Alcohol use is common in the United States. The vast majority of adults (84.0%) have drunk alcohol at some point in their lifetime, with most of them (79.5%) reporting having a drink in the last year. Many social events rely on the presence of alcohol, and most attend these events without alcohol disrupting their lives. At the same time, 29.5 million people ages 12 and older (10.6%) met the qualifications for Alcohol Use Disorder (AUD) in the last year.

Although it is often stigmatized, trivialized, or simply forgotten, AUD is a serious disease. It is characterized by the inability to stop or control alcohol use despite negative consequences, from problems at work to poor health. Many factors contribute to a person’s risk for developing AUD. Researchers are actively studying the molecular mechanismsand genetics underlying the progression of AUD, but studies have also linked the disease to behavioral patterns, such as binge drinking as an adolescent, and to traumatic experiences. To provide efficacious treatment solutions, physicians must be able to account for both genetic and environmental risk factors.

The pharmaceutical industry, which has focused on the disease’s molecular mechanisms, has been searching for a one-pill cure-all to end AUD since at least the 1980s. Today, the FDA has approved three medications to treat AUD: Naltrexone, Acamprosate, and Disulfiram. Each one targets a different alcohol mechanism, but none has become the long-sought panacea. Naltrexone is an opioid receptor antagonist, which means that it’s designed to reduce the rewarding effects of alcohol while drinking. Acamprosate, originally proposed to prevent relapse in alcohol-dependent patients, “resets” the balance of brain chemicals that alcohol use disrupts. It appears to suppress a patient’s craving,but it loses its effectiveness if the patient drinks again. Disulfiram, or Antabuse, is most often used as a second-line option to the others because of its extreme side effects. It inhibits aldehyde dehydrogenase, an important enzyme involved in removing alcohol’s toxic byproducts from the body. The resulting buildup leads to a flurry of adverse physical reactions, including, but not limited to, heart palpitations, facial flushing, nausea, vomiting, vertigo, hypotension, and tachycardia. In theory, these adverse reactions could dissuade alcohol consumption.

These three medications have been around for some time now, but their effectiveness is lacking. Either they are only effective in a subset of the population, or the side effects outweigh the benefits. As a result, they are not widely used in practice, with only about 9% of patients that require AUD treatment receiving medication. Even when the medications are prescribed, patients often don’t use them as directed. Brady Grainer, president and director of the healthcare solutions company BioCorRx, says, “The crazy thing about addiction treatment is we have medications that work really, really well … but people don’t want to take them.”  To combat issues with patient compliance, BioCorRX is developing an implantable, biodegradable, and long-lasting pellet of Naltrexone, named BICX104. Clinical trials are currently underway, but early data has been promising, showing efficacious levels of the drug three months after implantation.

Grainer doesn’t think targeting the molecular mechanisms of AUD will ever lead to a cure-all treatment, though. Grainer says, “Medications are very valuable, but they are only part of it. You really have to work on the psychological, behavioral, environmental — otherwise you’re putting a Band-Aid on something if you’re not helping [patients] deal with life.”  BioCorRx also provides patients with a comprehensive approach to treatment. The Beat Addiction Recovery Program applies currently available medications (primarily naltrexone) in combination with behavioral therapies to address both the molecular mechanisms of AUD and the behavioral patterns that lead to relapse.

Cognitive behavioral therapy, or CBT, focuses on behavioral modification, and it’s used for a variety of mental illnesses and substance use disorders. Generally, during a CBT session for a patient with AUD, a therapist helps the patient to understand their mental state in a previous situation in which they felt tempted to drink. The patient recalls specific thoughts, emotions, physiological reactions, and behaviors that led them to crave alcohol or even to relapse. CBT for substance use disorders is effective as a treatment on its own or in combination with medications, but it has obstacles. Primarily, recall bias can cause patients to recount events and emotions differently than they occurred. If the therapist’s and patient’s interpretation of the event is muddied, then the patient may receive improper counseling and suboptimal therapeutic benefit. Further, CBT curricula vary among providers. Many therapists choose to provide their own course to their patients, which leads to more individualization but also less standardization. Consequently, quality of care may vary from provider to provider.

