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Virtual Reality Cue Refusal Video Game for Alcohol and Cigarette Recovery Support: Summative Study

Virtual Reality Cue Refusal Video Game for Alcohol and Cigarette Recovery Support: Summative Study Background: New technologies such as virtual reality, augmented reality, and video games hold promise to support and enhance individuals in addiction treatment and recovery. Quitting or decreasing cigarette or alcohol use can lead to significant health improvements for individuals, decreasing heart disease risk and cancer risks (for both nicotine and alcohol use), among others. However, remaining in recovery from use is a significant challenge for most individuals. Objective: We developed and assessed the Take Control game, a partially immersive Kinect for Windows platform game that allows users to counter substance cues through active movements (hitting, kicking, etc). Methods: Formative analysis during phase I and phase II guided development. We conducted a small wait-list control trial using a quasi-random sampling technique (systematic) with 61 participants in recovery from addiction to alcohol or tobacco. Participants used the game 3 times and reported on substance use, cravings, satisfaction with the game experience, self-efficacy related to recovery, and side effects from exposure to a virtual reality intervention and substance cues. Results: Participants found the game engaging and fun and felt playing the game would support recovery efforts. On average, reported substance use decreased for participants during the intervention period. Participants in recovery for alcohol use saw more benefit than those in recovery for tobacco use, with a statistically significant increase in self-efficacy, attitude, and behavior during the intervention. Side effects from the use of a virtual reality intervention were minor and decreased over time; cravings and side effects also decreased during the study. Conclusions: The preliminary results suggest the intervention holds promise as an adjunct to standard treatment for those in recovery, particularly from alcohol use. (JMIR Serious Games 2018;6(2):e7) doi: 10.2196/games.9231 KEYWORDS addiction treatment; Kinect; serious games; motion control games; virtual reality the craving response or use a coping response [7-10]. In keeping Introduction with the theory that the treatment effect is due to practicing a healthier response to a cue, the player in our game is repeatedly Theoretical Basis for the Game Intervention exposed to an image of a substance, and rather than responding The Take Control recovery support game uses several familiar with use, the player is trained to substitute a more dynamic, and well-researched therapies to improve player treatment adaptive response. They must react appropriately (destroy the outcomes for addiction. Cue exposure therapy (CET) is a substance) in order to advance in the game. commonly used method in substance abuse treatment [1-6]. Another way to explain the effect of this game is Traditionally, CET is performed with pictures of a substance, counter-conditioning. The unwanted behavior of responding to the actual substance itself, or even its scent [2]. The patient is the cue to use a substance is being replaced with a positive repeatedly exposed to cues and stimuli and encouraged to ignore http://games.jmir.org/2018/2/e7/ JMIR Serious Games 2018 | vol. 6 | iss. 2 | e7 | p. 1 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Metcalf et al action, and the new behavior is rewarded [11]. The game virtual practice in a game environment may be uniquely helpful supports the rehearsal of the positive action of actively refusing because it can deliver a large dose of alternative practice in a a substance when it is presented and offers a reward to reinforce manner that people not only tolerate but enjoy. The fact that a the more positive response in the form of success in the game. short duration gaming experience in Girard et al [24] could improve outcomes in comparison with a placebo control The effectiveness of this game’s approach to substance abuse suggests that games that involve the body in alternative practice treatment also might be partially explained by the extinction may hold promise for treating addiction. response. Extinction therapy aims to reduce a patient’s conditioned response to a substance by repeated exposure Game Design without reinforcers in order to dull the craving response over The Take Control recovery support game was developed for time [12,13]. In our game, the patient is repeatedly exposed use with the Kinect motion sensor camera and device available visually to the substance without receiving the reinforcing effect with Xbox One and Windows operating systems. of the substance, which may produce some extinction effects. Users hit or kick away cue images as they fly toward the user, Creating new memories will overlap former memories, thus as seen in Figure 1. If a user successfully hits the image, it extinguishing old habits and responses [13]. Our game will explodes and the user gains in-game points. If an image hits the allow players to use movement to form new, more adaptive user or flies off the screen without being exploded, there is no associations with the substances. negative consequence to the user’s score. Virtual reality therapy (VRT) uses virtual environments to Users choose a background image, like the one in Figure 2, expose patients to stimuli in a safe and controlled manner, such from a menu using voice or mouse controls and then choose 1 as with phobias or posttraumatic stress disorder [14]. In VRT cue item to reject per round. Users were encouraged to focus for addiction treatment, the stimulus is the substance of the on 1 substance but could change items between rounds. Users patient’s addiction [5,7,9,10,15,16]. A VR video game has could replay the game using different backgrounds or cues as distinct advantages over other exposure methods (eg, pictures often as desired. produced by a counselor). Being in a VR environment allows the player to feel more immersed in the game, resulting in The game includes photo realistic backgrounds, seen in Figure greater involvement and translation into real-life actions [5]. 3, but drawn substance images, seen in Figure 4. During The game also addresses the need for a safe environment to formative studies with target audience members, it was practice refusal skills, as seen in coping skills training [5,17]. determined that photo realistic images of cue items (cigarettes, beer bottles, etc) were not preferred since users felt that such Exercise, which has been shown to aid in recovery from images were too specific, and thus made the experience less substance use disorders [18] and reduce comorbid factors that relevant to them individually. There were also reports from hinder overall health and wellbeing [19,20], is another factor formative testers that they believed realistic looking cues might that may mediate the game’s effect. Free movement is possible trigger cravings, while illustrations would be less likely to do with our game because Kinect (the system) is not hindered by so. a controller, cords, or bulky head gear. Objectives Cognitive behavioral therapy (CBT) has extensive research backing its effectiveness in addiction treatment [21,22]. One This study considers how a lower cost, easily accessible video important interpersonal component of CBT is refusal skill game could be used to support recovery treatment or individual practice. Patients learn how to respond rapidly, maintain eye self-efficacy, attitude, and behavior. The goal is to support users contact, and give a clear “no” when offered drugs [23]. In our in practicing refusal skills and increase self-efficacy by denying proposed game, players will practice refusal skills (such as trigger or cue items in the nonthreatening environment of the verbally saying “no” and physically turning one’s back) when video game. Using realistic backgrounds, users can hit or kick offered a substance by a character. trigger items that fly toward them. Hit items explode, and users gain points. In the specific field of technology-based interventions for substance abuse, we did not identify any similar games to Take Primary outcome measures were an increase in reported Control. However, there was a related study conducted by Girard self-efficacy, attitude, and behavior, a decrease or lack of et al [24] showing that 4 sessions performing behaviors increase in craving after having seen the trigger items, and incompatible with smoking cigarettes (crushing virtual satisfaction with the game experience. Self-reported data on cigarettes) within a virtual environment were more efficacious continued recovery status were also assessed. for smoking cessation than a similar game in which patients The primary goal of the study was to increase user self-efficacy, found and crushed virtual balls. The mechanism of this treatment attitude, and behavior by allowing the user to practice refusing in the study was not well understood, but we surmised that such trigger items in the game context. http://games.jmir.org/2018/2/e7/ JMIR Serious Games 2018 | vol. 6 | iss. 2 | e7 | p. 2 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Metcalf et al Figure 1. A staff developer