how to overcome fears, or phobias, such as fear of flying, fear of public speaking, and I literally cold-called the company and said, hey I’m doing substance abuse treatment and research, are you interested in maybe looking at how we can use virtual reality to create some of these scenarios in the virtual space? And overwhelmingly they said we’ve been waiting for a call like this for four years.
For that virtual reality setting, does that apply to all different types of addictions or do you have it for alcohol or a particular type of drug, or cigarettes? What type of addiction do you focus on?
Dr. Bordnick: After trying to figure out how we could best do this in a lab, I came across virtual reality technology which was pretty primitive fifteen years ago. It was cumbersome, multiple computers, and had large headsets for people to view the content. We wrote a small grant to study nicotine and smoking in ways to see if virtual reality environments trigger the same craving as bringing someone in to a regular laboratory setting. Subsequently, we did it for alcohol, and there were other folks at that time who did it for cocaine. At the current time, we have environments for most substances and are working on some of the newer substances such as pain killers, or prescription opiates, where people are now misusing or becoming dependent. So, thinking of new scenarios such as a pharmacy, a doctor’s office, or a chronic pain clinic. Well, if we created a virtual party that same part could be used for social settings for smoking, for alcohol, for marijuana, for cocaine, even for heroin. And just changing out some key factors in that party, we can now leverage that particular scenario to teach people skills and empower them to not in that environment with that particular drug of choice.
What type of virtual environments or settings do you create?
Dr. Bordnick: When we think about, from a clinical standpoint or even from a research standpoint, how or why people relapse or create certain drugs of abuse, there’s a lot of common things that we call cues or triggers that may initiate a craving or a relapse episode. It could be a party or even a group hanging out in the front of a building, if you’re a smoker, for example. The environment itself, the people, the sites and smells, and sound all become paired with smoking or the drug administration. We have to think about, how do we now empower each people’s skills so that when they encounter that environment, they are able to manage the thoughts in that environment. How do we teach them to be assertive to refuse that cigarette that was offered? This is where the virtual environments and settings come into play.
How big is the addiction problem in the U.S.?
Dr. Bordnick: Recent data in the past year has come out that more people are dying from substance abuse in this country than are dying by handguns. We’ve not seen that before in this country. What I think people need to understand is substances cycle over time. You saw in the sixties or seventies there was large use of hallucinogenic drugs and in the eighties we had cocaine. But a couple of substances have always been around in the background that we tend not to think about because they are legal. More people have problems with alcohol and cigarettes in this country than most other drugs because it is prevalent. We’re also seeing some statistics come out that are somewhat alarming especially with the opioid crisis. Those of us who have been doing this type of work for years have seen this ongoing problem for a very long time.
Once somebody gets clean, how difficult is the battle for them to not relapse?
Dr. Bordnick: Let’s say you’re a pack a day smoker and there are twenty cigarettes in a pack, and each cigarette you roughly take five drags off of. Each time you take a drag off a cigarette, you’re administering a drug called nicotine. So, in one pack of cigarettes, you have a hundred drug administration’s each day. Now, imagine each day that, that drug administration is paired with something in your environment, an emotional state, or setting, or things that are going on in your job. Then, one day you want to stop. All of those pairing and drug administrations have pretty much become who you are and what you do during your daily life. So, we’re really asking someone to fundamentally change their lifestyle and who they are from being a smoker to being a non-smoker. Essentially we’re asking someone to change a lot of fundamental things about them. People often ask me, what do you know about behavioral change? And I sort of draw upon my own battle with weight all my life. I used to weight two hundred and thirty three pounds. People ask, well how did you do it? I usually pause and say, the hard way in changing my diet and what I eat and exercise. People just sort of walk away dejected like I should have some miracle cure or a pill or something like that. But it’s really a more fundamental thing. Every day is a challenge for me, it’s not as hard as it was twenty years ago but I had to really change my relationship with food and what it meant for me and how I was using food in the past. We think about substances the same way. If someone is drinking every single day and that is what they do, they seek out alcohol, they use it to change their emotional state, and use it to sort of check out from the stress and anxiety. How do we have to work with that person to teach them skills not only to overcome seeing the substance but the emotional interaction, or the social interactions with that? How we also deal with some of the other psychological aspects of why they’re using. So the question that always comes up is why virtual reality and what place does it have in substance abuse and providing interventions and treatment and research? I often think about how we do therapy in a clinical setting or even how we study why people relapse to substances. We need to really find a way to bring the real world in to the clinical setting whether we’re trying to understand whether somebody relapses or to teach them skills not to relapse. So the best way we have right now to do that is using virtual reality.
How does a therapist do that?