Dr. Daniel Thaysen Petersen, a trained psychiatrist, was drawn to the field when he realized “how horrible the treatments were. Even in Denmark, where we have universal healthcare, it is not prioritized. Even though treatment is free, the quality is just horrible, and also the lack of research resources… [led to] accepting conditions how they were.” He decided he wanted to help change the status quo. He grew interested in using virtual reality headsets to improve behavioral therapy in addiction cases, and he enrolled as a Ph.D. student in the Department of Psychiatry at the Psychiatric Center in Copenhagen. Now, Dr. Thaysen Petersen is one of the researchers leading a clinical trial to compare the efficacy of CBT and virtual reality-assisted cognitive behavioral therapy (VR-CBT) for treating patients with AUD.

The researchers are not trying to fundamentally change CBT with virtual reality headsets, but rather enhance the practice. A typical VR-CBT session begins like a traditional CBT session. The therapist checks in with the patient, discusses outstanding issues from the last meeting, and sets goals and an agenda for the current one. However, once the treatment itself begins, a virtual reality headset allows a patient to experience a high-risk situation in real time, rather than relying on their memory of an experience in the past week.

During a VR-CBT session, the patient does not need to remember the feelings that a previous experience elicited because the virtual reality headset prompts them to experience those feelings during the session.  The therapist can ask questions about the patient’s current state of mind, like “How much craving are you experiencing?” or “Are you anxious?” The patient can experience a simulation of a high-risk situation without the actual risk. Together, they can work to understand the steps that could lead to a relapse, and then they can identify practices to avoid that outcome. Dr. Thaysen Petersen says, “If the patient has craving, [we] practice coping skills: breathing exercises, distraction exercises.” He adds that the patient and therapist may “discuss the consequences of drinking and the positive things of not drinking.” Those are discussions that would happen in typical CBT sessions, but there’s a much greater sense of immediacy in VR-CBT. Dr. Thaysen Petersen says that including virtual reality allows a patient and a therapist to “use all of the thoughts and emotions, to really take everything that happens and use that as part of the therapy and identify the dysfunctional patterns, which you don’t do in normal exposure therapy.”

To realize the potential of VR-CBT, therapists need realistic virtual reality settings for their patients to experience. Before beginning the trial, Dr. Thaysen Petersen worked with a VR video studio and director to make 30 videos in five separate settings, including the supermarket, the home, a restaurant, a party, and a bar. The various settings allow the therapist to identify a situation that is most similar to something a patient is likely to experience. The videos ramp up in terms of intensity. For instance, a patient in the supermarket setting may start by simply walking by the drinks aisle. If the patient does not react, they can move up to a more intense setting. At the highest level, the videos are incredibly influential, often filled with alcohol related cues. In some cases, they even include direct interactions with actors who pressure the patient to take a drink.

The same 30 videos are available for all the patients in the trial, so they are generalized settings that do not exactly match the lived reality of individual patients. However, Dr. Thaysen Petersen believes improving technology could lead to more specialization and further refinement. He hypothesizes, “In the future, you are going to tell artificial intelligence, ‘Look into this patient’s Instagram and recreate their home.’” Hyper-realistic trial sequences of a situation a patient would actually experience could allow them to practice the coping mechanisms they have been taught from the safety of a therapist’s office. On the other hand, Dr. Thaysen Petersen believes augmented reality (AR) therapy could allow patients to interact with therapists while out in the real world. For example, if a patient wears AR glasses in their home, a therapist could use the technology to make different bottles of alcohol appear before the patient. Other gear could enable the therapist to monitor the patient’s physiological reactions, like changes in their heart rate, breathing, and perspiration. As these technologies continue to advance, the realism and relatability of therapeutic treatments that employ them will increase. Proponents like Dr. Thaysen Petersen expect the efficacy of these treatments will increase as well.

Treatment options and availability for alcohol use disorder have a long way to go before everyone that needs help receives it. Currently, the medications for treatment are lackluster. Promising drugs pop up every year, but for now it appears that medications are most successful when used alongside cognitive behavioral therapy. The fusion of VR technology with effective behavioral therapy is an exciting new avenue for the field. Further improvements in the technology may herald a new age of specialized treatments that match the needs of individual patients. But even then, a person’s unwillingness to seek treatment will remain one of the most significant barriers to treatment for AUD, and changes in social attitudes could have the greatest impact for people struggling with alcohol dependence. A society that has a healthy relationship with alcohol is one that does not stigmatize and one that provides information and resources to direct those with problem-drinking behavioral patterns to the help they need.

Photo credited to EdZbarzhyvetsky