swipes away a beer bottle during game play. Figure 2. Players can select specific backgrounds for the game. http://games.jmir.org/2018/2/e7/ JMIR Serious Games 2018 | vol. 6 | iss. 2 | e7 | p. 3 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Metcalf et al Figure 3. Game backgrounds include realistic photos. Figure 4. Substance images were drawn to be less specific as preferred by the target audience. Participants also had to be able to travel to a game setup Methods location. For most participants, this was a small office near a local church building, on the local free bus line, with free Participants parking available. Participants received a gift card to a national The study was reviewed and approved by the Clinical Tools store with multiple locations in the area at each of the 4 possible Inc Institutional Review Board. Participants were healthy adult sessions. Sessions typically lasted more than 15 minutes but volunteers who self-identified as having recently quit using less than 30 minutes. Participants were asked to play 8 rounds cigarettes, tobacco, or alcohol. We did not collect data on (60 seconds per round) of the game. coaddictions. Participants were recruited through advertisements Use of the video game was private; research staff were available in a local weekly news circular, on the Internet (Raleigh to assist with any technical difficulties or usability question Craigslist), flyers placed in local public places (community outside of the testing room, but staff did observe use of the game centers, outside grocery stores), and via word of mouth. through a window (where players could not see them) to allow Interested volunteers completed a short, open online survey that users to behave naturally and not feel judged for their ability to reviewed eligibility requirements (aged over 18 years, recent play the game. A computer log documented use time and score, quitting, lack of mobility issues that would prohibit game use, and this was associated with the participant number. The study fluent in English). The survey contained an informed consent version incorporated the Kinect for Windows software and ran section with study purpose, methods and procedures, on a personal computer with a large monitor to facilitate viewing confidentiality, benefits and inconveniences, precautions and of the game. risks, and survey submissions were limited via IP addresses. http://games.jmir.org/2018/2/e7/ JMIR Serious Games 2018 | vol. 6 | iss. 2 | e7 | p. 4 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Metcalf et al Textbox 1. Case and wait-list control group schedules. Case: Preassessment and Take Control game session 1 Take Control game session 2 and assessment Take Control game session 3 and assessment One- to 2-week interval Follow-up assessment Wait-list control: Preassessment Two-week interval—no assessment Preassessment and Take Control game session 1 Take Control game session 2 and assessment Take Control game session 3 and assessment African American, 13 white, 1 other, 2 multiracial, 1 prefer not Data Collection to answer) and 32 males (1 Asian, 14 African American, 15 The study was a quasi-experimental, stratified, wait-list control white, 1 other, 1 prefer not to answer); 1 participant was trial using a convenience sample due to time limitations. unknown (chose prefer not to answer for both gender and race categories). Participants in each group had the opportunity to play the game at the Clinical Tools office 3 times, with 7 to 12 days in between Data Collection uses. Case group participants were asked to complete a Quantitative Results—Substance Use follow-up set of measures 1 to 2 weeks after the final game use. Control group users completed a baseline set of instruments The 7-Day Timeline instrument allowed the participant to report and then after at least a 2-week wait period repeated the baseline any substance they had used the week prior to playing the game. measures and then used the game 3 times. In Table 1, percentages are reported based on a starting point of 100% for those reporting use of a substance in session 1. Thus, each group had a total of 4 assessment interactions and After playing the game twice, case participants who reported 3 game play interactions (see Textbox 1). Assessments were using a substance on the first 7-Day Timeline (n=17) had an mostly Likert-style questions except for the 7-Day Timeline average drop to 38% of what they had been using at baseline. (fill-in-the-blank), Side Effects (multiple choice), and Stages Of those who reported some substance use at baseline, 5 out of of Change (multiple choice). A random number was assigned 17 (29%) stopped using altogether (0% use) after 2 weeks of to participants and the information kept in a locked location. participation. Control participants who reported using a Researchers used this number to log participants into the surveys substance on the first 7-Day Timeline had an average substance associated with specific session numbers to keep the use increase from 100% to 110% during the 2-week period prior participant’s multiple sessions linked. to playing the game. As shown in Table 2, average substance Data collected for this study were sent to University of North use increased between the last game play (session 3) and 1-week Carolina at Chapel Hill, where a doctoral student in statistics follow-up (session 4) for those who completed the optional analyzed the data. fourth session (15/17). Therefore, they went from 100% at week 1 down to 38% at week 3, and back up (average session 3) to Results 52% at week 4 (average session 4). Overall, there was improvement from session 1 to session 4 of about 50%. Participants At the follow-up point for the 7-Day Timeline, a third of those A total of 76 participants were enrolled in the summative study. who filled out the follow-up survey had reached 0% use by the A total of 7 case participants were withdrawn from the analysis: last game play session and maintained abstinence. However, 2 case participants were withdrawn due to inconsistent data and 27% of participants (4/15) increased substance use after 5 were withdrawn due to not completing the study. A total of completing the study. One participant, who had reported 0% 8 control participants were withdrawn from the study, all due substance use at all 3 game play sessions, reported using again to not completing the study. A total of 61 participants were at follow-up. included in the analysis. There were 28 females (1 Asian, 10 http://games.jmir.org/2018/2/e7/ JMIR Serious Games 2018 | vol. 6 | iss. 2 | e7 | p. 5 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Metcalf et al Table 1. Change in substance use after 2 weeks (percentage based on first reported use). Characteristic Control without game (n=11) Case with game (n=17) 110 38 Average change in substance use compared to initial 100%, % Number who quit, n 0 5 Number who restarted, n 2 1 Percentage reflects the amount of substance use increase. Table 2. Substance use in case group (n=15). N/A: not applicable. Use for participants who completed session 4 from 7-Day Timeline Session 1 Session 3 Session 4 Participants still using their substance Used substance, % 100.00 37.74 52.37 Increased since previous session, n N/A 2 4 Decreased since previous session, n N/A 7 2 Use stayed the same, n N/A 1 3 Decreased and stayed at 0% use, n 5 6 Total, n 15 15 15 Participants with no substance use or those at 0%, n 15 15 14 Restarted N/A N/A 1 Attitude Results Quantitative Results—Self-Efficacy, Attitude, Behavior, Scores on attitude questions, which focused on or Intended Behavior self-responsibility to use help, started fairly low at week 1 Self-Efficacy Results (average 3.88), rose slightly by week 3 (average 3.99), and fell even below baseline by 1-week follow-up (average 3.67). In general, participants reported an increase in self-efficacy after spending 3 weeks playing the game. Table 3 displays Quantitative Results—Alcohol versus Tobacco results for each self-efficacy question and shows a growth trend Self-reported, self-efficacy, attitude, and behavior scores that for self-efficacy between sessions 1 and 3, followed by a were collected via Likert-style surveys at the beginning of the decrease by the 1-week follow-up session 4. The difference first game play session, and after the third, or last, session of between sessions 3 and 4 showed the most decrease in patient game play for both case and control were analyzed by the self-efficacy. However, on the fourth week, after not coming substance used. Participants who had selected alcohol as their back and playing the game, participant average self-efficacy problem substance showed improvement in scores from an rating drops off. We found differences between session 3 and average of 4.19 at baseline (game play 1) to 4.31 at the third session 4 values in that most of the participants (21/29) had a session (game play 3)—an increase of 0.11 (2-tailed t test, decreased self-efficacy score or remained the same. Only 8 P=.09; see Multimedia Appendix 1). When participants who participants had increased self-efficacy at session 4, a week were still using alcohol at baseline were considered separately after the last time they played the game. (11/26), the increase in scores over the 3 weeks was significant Intended Behavior Results (going from 4.04 to 4.28, P=.03). In contrast, those who chose tobacco howed a slight decrease in self-efficacy scores of 0.02 Several individual measures improved for case intended points in the 2 weeks. Tobacco substance users had a decrease behavior from baseline (week 1) through 1-week follow-up in mean self-efficacy score of 0.07. (week 4). Case participants, on average, showed an increase from baseline to 1-week follow-up in their ratings on a 5-point The rate of participants continuing substance use after entering Likert-type scale of their intentions to use health care (0.61 the study decreased for both alcohol and tobacco users (Table points), resources (0.24 points), and support groups (0.18 points) 4). Participants with alcohol substance use decreased their to assist with their substance use issues. All other intended amount of substance used by 75%, whereas tobacco substance behaviors measured showed a slight downward trend from users only decreased their substance use by 4%. baseline to follow-up (Table 3). http://games.jmir.org/2018/2/e7/ JMIR Serious Games 2018 | vol. 6 | iss. 2 | e7 | p. 6 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Metcalf et al Table 3. Case player self-assessment scores (5-point Likert-type scale; n=29). Characteristics Session 1 Session 3 Session 1 to 3 Session 4 (1-week (Baseline) (Difference) follow-up) Self-efficacy—I currently feel that: I am happy with how far I have come in my substance use treatment and recovery 4.07 4.17 0.10 4.14 I feel good about my future regarding substance use abstinence 4.21 4.34 0.13 4.03 I am confident in my ability to overcome my substance use issue 4.07 4.38 0.31 4.07 I am confident in my ability to refuse the use of problematic substances (alco- 3.93 4.07 0.14 3.79 hol/drugs/tobacco) Average self-efficacy 4.07 4.24 0.17 4.01 Attitude—It is my responsibility to take control of my substance use issues by: Using the help of support channels 4.00 4.07 0.07 3.86 Using the help of health care professionals 3.41 3.72 0.31 3.45 Using the help of friends 4.24 4.17 –0.07 3.97 Average attitude 3.88 3.99 0.10 3.67 Behavior—I intend to quit using problematic substances (alcohol/drugs/tobacco) 4.27 4.00 –0.27 3.93 I intend to reduce my use of problematic substances (alcohol/drugs/tobacco) 4.56 4.43 –0.13 4.15 Behavior—I intend to use or continue using the help of: Health care to assist with my substance use issues 2.96 3.57 0.61 3.41 Friends to assist with my substance use issues 4.07 4.03 –0.04 3.90 Family to assist with my substance use issues 3.43 3.61 0.18 3.34 Support groups to assist with my substance use issues 3.54 3.50 –0.04 3.61 Resources to assist with my substance use issues 3.79 4.03 0.24 3.93 Behavior—I intend to seek out and participate in: Healthy lifestyle behaviors such as eating healthily 4.31 4.48 0.17 4.10 Healthy lifestyle behaviors such as exercising 4.38 4.48 0.10 4.21 Healthy lifestyle behaviors such as socializing 4.41 4.48 0.07 4.03 Healthy lifestyle behaviors such as hobbies 4.34 4.62 0.32 4.24 Average behavior or intended behavior 4.00 4.11 0.11 3.89 Table 4. Average change in substance use for participants who started the study using a substance within the past week (n=24). Substance type Session 1 attendance, n (%) Session 3 attendance, n (%) Tobacco 13 (100) 12 (96) Alcohol 11 (100) 7 (25) game. The positive and negative comments were divided into Quantitative Results—Satisfaction more general and specific comments, and the game design The trend, on average, was that participant satisfaction with the suggestions were recorded. Of the 76 unique comments, 50% game was positive, with scores averaging between 3.34 and (38/75) were positive about the game and playing the game, 4.25 (neutral and agreement) on a 5-point Likert-type scale in 9% (7/75) were negative, and 41% (31/75) were neutral or response to 5 satisfaction questions (see Table 5). The average involved game design suggestions for the future (such as agreement decreased slightly by the end of the study, perhaps changes to fonts, scoring, additional backgrounds or images). because of the decrease in novelty or instrument fatigue. Many of the positive comments (21/38) included evaluative Participants agreed with all satisfaction statements at the end statements like, “Fun,” “Cool,” and “Liked it.” The negative of the study, however. comments comprised a mixture of skepticism about the game efficacy, stress inducement, soreness, or general dislike. Qualitative Results A total of 48 participants offered additional comments in the surveys as well as in an unstructured interview after playing the http://games.jmir.org/2018/2/e7/ JMIR Serious Games 2018 | vol. 6 | iss. 2 | e7 | p. 7 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Metcalf et al Table 5. Game satisfaction scores (5-point Likert-type scale). N/A: not applicable. Game satisfaction Session 1 Session 2 Session 3 Session 4 (1-week (n=52) (n=52) (n=52) follow-up; n=29) Game focus—I feel that: The game was fun. 4.43 4.48 4.37 4.10 This game was engaging. 4.58 4.48 4.48 4.17 Based on my experience, I would recommend this game to other patients in 3.88 3.98 4.00 3.67 treatment for substance use problems. Based on my experience, this game will aid in my substance use treatment and 3.45 3.55 3.81 3.53 recovery. Overall, this game will be a useful substance use treatment and recovery tool. 3.78 3.83 4.12 3.70 Game feedback—The game seems like it will help with my treatment in terms of: Relapse prevention 3.41 3.40 3.65 N/A Seeking help 3.22 3.10 3.38 N/A Sticking to treatment 3.68 3.60 3.88 N/A Better long-term outcomes 3.76 3.65 3.69 N/A Higher quality of life 3.61 3.70 3.71 N/A to cues for substance use can have a triggering effect and thus Discussion have the potential to undermine recovery. This did not happen often, which is encouraging and a necessary result for further Quantitative Results research into the use of game- or electronic-based CET There are several important results of this brief study. First, that adjunctive technologies. participation in the study and use of the game seem to support Participant Satisfaction, Self-Efficacy, and Behavior abstinence from substance use based on the 7-Day Timeline reports when game users are compared to participants in the Key Findings control group. The 7-Day Timeline instrument reported Secondary findings revolve around participant enthusiasm for decreased or maintenance of no substance use at a poststudy the game experience and impact the potential of the game as a follow up for most of the 29 participants in the game use group. supportive product in the future. Participants found the game That is, substance use decreased or remained the same for most engaging and fun. users, although more for alcohol users than for tobacco users. Additionally, participants felt playing the game during recovery This suggests that participation in the study did support would help with relapse prevention and related behaviors. abstinence from substance use and that the effect might be Agreement with this was highest after session 3. stronger for alcohol use than tobacco use. Additional research There was a slight but intriguing difference in results for those is needed to determine if this effect is due to participation in a who reported recovery for alcohol use as their primary goal study or the intervention. versus those who chose recovery from tobacco use. Specifically, A second finding is that there were fewer positive results seen self-efficacy increased for those in recovery for alcohol use, but in substance use during the wait-list control period for those there was a minor, not statistically significant decrease in participants. In other words, there was a general increase in use, self-efficacy for former tobacco users. Differences between not decrease while controls waited. This suggests that being in these 2 groups could be an area of further research, as misuse a study and knowing that they would have to report on their of both substances is harmful to health in the US population. substance use did not change their baseline behavior. This result Another improvement seen from pre- to postintervention strengthens the argument that it was use of the game that follow-up was an increased intention to use health care, decreased substance use for participants, rather than participation resources, and support groups. in the study. Future research could examine this finding further. Limitations A third finding is that scores for self-efficacy, attitude, and There are limitations worth noting in this study. The study intended behavior went up significantly from baseline to week population was small and was a convenience sample of 3 (P=.03) for patients still using alcohol at baseline. This, participants who were interested in maintaining their status in together with the greater decrease in substance use for the group recovery, and thus they may not be typical of all individuals that selected alcohol as the substance to work on, suggests that having substance use problems. Second, time was constrained, the game benefits may be greater with respect to alcohol use. which impacted how often participants could use the game. In Finally, it is noteworthy that few participants reported an an ideal setting, the game experience would be available to increase in use