Dr. Bordnick: So the way the technology is used is a therapist would have at their disposal on a smart phone or a self-contained virtual reality device in their office a series of scenarios; a bar, a place where someone would use cocaine, a restaurant, or a party scenario. This is traditional evidence-based cognitive behavioral and relapse-prevention therapy. But, you’re replacing the role play with the virtual reality. So, the therapist can accompany you while you’re in a bar or a party setting and teach you skills in that therapy session, in that realistic setting, which then better empowers you when you’re in the settings in the real world to practice those coping skills and to lead to long-term sobriety. One of the studies we did early on a few years ago was with smokers. We had two groups of smokers, and both were receiving nicotine patches. One group got traditional therapy, which is meeting with a clinician once a week and talking about the dangers of smoking and why you shouldn’t smoke. The other group got virtual reality based coping skills therapy. They were put in relapse situations, a bar, a party, being home alone, a restaurant and were taught skills. What we saw six months post-treatment is the group that got the virtual reality skills training actually felt more empowered to refuse or not smoke in these high-risk situations and were actually smoking less than the other group. This gives us that initial evidence that virtual reality can provide exposure to these situations in a safe clinical setting and empower more people for long-term change toward sobriety.
You mentioned during the study the way you measure, or self-report, patients and how they felt and how much they were smoking during that time. Can you elaborate?
Dr. Bordnick: So when we look at relapse or why somebody relapses, not only do we want to understand what’s happening right before they relapse, we want to know what’s going on when they enter a high-risk situation. So, we would ask a self-reporting craving on a scale from zero to one hundred. Zero you’re not craving the drug or substance at all, one hundred means you’re ready to relapse. That’s one way to self-report. We also like to look at what is someone’s confidence to resist using in a variety of scenarios. There’s a couple of standardized instruments you can use, like if you’re in a stressful situation at work, what is your ability to not utilize the substance after this stressful situation. We look at various indicators to give us an idea of how well and how prepared that person is to handle these high-risk situations when they leave the clinical setting. Most importantly, I think that’s the thing we need to figure out with the technology going forward. The most vulnerable time for somebody is when they leave the clinical setting. When you’re working with your therapist, you feel empowered; you come out of the session ready to take on the world. But then you may not be seeing that clinician, you might not see them for another week. How do we prepare someone for their daily lives and to practice to not relapse? With virtual reality, the hope is that you can practice these skills with a therapist and then also be able to take home a virtual reality headset and re-practice these skills over and over in these environments so they become almost second nature.
Is this something that therapists could apply now or is this something in the works?
Dr. Bordnick: After years of doing virtual reality research it became clear that there was a difficulty in translating this technology to a clinical setting. Most of the equipment in university labs run anywhere from sixty thousand dollars to over a ½ million dollars, which is not very practical. The goal of my research has always been how do we get this in the hands of clinicians and patients to empower them in a clinical setting, and how do you make it easy to use? What we are developing in the next six to twelve months are applications that will run on a self-contained virtual reality headset that operates on Wi-Fi with a tablet, probably under three hundred dollars and you’ll have a variety of scenarios that the therapist and patient can then use to empower them for change in the real world. The biggest thing is trying to figure out how to make it as user-friendly as possible so it’s not difficult to launch or utilize. I think we’re just about there and in the process of developing all the environments. Even looking at the next generation of environments where people are using opiates and prescription opiates. So, we’re really trying to empower people for social change. Not only to teach the skills not to use but also to have these conversations with their clinicians as well as their families.
What other work has come out of this particular research?
Dr. Bordnick: When I utilize technology, I often like to think about what is the scale ability and how can we use this for other situations and other clinical teaching applications or potential people. Technology is still expensive in developing apps and things. When we develop them, I like to look at what are as many uses as we can get out of a particular environment. And, an interesting thing happened a few years ago in my lab. I have a twelve-year-old daughter who has autism spectrum disorder and she was in my lab one day after school and asked to try the VR She was in an environment where people were drinking bottled water and sodas. As I was watching her, she was going up to people in crowds and approaching them. Something she doesn’t do in the real world. And literally, it was one of those light bulb moments, but I was like, wow, I wonder if we could develop environments to teach my daughter, let’s say a virtual classroom or playground, to teach her social skills to improve her quality of life, something that she doesn’t automatically access. How could we literally use this technology to teach her skills? Then, as I thought about it more, how do we teach adults with autism, job-interviewing skills, and social interactions? Again, leaning towards quality of life. As you scale up, you can really think about how do we really leverage technology for teaching people interviewing skills.
Another use case would be to take this technology into the prison system to teach inmates job interviewing skills to prepare for life outside of prison. . Therefore, you can see as we scale things up if we set, the environments right and create the right environments; they can have applicability outside of addiction. We can really scale this up and empower people to have the skills that they need to be successful in life.
END OF INTERVIEW
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