of their substance. This was a concern due to the possibility, as seen in CET modalities, that exposing users http://games.jmir.org/2018/2/e7/ JMIR Serious Games 2018 | vol. 6 | iss. 2 | e7 | p. 8 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Metcalf et al participants more frequently, and a dose-response investigation Finally, Microsoft is no longer actively developing Kinect could be conducted. applications; although current versions of the Xbox One continue to support use (as of August 2017). Thus, future Kinect is a kinesthetic game and requires a minimum level of versions of the game should explore additional platforms while physical ability to move arms or legs, and this limits the reach maintaining the kinesthetic element of game play and explore of the game. A participant was able to use the game from a how this impacts results. wheelchair in early testing, but more modifications are needed to effectively reach a mobility-limited population. Also, in terms Conclusions of the physicality of the game, we believe that the possible This study indicates that a serious game–based intervention has aggressiveness of the game is balanced by the positive potential to be a useful part of recovery efforts for individuals interactions of taking control of one’s environment; however, seeking to maintain abstinence from alcohol or tobacco misuse a psychological professional would need to evaluate whether or use. The use of a kinesthetic game based in a cue refusal this game is appropriate for individuals with aggressive theory framework-based intervention could prove a valuable tendencies. adjunct to therapy in the future. Games have the ability to reach and engage a significant audience segment, and the use of an Given this was a short-term feasibility study, long-term studies individually tailored game could expand potential treatment would need to be conducted to address the complexities of experiences. rehabilitation from various addictions. Acknowledgments This project was supported entirely by an Small Business Innovation Research (SBIR) contract from the National Institutes of Health (HHSN2712013000041C). Conflicts of Interest The authors are the employees of the small business that received the SBIR contract to develop and evaluate this game. All development and evaluation (except for the data analysis) was performed by Clinical Tools staff, including the study design, collection of data, writing of the report, and the decision to submit the report for publication. Brad Tanner is the owner of Clinical Tools Inc and may profit from any sale of the game. Multimedia Appendix 1 Self-efficacy, attitude, and intended behavior scores for case and control participants who completed 3 game play sessions (N=50). [PDF File (Adobe PDF File), 18KB-Multimedia Appendix 1] References 1. Traylor AC, Parrish DE, Copp HL, Bordnick PS. Using virtual reality to investigate complex and contextual cue reactivity in nicotine dependent problem drinkers. Addict Behav 2011 Nov;36(11):1068-1075. [doi: 10.1016/j.addbeh.2011.06.014] [Medline: 21783326] 2. Monti PM, Rohsenow DJ. Coping-skills training and cue-exposure therapy in the treatment of alcoholism. Alcohol Res Health 1999;23(2):107-115. [Medline: 10890804] 3. Lee JS, Namkoong K, Ku J, Cho S, Park JY, Choi YK, et al. Social pressure-induced craving in patients with alcohol dependence: application of virtual reality to coping skill training. Psychiatry Investig 2008 Dec;5(4):239-243 [FREE Full text] [doi: 10.4306/pi.2008.5.4.239] [Medline: 20046344] 4. Paris MM, Carter BL, Traylor AC, Bordnick PS, Day SX, Armsworth MW, et al. Cue reactivity in virtual reality: the role of context. Addict Behav 2011 Jul;36(7):696-699 [FREE Full text] [doi: 10.1016/j.addbeh.2011.01.029] [Medline: 21349649] 5. García-Rodríguez O, Pericot-Valverde I, Gutiérrez-Maldonado J, Ferrer-García M, Secades-Villa R. Validation of smoking-related virtual environments for cue exposure therapy. Addict Behav 2012 Jun;37(6):703-708. [doi: 10.1016/j.addbeh.2012.02.013] [Medline: 22385732] 6. Bordnick PS, Traylor A, Copp HL, Graap KM, Carter B, Ferrer M, et al. Assessing reactivity to virtual reality alcohol based cues. Addict Behav 2008 Jun;33(6):743-756. [doi: 10.1016/j.addbeh.2007.12.010] [Medline: 18282663] 7. Girard B, Turcotte V, Bouchard S, Girard B. Crushing virtual cigarettes reduces tobacco addiction and treatment discontinuation. Cyberpsychol Behav 2009 Oct;12(5):477-483. [doi: 10.1089/cpb.2009.0118] [Medline: 19817561] 8. Girard B, Turcotte V. A virtual arm to stop smoking, a perceptual learning experiment. 2007. URL: https://www. clinicaltrials.gov/ct2/show/NCT00639093 [accessed 2017-11-27] [WebCite Cache ID 6vHvl1Qmz] 9. Pericot-Valverde I, García-Rodríguez O, Gutierrez-Maldonado J, Ferrer-García M, Secades-Villa R. Evolution of smoking urge during exposure through virtual reality. Stud Health Technol Inform 2011;167:74-79. [Medline: 21685645] 10. Lee J, Kwon H, Choi J, Yang B. Cue-exposure therapy to decrease alcohol craving in virtual environment. Cyberpsychol Behav 2007 Oct;10(5):617-623. [doi: 10.1089/cpb.2007.9978] [Medline: 17927528] http://games.jmir.org/2018/2/e7/ JMIR Serious Games 2018 | vol. 6 | iss. 2 | e7 | p. 9 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Metcalf et al 11. Van Gucht D, Baeyens F, Vansteenwegen D, Hermans D, Beckers T. Counterconditioning reduces cue-induced craving and actual cue-elicited consumption. Emotion 2010 Oct;10(5):688-695. [doi: 10.1037/a0019463] [Medline: 21038951] 12. O'Brien CP, Childress AR, McLellan T, Ehrman R. Integrating systemic cue exposure with standard treatment in recovering drug dependent patients. Addict Behav 1990;15(4):355-365. [Medline: 2248109] 13. Kaplan GB, Heinrichs SC, Carey RJ. Treatment of addiction and anxiety using extinction approaches: neural mechanisms and their treatment implications. Pharmacol Biochem Behav 2011 Jan;97(3):619-625. [doi: 10.1016/j.pbb.2010.08.004] [Medline: 20723558] 14. Romano D. Virtual reality therapy. Dev Med Child Neurol 2005 Sep 01;47(9):580. [doi: 10.1111/j.1469-8749.2005.tb01206.x] 15. Bordnick PS, Carter BL, Traylor AC. What virtual reality research in addictions can tell us about the future of obesity assessment and treatment. J Diabetes Sci Technol 2011 Mar 01;5(2):265-271 [FREE Full text] [doi: 10.1177/193229681100500210] [Medline: 21527092] 16. Glanz K, Rizzo A, Graap K. Virtual reality for psychotherapy: current reality and future possibilities. Psychother Theory Res Pract Train 2003;40(1-2):55-67. [doi: 10.1037/0033-3204.40.1-2.55] 17. Litt MD, Kadden RM, Kabela-Cormier E. Individualized assessment and treatment program for alcohol dependence: results of an initial study to train coping skills. Addiction 2009 Nov;104(11):1837-1838 [FREE Full text] [doi: 10.1111/j.1360-0443.2009.02693.x] [Medline: 19712124] 18. Roessler KK. Exercise treatment for drug abuse—a Danish pilot study. Scand J Public Health 2010 Aug;38(6):664-669. [doi: 10.1177/1403494810371249] [Medline: 20529968] 19. Smith MA, Lynch WJ. Exercise as a potential treatment for drug abuse: evidence from preclinical studies. Front Psychiatry 2011;2:82 [FREE Full text] [doi: 10.3389/fpsyt.2011.00082] [Medline: 22347866] 20. Principles of drug addiction treatment: a research-based guide. 3rd Edition.: National Institute on Drug Abuse; 2015 Nov 3. URL: https://d14rmgtrwzf5a.cloudfront.net/sites/default/files/ 675-principles-of-drug-addiction-treatment-a-research-based-guide-third-edition.pdf [accessed 2018-03-31] [WebCite Cache ID 6yL3x8uhq] 21. Holder H, Longabaugh R, Miller WR, Rubonis AV. The cost effectiveness of treatment for alcoholism: a first approximation. J Stud Alcohol 1991 Nov;52(6):517-540. [Medline: 1661799] 22. Hester RK, editor. Handbook of Alcoholism Treatment Approaches: Effective Alternatives, 3rd Edition. Boston: Allyn and Bacon; 2002. 23. Carroll K. Cognitive-behavioral approach: treating cocaine addiction. 2013 Feb 7. URL: https://archives.drugabuse.gov/ sites/default/files/cbt.pdf [accessed 2018-03-31] [WebCite Cache ID 6yL4F42AL] 24. Girard B, Turcotte V, Bouchard S, Girard B. Crushing virtual cigarettes reduces tobacco addiction and treatment discontinuation. Cyberpsychol Behav 2009 Oct;12(5):477-483. [doi: 10.1089/cpb.2009.0118] [Medline: 19817561] Abbreviations CBT: cognitive behavior therapy CET: cue exposure therapy SBIR: Small Business Innovation Research VRT: virtual reality therapy Edited by G Eysenbach; submitted 20.10.17; peer-reviewed by AE Eleftheriou, C Tziraki; comments to author 03.11.17; revised version received 23.02.18; accepted 13.03.18; published 16.04.18 Please cite as: Metcalf M, Rossie K, Stokes K, Tallman C, Tanner B JMIR Serious Games 2018;6(2):e7 URL: http://games.jmir.org/2018/2/e7/ doi: 10.2196/games.9231 PMID: 29661748 ©Mary Metcalf, Karen Rossie, Katie Stokes, Christina Tallman, Bradley Tanner. Originally published in JMIR Serious Games (http://games.jmir.org), 16.04.2018. This is an open-access article distributed under the terms of the Creative Commons Attribution License (https://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work, first published in JMIR Serious Games, is properly cited. The complete bibliographic information, a link to the original publication on http://games.jmir.org, as well as this copyright and license information must be included. http://games.jmir.org/2018/2/e7/ JMIR Serious Games 2018 | vol. 6 | iss. 2 | e7 | p. 10 (page number not for citation purposes) XSL FO RenderX http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png JMIR Serious Games JMIR Publications

Virtual Reality Cue Refusal Video Game for Alcohol and Cigarette Recovery Support: Summative Study

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Abstract

Background: New technologies such as virtual reality, augmented reality, and video games hold promise to support and enhance individuals in addiction treatment and recovery. Quitting or decreasing cigarette or alcohol use can lead to significant health improvements for individuals, decreasing heart disease risk and cancer risks (for both nicotine and alcohol use), among others. However, remaining in recovery from use is a significant challenge for most individuals. Objective: We developed and assessed the Take Control game, a partially immersive Kinect for Windows platform game that allows users to counter substance cues through active movements (hitting, kicking, etc). Methods: Formative analysis during phase I and phase II guided development. We conducted a small wait-list control trial using a quasi-random sampling technique (systematic) with 61 participants in recovery from addiction to alcohol or tobacco. Participants used the game 3 times and reported on substance use, cravings, satisfaction with the game experience, self-efficacy related to recovery, and side effects from exposure to a virtual reality intervention and substance cues. Results: Participants found the game engaging and fun and felt playing the game would support recovery efforts. On average, reported substance use decreased for participants during the intervention period. Participants in recovery for alcohol use saw more benefit than those in recovery for tobacco use, with a statistically significant increase in self-efficacy, attitude, and behavior during the intervention. Side effects from the use of a virtual reality intervention were minor and decreased over time; cravings and side effects also decreased during the study. Conclusions: The preliminary results suggest the intervention holds promise as an adjunct to standard treatment for those in recovery, particularly from alcohol use. (JMIR Serious Games 2018;6(2):e7) doi: 10.2196/games.9231 KEYWORDS addiction treatment; Kinect; serious games; motion control games; virtual reality the craving response or use a coping response [7-10]. In keeping Introduction with the theory that the treatment effect is due to practicing a healthier response to a cue, the player in our game is repeatedly Theoretical Basis for the Game Intervention exposed to an image of a substance, and rather than responding The Take Control recovery support game uses several familiar with use, the player is trained to substitute a more dynamic, and well-researched therapies to improve player treatment adaptive response. They must react appropriately (destroy the outcomes for addiction. Cue exposure therapy (CET) is a substance) in order to advance in the game. commonly used method in substance abuse treatment [1-6]. Another way to explain the effect of this game is Traditionally, CET is performed with pictures of a substance, counter-conditioning. The unwanted behavior of responding to the actual substance itself, or even its scent [2]. The patient is the cue to use a substance is being replaced with a positive repeatedly exposed to cues and stimuli and encouraged to ignore http://games.jmir.org/2018/2/e7/ JMIR Serious Games 2018 | vol. 6 | iss. 2 | e7 | p. 1 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Metcalf et al action, and the new behavior is rewarded [11]. The game virtual practice in a game environment may be uniquely helpful supports the rehearsal of the positive action of actively refusing because it can deliver a large dose of alternative practice in a a substance when it is presented and offers a reward to reinforce manner that people not only tolerate but enjoy. The fact that a the more positive response in the form of success in the game. short duration gaming experience in Girard et al [24] could improve outcomes in comparison with a placebo control The effectiveness of this game’s approach to substance abuse suggests that games that involve the body in alternative practice treatment also might be partially explained by the extinction may hold promise for treating addiction. response. Extinction therapy aims to reduce a patient’s conditioned response to a substance by repeated exposure Game Design without reinforcers in order to dull the craving response over The Take Control recovery support game was developed for time [12,13]. In our game, the patient is repeatedly exposed use with the Kinect motion sensor camera and device available visually to the substance without receiving the reinforcing effect with Xbox One and Windows operating systems. of the substance, which may produce some extinction effects. Users hit or kick away cue images as they fly toward the user, Creating new memories will overlap former memories, thus as seen in Figure 1. If a user successfully hits the image, it extinguishing old habits and responses [13]. Our game will explodes and the user gains in-game points. If an image hits the allow players to use movement to form new, more adaptive user or flies off the screen without being exploded, there is no associations with the substances. negative consequence to the user’s score. Virtual reality therapy (VRT) uses virtual environments to Users choose a background image, like the one in Figure 2, expose patients to stimuli in a safe and controlled manner, such from a menu using voice or mouse controls and then choose 1 as with phobias or posttraumatic stress disorder [14]. In VRT cue item to reject per round. Users were encouraged to focus for addiction treatment, the stimulus is the substance of the on 1 substance but could change items between rounds. Users patient’s addiction [5,7,9,10,15,16]. A VR video game has could replay the game using different backgrounds or cues as distinct advantages over other exposure methods (eg, pictures often as desired. produced by a counselor). Being in a VR environment allows the player to feel more immersed in the game, resulting in The game includes photo realistic backgrounds, seen in Figure greater involvement and translation into real-life actions [5]. 3, but drawn substance images, seen in Figure 4. During The game also addresses the need for a safe environment to formative studies with target audience members, it was practice refusal skills, as seen in coping skills training [5,17]. determined that photo realistic images of cue items (cigarettes, beer bottles, etc) were not preferred since users felt that such Exercise, which has been shown to aid in recovery from images were too specific, and thus made the experience less substance use disorders [18] and reduce comorbid factors that relevant to them individually. There were also reports from hinder overall health and wellbeing [19,20], is another factor formative testers that they believed realistic looking cues might that may mediate the game’s effect. Free movement is possible trigger cravings, while illustrations would be less likely to do with our game because Kinect (the system) is not hindered by so. a controller, cords, or bulky head gear. Objectives Cognitive behavioral therapy (CBT) has extensive research backing its effectiveness in addiction treatment [21,22]. One This study considers how a lower cost, easily accessible video important interpersonal component of CBT is refusal skill game could be used to support recovery treatment or individual practice. Patients learn how to respond rapidly, maintain eye self-efficacy, attitude, and behavior. The goal is to support users contact, and give a clear “no” when offered drugs [23]. In our in practicing refusal skills and increase self-efficacy by denying proposed game, players will practice refusal skills (such as trigger or cue items in the nonthreatening environment of the verbally saying “no” and physically turning one’s back) when video game. Using realistic backgrounds, users can hit or kick offered a substance by a character. trigger items that fly toward them. Hit items explode, and users gain points. In the specific field of technology-based interventions for substance abuse, we did not identify any similar games to Take Primary outcome measures were an increase in reported Control. However, there was a related study conducted by Girard self-efficacy, attitude, and behavior, a decrease or lack of et al [24] showing that 4 sessions performing behaviors increase in craving after having seen the trigger items, and incompatible with smoking cigarettes (crushing virtual satisfaction with the game experience. Self-reported data on cigarettes) within a virtual environment were more efficacious continued recovery status were also assessed. for smoking cessation than a similar game in which patients The primary goal of the study was to increase user self-efficacy, found and crushed virtual balls. The mechanism of this treatment attitude, and behavior by allowing the user to practice refusing in the study was not well understood, but we surmised that such trigger items in the game context. http://games.jmir.org/2018/2/e7/ JMIR Serious Games 2018 | vol. 6 | iss. 2 | e7 | p. 2 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Metcalf et al Figure 1. A staff developer swipes away a beer bottle during game play. Figure 2. Players can select specific backgrounds for the game. http://games.jmir.org/2018/2/e7/ JMIR Serious Games 2018 | vol. 6 | iss. 2 | e7 | p. 3 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Metcalf et al Figure 3. Game backgrounds include realistic photos. Figure 4. Substance images were drawn to be less specific as preferred by the target audience. Participants also had to be able to travel to a game setup Methods location. For most participants, this was a small office near a local church building, on the local free bus line, with free Participants parking available. Participants received a gift card to a national The study was reviewed and approved by the Clinical Tools store with multiple locations in the area at each of the 4 possible Inc Institutional Review Board. Participants were healthy adult sessions. Sessions typically lasted more than 15 minutes but volunteers who self-identified as having recently quit using less than 30 minutes. Participants were asked to play 8 rounds cigarettes, tobacco, or alcohol. We did not collect data on (60 seconds per round) of the game. coaddictions. Participants were recruited through advertisements Use of the video game was private; research staff were available in a local weekly news circular, on the Internet (Raleigh to assist with any technical difficulties or usability question Craigslist), flyers placed in local public places (community outside of the testing room, but staff did observe use of the game centers, outside grocery stores), and via word of mouth. through a window (where players could not see them) to allow Interested volunteers completed a short, open online survey that users to behave naturally and not feel judged for their ability to reviewed eligibility requirements (aged over 18 years, recent play the game. A computer log documented use time and score, quitting, lack of mobility issues that would prohibit game use, and this was associated with the participant number. The study fluent in English). The survey contained an informed consent version incorporated the Kinect for Windows software and ran section with study purpose, methods and procedures, on a personal computer with a large monitor to facilitate viewing confidentiality, benefits and inconveniences, precautions and of the game. risks, and survey submissions were limited via IP addresses. http://games.jmir.org/2018/2/e7/ JMIR Serious Games 2018 | vol. 6 | iss. 2 | e7 | p. 4 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Metcalf et al Textbox 1. Case and wait-list control group schedules. Case: Preassessment and Take Control game session 1 Take Control game session 2 and assessment Take Control game session 3 and assessment One- to 2-week interval Follow-up assessment Wait-list control: Preassessment Two-week interval—no assessment Preassessment and Take Control game session 1 Take Control game session 2 and assessment Take Control game session 3 and assessment African American, 13 white, 1 other, 2 multiracial, 1 prefer not Data Collection to answer) and 32 males (1 Asian, 14 African American, 15 The study was a quasi-experimental, stratified, wait-list control white, 1 other, 1 prefer not to answer); 1 participant was trial using a convenience sample due to time limitations. unknown (chose prefer not to answer for both gender and race categories). Participants in each group had the opportunity to play the game at the Clinical Tools office 3 times, with 7 to 12 days in between Data Collection uses. Case group participants were asked to complete a Quantitative Results—Substance Use follow-up set of measures 1 to 2 weeks after the final game use. Control group users completed a baseline set of instruments The 7-Day Timeline instrument allowed the participant to report and then after at least a 2-week wait period repeated the baseline any substance they had used the week prior to playing the game. measures and then used the game 3 times. In Table 1, percentages are reported based on a starting point of 100% for those reporting use of a substance in session 1. Thus, each group had a total of 4 assessment interactions and After playing the game twice, case participants who reported 3 game play interactions (see Textbox 1). Assessments were using a substance on the first 7-Day Timeline (n=17) had an mostly Likert-style questions except for the 7-Day Timeline average drop to 38% of what they had been using at baseline. (fill-in-the-blank), Side Effects (multiple choice), and Stages Of those who reported some substance use at baseline, 5 out of of Change (multiple choice). A random number was assigned 17 (29%) stopped using altogether (0% use) after 2 weeks of to participants and the information kept in a locked location. participation. Control participants who reported using a Researchers used this number to log participants into the surveys substance on the first 7-Day Timeline had an average substance associated with specific session numbers to keep the use increase from 100% to 110% during the 2-week period prior participant’s multiple sessions linked. to playing the game. As shown in Table 2, average substance Data collected for this study were sent to University of North use increased between the last game play (session 3) and 1-week Carolina at Chapel Hill, where a doctoral student in statistics follow-up (session 4) for those who completed the optional analyzed the data. fourth session (15/17). Therefore, they went from 100% at week 1 down to 38% at week 3, and back up (average session 3) to Results 52% at week 4 (average session 4). Overall, there was improvement from session 1 to session 4 of about 50%. Participants At the follow-up point for the 7-Day Timeline, a third of those A total of 76 participants were enrolled in the summative study. who filled out the follow-up survey had reached 0% use by the A total of 7 case participants were withdrawn from the analysis: last game play session and maintained abstinence. However, 2 case participants were withdrawn due to inconsistent data and 27% of participants (4/15) increased substance use after 5 were withdrawn due to not completing the study. A total of completing the study. One participant, who had reported 0% 8 control participants were withdrawn from the study, all due substance use at all 3 game play sessions, reported using again to not completing the study. A total of 61 participants were at follow-up. included in the analysis. There were 28 females (1 Asian, 10 http://games.jmir.org/2018/2/e7/ JMIR Serious Games 2018 | vol. 6 | iss. 2 | e7 | p. 5 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Metcalf et al Table 1. Change in substance use after 2 weeks (percentage based on first reported use). Characteristic Control without game (n=11) Case with game (n=17) 110 38 Average change in substance use compared to initial 100%, % Number who quit, n 0 5 Number who restarted, n 2 1 Percentage reflects the amount of substance use increase. Table 2. Substance use in case group (n=15). N/A: not applicable. Use for participants who completed session 4 from 7-Day Timeline Session 1 Session 3 Session 4 Participants still using their substance Used substance, % 100.00 37.74 52.37 Increased since previous session, n N/A 2 4 Decreased since previous session, n N/A 7 2 Use stayed the same, n N/A 1 3 Decreased and stayed at 0% use, n 5 6 Total, n 15 15 15 Participants with no substance use or those at 0%, n 15 15 14 Restarted N/A N/A 1 Attitude Results Quantitative Results—Self-Efficacy, Attitude, Behavior, Scores on attitude questions, which focused on or Intended Behavior self-responsibility to use help, started fairly low at week 1 Self-Efficacy Results (average 3.88), rose slightly by week 3 (average 3.99), and fell even below baseline by 1-week follow-up (average 3.67). In general, participants reported an increase in self-efficacy after spending 3 weeks playing the game. Table 3 displays Quantitative Results—Alcohol versus Tobacco results for each self-efficacy question and shows a growth trend Self-reported, self-efficacy, attitude, and behavior scores that for self-efficacy between sessions 1 and 3, followed by a were collected via Likert-style surveys at the beginning of the decrease by the 1-week follow-up session 4. The difference first game play session, and after the third, or last, session of between sessions 3 and 4 showed the most decrease in patient game play for both case and control were analyzed by the self-efficacy. However, on the fourth week, after not coming substance used. Participants who had selected alcohol as their back and playing the game, participant average self-efficacy problem substance showed improvement in scores from an rating drops off. We found differences between session 3 and average of 4.19 at baseline (game play 1) to 4.31 at the third session 4 values in that most of the participants (21/29) had a session (game play 3)—an increase of 0.11 (2-tailed t test, decreased self-efficacy score or remained the same. Only 8 P=.09; see Multimedia Appendix 1). When participants who participants had increased self-efficacy at session 4, a week were still using alcohol at baseline were considered separately after the last time they played the game. (11/26), the increase in scores over the 3 weeks was significant Intended Behavior Results (going from 4.04 to 4.28, P=.03). In contrast, those who chose tobacco howed a slight decrease in self-efficacy scores of 0.02 Several individual measures improved for case intended points in the 2 weeks. Tobacco substance users had a decrease behavior from baseline (week 1) through 1-week follow-up in mean self-efficacy score of 0.07. (week 4). Case participants, on average, showed an increase from baseline to 1-week follow-up in their ratings on a 5-point The rate of participants continuing substance use after entering Likert-type scale of their intentions to use health care (0.61 the study decreased for both alcohol and tobacco users (Table points), resources (0.24 points), and support groups (0.18 points) 4). Participants with alcohol substance use decreased their to assist with their substance use issues. All other intended amount of substance used by 75%, whereas tobacco substance behaviors measured showed a slight downward trend from users only decreased their substance use by 4%. baseline to follow-up (Table 3). http://games.jmir.org/2018/2/e7/ JMIR Serious Games 2018 | vol. 6 | iss. 2 | e7 | p. 6 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Metcalf et al Table 3. Case player self-assessment scores (5-point Likert-type scale; n=29). Characteristics Session 1 Session 3 Session 1 to 3 Session 4 (1-week (Baseline) (Difference) follow-up) Self-efficacy—I currently feel that: I am happy with how far I have come in my substance use treatment and recovery 4.07 4.17 0.10 4.14 I feel good about my future regarding substance use abstinence 4.21 4.34 0.13 4.03 I am confident in my ability to overcome my substance use issue 4.07 4.38 0.31 4.07 I am confident in my ability to refuse the use of problematic substances (alco- 3.93 4.07 0.14 3.79 hol/drugs/tobacco) Average self-efficacy 4.07 4.24 0.17 4.01 Attitude—It is my responsibility to take control of my substance use issues by: Using the help of support channels 4.00 4.07 0.07 3.86 Using the help of health care professionals 3.41 3.72 0.31 3.45 Using the help of friends 4.24 4.17 –0.07 3.97 Average attitude 3.88 3.99 0.10 3.67 Behavior—I intend to quit using problematic substances (alcohol/drugs/tobacco) 4.27 4.00 –0.27 3.93 I intend to reduce my use of problematic substances (alcohol/drugs/tobacco) 4.56 4.43 –0.13 4.15 Behavior—I intend to use or continue using the help of: Health care to assist with my substance use issues 2.96 3.57 0.61 3.41 Friends to assist with my substance use issues 4.07 4.03 –0.04 3.90 Family to assist with my substance use issues 3.43 3.61 0.18 3.34 Support groups to assist with my substance use issues 3.54 3.50 –0.04 3.61 Resources to assist with my substance use issues 3.79 4.03 0.24 3.93 Behavior—I intend to seek out and participate in: Healthy lifestyle behaviors such as eating healthily 4.31 4.48 0.17 4.10 Healthy lifestyle behaviors such as exercising 4.38 4.48 0.10 4.21 Healthy lifestyle behaviors such as socializing 4.41 4.48 0.07 4.03 Healthy lifestyle behaviors such as hobbies 4.34 4.62 0.32 4.24 Average behavior or intended behavior 4.00 4.11 0.11 3.89 Table 4. Average change in substance use for participants who started the study using a substance within the past week (n=24). Substance type Session 1 attendance, n (%) Session 3 attendance, n (%) Tobacco 13 (100) 12 (96) Alcohol 11 (100) 7 (25) game. The positive and negative comments were divided into Quantitative Results—Satisfaction more general and specific comments, and the game design The trend, on average, was that participant satisfaction with the suggestions were recorded. Of the 76 unique comments, 50% game was positive, with scores averaging between 3.34 and (38/75) were positive about the game and playing the game, 4.25 (neutral and agreement) on a 5-point Likert-type scale in 9% (7/75) were negative, and 41% (31/75) were neutral or response to 5 satisfaction questions (see Table 5). The average involved game design suggestions for the future (such as agreement decreased slightly by the end of the study, perhaps changes to fonts, scoring, additional backgrounds or images). because of the decrease in novelty or instrument fatigue. Many of the positive comments (21/38) included evaluative Participants agreed with all satisfaction statements at the end statements like, “Fun,” “Cool,” and “Liked it.” The negative of the study, however. comments comprised a mixture of skepticism about the game efficacy, stress inducement, soreness, or general dislike. Qualitative Results A total of 48 participants offered additional comments in the surveys as well as in an unstructured interview after playing the http://games.jmir.org/2018/2/e7/ JMIR Serious Games 2018 | vol. 6 | iss. 2 | e7 | p. 7 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Metcalf et al Table 5. Game satisfaction scores (5-point Likert-type scale). N/A: not applicable. Game satisfaction Session 1 Session 2 Session 3 Session 4 (1-week (n=52) (n=52) (n=52) follow-up; n=29) Game focus—I feel that: The game was fun. 4.43 4.48 4.37 4.10 This game was engaging. 4.58 4.48 4.48 4.17 Based on my experience, I would recommend this game to other patients in 3.88 3.98 4.00 3.67 treatment for substance use problems. Based on my experience, this game will aid in my substance use treatment and 3.45 3.55 3.81 3.53 recovery. Overall, this game will be a useful substance use treatment and recovery tool. 3.78 3.83 4.12 3.70 Game feedback—The game seems like it will help with my treatment in terms of: Relapse prevention 3.41 3.40 3.65 N/A Seeking help 3.22 3.10 3.38 N/A Sticking to treatment 3.68 3.60 3.88 N/A Better long-term outcomes 3.76 3.65 3.69 N/A Higher quality of life 3.61 3.70 3.71 N/A to cues for substance use can have a triggering effect and thus Discussion have the potential to undermine recovery. This did not happen often, which is encouraging and a necessary result for further Quantitative Results research into the use of game- or electronic-based CET There are several important results of this brief study. First, that adjunctive technologies. participation in the study and use of the game seem to support Participant Satisfaction, Self-Efficacy, and Behavior abstinence from substance use based on the 7-Day Timeline reports when game users are compared to participants in the Key Findings control group. The 7-Day Timeline instrument reported Secondary findings revolve around participant enthusiasm for decreased or maintenance of no substance use at a poststudy the game experience and impact the potential of the game as a follow up for most of the 29 participants in the game use group. supportive product in the future. Participants found the game That is, substance use decreased or remained the same for most engaging and fun. users, although more for alcohol users than for tobacco users. Additionally, participants felt playing the game during recovery This suggests that participation in the study did support would help with relapse prevention and related behaviors. abstinence from substance use and that the effect might be Agreement with this was highest after session 3. stronger for alcohol use than tobacco use. Additional research There was a slight but intriguing difference in results for those is needed to determine if this effect is due to participation in a who reported recovery for alcohol use as their primary goal study or the intervention. versus those who chose recovery from tobacco use. Specifically, A second finding is that there were fewer positive results seen self-efficacy increased for those in recovery for alcohol use, but in substance use during the wait-list control period for those there was a minor, not statistically significant decrease in participants. In other words, there was a general increase in use, self-efficacy for former tobacco users. Differences between not decrease while controls waited. This suggests that being in these 2 groups could be an area of further research, as misuse a study and knowing that they would have to report on their of both substances is harmful to health in the US population. substance use did not change their baseline behavior. This result Another improvement seen from pre- to postintervention strengthens the argument that it was use of the game that follow-up was an increased intention to use health care, decreased substance use for participants, rather than participation resources, and support groups. in the study. Future research could examine this finding further. Limitations A third finding is that scores for self-efficacy, attitude, and There are limitations worth noting in this study. The study intended behavior went up significantly from baseline to week population was small and was a convenience sample of 3 (P=.03) for patients still using alcohol at baseline. This, participants who were interested in maintaining their status in together with the greater decrease in substance use for the group recovery, and thus they may not be typical of all individuals that selected alcohol as the substance to work on, suggests that having substance use problems. Second, time was constrained, the game benefits may be greater with respect to alcohol use. which impacted how often participants could use the game. In Finally, it is noteworthy that few participants reported an an ideal setting, the game experience would be available to increase in use of their substance. This was a concern due to the possibility, as seen in CET modalities, that exposing users http://games.jmir.org/2018/2/e7/ JMIR Serious Games 2018 | vol. 6 | iss. 2 | e7 | p. 8 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Metcalf et al participants more frequently, and a dose-response investigation Finally, Microsoft is no longer actively developing Kinect could be conducted. applications; although current versions of the Xbox One continue to support use (as of August 2017). Thus, future Kinect is a kinesthetic game and requires a minimum level of versions of the game should explore additional platforms while physical ability to move arms or legs, and this limits the reach maintaining the kinesthetic element of game play and explore of the game. A participant was able to use the game from a how this impacts results. wheelchair in early testing, but more modifications are needed to effectively reach a mobility-limited population. Also, in terms Conclusions of the physicality of the game, we believe that the possible This study indicates that a serious game–based intervention has aggressiveness of the game is balanced by the positive potential to be a useful part of recovery efforts for individuals interactions of taking control of one’s environment; however, seeking to maintain abstinence from alcohol or tobacco misuse a psychological professional would need to evaluate whether or use. The use of a kinesthetic game based in a cue refusal this game is appropriate for individuals with aggressive theory framework-based intervention could prove a valuable tendencies. adjunct to therapy in the future. Games have the ability to reach and engage a significant audience segment, and the use of an Given this was a short-term feasibility study, long-term studies individually tailored game could expand potential treatment would need to be conducted to address the complexities of experiences. rehabilitation from various addictions. Acknowledgments This project was supported entirely by an Small Business Innovation Research (SBIR) contract from the National Institutes of Health (HHSN2712013000041C). Conflicts of Interest The authors are the employees of the small business that received the SBIR contract to develop and evaluate this game. All development and evaluation (except for the data analysis) was performed by Clinical Tools staff, including the study design, collection of data, writing of the report, and the decision to submit the report for publication. Brad Tanner is the owner of Clinical Tools Inc and may profit from any sale of the game. Multimedia Appendix 1 Self-efficacy, attitude, and intended behavior scores for case and control participants who completed 3 game play sessions (N=50). [PDF File (Adobe PDF File), 18KB-Multimedia Appendix 1] References 1. Traylor AC, Parrish DE, Copp HL, Bordnick PS. Using virtual reality to investigate complex and contextual cue reactivity in nicotine dependent problem drinkers. Addict Behav 2011 Nov;36(11):1068-1075. [doi: 10.1016/j.addbeh.2011.06.014] [Medline: 21783326] 2. Monti PM, Rohsenow DJ. Coping-skills training and cue-exposure therapy in the treatment of alcoholism. Alcohol Res Health 1999;23(2):107-115. [Medline: 10890804] 3. Lee JS, Namkoong K, Ku J, Cho S, Park JY, Choi YK, et al. Social pressure-induced craving in patients with alcohol dependence: application of virtual reality to coping skill training. Psychiatry Investig 2008 Dec;5(4):239-243 [FREE Full text] [doi: 10.4306/pi.2008.5.4.239] [Medline: 20046344] 4. Paris MM, Carter BL, Traylor AC, Bordnick PS, Day SX, Armsworth MW, et al. Cue reactivity in virtual reality: the role of context. Addict Behav 2011 Jul;36(7):696-699 [FREE Full text] [doi: 10.1016/j.addbeh.2011.01.029] [Medline: 21349649] 5. García-Rodríguez O, Pericot-Valverde I, Gutiérrez-Maldonado J, Ferrer-García M, Secades-Villa R. Validation of smoking-related virtual environments for cue exposure therapy. Addict Behav 2012 Jun;37(6):703-708. [doi: 10.1016/j.addbeh.2012.02.013] [Medline: 22385732] 6. Bordnick PS, Traylor A, Copp HL, Graap KM, Carter B, Ferrer M, et al. Assessing reactivity to virtual reality alcohol based cues. Addict Behav 2008 Jun;33(6):743-756. [doi: 10.1016/j.addbeh.2007.12.010] [Medline: 18282663] 7. Girard B, Turcotte V, Bouchard S, Girard B. Crushing virtual cigarettes reduces tobacco addiction and treatment discontinuation. Cyberpsychol Behav 2009 Oct;12(5):477-483. [doi: 10.1089/cpb.2009.0118] [Medline: 19817561] 8. Girard B, Turcotte V. A virtual arm to stop smoking, a perceptual learning experiment. 2007. URL: https://www. clinicaltrials.gov/ct2/show/NCT00639093 [accessed 2017-11-27] [WebCite Cache ID 6vHvl1Qmz] 9. Pericot-Valverde I, García-Rodríguez O, Gutierrez-Maldonado J, Ferrer-García M, Secades-Villa R. Evolution of smoking urge during exposure through virtual reality. Stud Health Technol Inform 2011;167:74-79. [Medline: 21685645] 10. Lee J, Kwon H, Choi J, Yang B. Cue-exposure therapy to decrease alcohol craving in virtual environment. Cyberpsychol Behav 2007 Oct;10(5):617-623. [doi: 10.1089/cpb.2007.9978] [Medline: 17927528] http://games.jmir.org/2018/2/e7/ JMIR Serious Games 2018 | vol. 6 | iss. 2 | e7 | p. 9 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Metcalf et al 11. Van Gucht D, Baeyens F, Vansteenwegen D, Hermans D, Beckers T. Counterconditioning reduces cue-induced craving and actual cue-elicited consumption. Emotion 2010 Oct;10(5):688-695. [doi: 10.1037/a0019463] [Medline: 21038951] 12. O'Brien CP, Childress AR, McLellan T, Ehrman R. Integrating systemic cue exposure with standard treatment in recovering drug dependent patients. Addict Behav 1990;15(4):355-365. [Medline: 2248109] 13. Kaplan GB, Heinrichs SC, Carey RJ. Treatment of addiction and anxiety using extinction approaches: neural mechanisms and their treatment implications. Pharmacol Biochem Behav 2011 Jan;97(3):619-625. [doi: 10.1016/j.pbb.2010.08.004] [Medline: 20723558] 14. Romano D. Virtual reality therapy. Dev Med Child Neurol 2005 Sep 01;47(9):580. [doi: 10.1111/j.1469-8749.2005.tb01206.x] 15. Bordnick PS, Carter BL, Traylor AC. What virtual reality research in addictions can tell us about the future of obesity assessment and treatment. J Diabetes Sci Technol 2011 Mar 01;5(2):265-271 [FREE Full text] [doi: 10.1177/193229681100500210] [Medline: 21527092] 16. Glanz K, Rizzo A, Graap K. Virtual reality for psychotherapy: current reality and future possibilities. Psychother Theory Res Pract Train 2003;40(1-2):55-67. [doi: 10.1037/0033-3204.40.1-2.55] 17. Litt MD, Kadden RM, Kabela-Cormier E. Individualized assessment and treatment program for alcohol dependence: results of an initial study to train coping skills. Addiction 2009 Nov;104(11):1837-1838 [FREE Full text] [doi: 10.1111/j.1360-0443.2009.02693.x] [Medline: 19712124] 18. Roessler KK. Exercise treatment for drug abuse—a Danish pilot study. Scand J Public Health 2010 Aug;38(6):664-669. [doi: 10.1177/1403494810371249] [Medline: 20529968] 19. Smith MA, Lynch WJ. Exercise as a potential treatment for drug abuse: evidence from preclinical studies. Front Psychiatry 2011;2:82 [FREE Full text] [doi: 10.3389/fpsyt.2011.00082] [Medline: 22347866] 20. Principles of drug addiction treatment: a research-based guide. 3rd Edition.: National Institute on Drug Abuse; 2015 Nov 3. URL: https://d14rmgtrwzf5a.cloudfront.net/sites/default/files/ 675-principles-of-drug-addiction-treatment-a-research-based-guide-third-edition.pdf [accessed 2018-03-31] [WebCite Cache ID 6yL3x8uhq] 21. Holder H, Longabaugh R, Miller WR, Rubonis AV. The cost effectiveness of treatment for alcoholism: a first approximation. J Stud Alcohol 1991 Nov;52(6):517-540. [Medline: 1661799] 22. Hester RK, editor. Handbook of Alcoholism Treatment Approaches: Effective Alternatives, 3rd Edition. Boston: Allyn and Bacon; 2002. 23. Carroll K. Cognitive-behavioral approach: treating cocaine addiction. 2013 Feb 7. URL: https://archives.drugabuse.gov/ sites/default/files/cbt.pdf [accessed 2018-03-31] [WebCite Cache ID 6yL4F42AL] 24. Girard B, Turcotte V, Bouchard S, Girard B. Crushing virtual cigarettes reduces tobacco addiction and treatment discontinuation. Cyberpsychol Behav 2009 Oct;12(5):477-483. [doi: 10.1089/cpb.2009.0118] [Medline: 19817561] Abbreviations CBT: cognitive behavior therapy CET: cue exposure therapy SBIR: Small Business Innovation Research VRT: virtual reality therapy Edited by G Eysenbach; submitted 20.10.17; peer-reviewed by AE Eleftheriou, C Tziraki; comments to author 03.11.17; revised version received 23.02.18; accepted 13.03.18; published 16.04.18 Please cite as: Metcalf M, Rossie K, Stokes K, Tallman C, Tanner B JMIR Serious Games 2018;6(2):e7 URL: http://games.jmir.org/2018/2/e7/ doi: 10.2196/games.9231 PMID: 29661748 ©Mary Metcalf, Karen Rossie, Katie Stokes, Christina Tallman, Bradley Tanner. Originally published in JMIR Serious Games (http://games.jmir.org), 16.04.2018. 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JMIR Serious Games – JMIR Publications

Published: Apr 16, 2018

Keywords: addiction treatment; Kinect; serious games; motion control games; virtual reality

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