A smoker trying to quit walks into the midst of a party in full swing. Guests with drinks and cigarettes in hand already fill the room. It is only a matter of minutes before revelers eager to make small talk approach the new arrival with questions. As a courtesy, someone offers a cigarette. But this is no ordinary cigarette; in fact, it doesn’t even exist.

The whole scene is part of a newly developed virtual reality software program designed to help treat people addicted to nicotine. It is one of the first efforts to apply virtual reality to drug addiction treatment. Researchers are also attempting to expand the model to cocaine addiction by creating a virtual crack house. The hope is that virtual reality will provide an effective tool for a group of people notoriously hard to treat.

Addicts often experience a profound desire or craving for a drug when they come across cues associated with it, and this can lead to a relapse. Money commonly triggers cravings in cocaine users, as does coffee in cigarette smokers, but people, places, paraphernalia, and other objects can also act as cues. Accordingly, therapy is often based on exposure to drug cues that trigger cravings. The idea is that if an addict can work through their urges in a therapist’s office, this will help decrease cravings when they are confronted with cues in the real world.

Traditionally, therapists use role-playing within a doctor’s office or devices such as slides, videotapes, pictures, or objects to help desensitize addicts to drug cues. But some do not think this is the most effective therapeutic tool for patients. “Role-playing can be kind of goofy,” said Patrick Bordnick, assistant professor of social work at the University of Georgia, who has extensive experience working with cocaine addicts. “I can be a pretty convincing crack addict, but in the end they still know it is Dr. Bordnick.”

Virtual reality now offers a possible alternative. It first emerged in the medical community about a decade ago as a tool for treating phobias. The first controlled study, conducted in 1995 by Barbara Rothbaum, director of the Trauma and Anxiety Recovery Program at Emory University School of Medicine, focused on the fear of heights. During the study, she exposed subjects to virtual bridges, balconies and a glass hotel elevator that climbed 49 floors. Her results showed a decrease in stress and anxiety among those in the group treated with virtual reality and revealed that they reported more positive attitudes about height than those in the control group. More than 50 percent of treatment group members exposed themselves to heights in the real world without being asked to do so.

Meanwhile, the cost of virtual reality technology began to decline. “It was kind of an intuitive fit with phobias,” said Brenda Wiederhold, executive director of the Virtual Reality Medical Center in San Diego, a clinical practice devoted to virtual reality as a tool for treating psychiatric disorders. Traditionally, therapists would have patients imagine what they were afraid of or take them into a real-world situation in order to desensitize them. Now, therapists can expose patients to a variety of situations right there in the office. For example, therapists with patients afraid of flying no longer have to travel all the way to the airport to have them sit on a plane. Instead, they can expose patients to a complete flight, making it smooth, turbulent or stormy, in the course of one therapy session.

Treatment of addicts is similar in principle to exposure therapy for phobias. One of the first clinics to use virtual reality to expose addicts to cravings was Virtually Better in Decatur, Ga. When the center opened in 1996, Ken Graap, the company’s president, helped therapists treat Vietnam veterans suffering from post-traumatic stress disorder by exposing them to virtual war scenes. He noticed that a lot of these men were also addicted to nicotine or other drugs and wondered if virtual reality could treat those problems, too. He teamed up with Bordnick, who had been wondering how virtual reality might help addicts reduce cravings in the real world.

Funded by a grant from the National Institute on Drug Abuse, Bordnick and Graap started a controlled clinical trail in 2002 with 20 people in order to determine whether a virtual environment could help smokers quit. Their first goal was to test whether the cues in the program actually triggered cravings.

To enter the virtual world they created, you stand on a platform and don a helmet equipped with headphones and a visor that falls over your eyes. The smoking program designed for the study, which lasts about 20 minutes, consists of three rooms. The first contains underwater aquarium scenes unrelated to smoking, what Graap calls a “neutral environment,” where you’re asked a series of questions about your current desire to smoke. This allows researchers to get base-line physiologic data such as heart rate and sweat gland activity as well as base-line information on craving and mood.

From there, the program randomly sends you to one of two rooms. One room contains a table laid out with bottles of beer, packs of cigarettes and a burning cigarette resting in an ashtray. Before the session begins, a therapist can program the specific brand of cigarette you use so a familiar pack appears on the table. On a side table along the wall is a large pot of coffee. On the way out there is a mini bar with the sound of ice clinking in glasses and bottles of alcohol arranged neatly on the shelves. Bordnick and Graap hope to add olfactory cues to accompany the images you see as you move through the rooms. The goal is to have the smell of cigarette smoke waft towards you as you walk past the table, followed by the smell of coffee brewing as you approach the far wall.

The other room contains a virtual party with three groups of people in a living room holding beer bottles and cigarettes and talking. Upon entering, the first group approaches you, asking questions and making small talk. Others discuss smoking and offer cigarettes.

Ultimately, you’ll experience all three environments — the neutral room, the inanimate objects room and the virtual party. After a stay in each room, your physiological responses are monitored and you again rate your craving to smoke by answering a series of questions.

During the study, Bordnick had people reaching for packs of virtual cigarettes while using the program. This convinced him that the virtual environment had the potential to elicit cravings. It turns out he was right. The final results show that you can induce nicotine craving in a virtual environment. The study is currently in press at the Addictive Behaviors journal.

Now that their research has revealed that the program can elicit cravings, Bordnick and Graap hope to design a program that can reliably induce cravings. From there, the program could also be used to test pharmaceuticals developed to reduce cravings for cigarettes.

After her success with virtual reality and phobias, Rothbaum also saw the potential of using the technique for addictions. Last summer, she received a separate grant with Virtually Better to test the idea of a virtual crack house for cocaine addicts. The virtual crack house will work in much the same way as the virtual smoking program. The design team for Virtually Better visited local drug dens with local police in Georgia before they began creating the environment, eventually working from digital pictures. As a result, subjects will be able to view drug deals occurring in dark doorways and explore dim, dingy rooms. They will also hear the sounds of sexual encounters through closed doors and see addicts huddled in corners smoking pipes or sprawled on the floor. According to Rothbaum, a therapist would work with the subject throughout the experience to monitor and rate drug craving through a series of questions.

Researchers are also using virtual reality technology to add another layer to their studies. By projecting virtual environments into a functional magnetic resonance imaging scanner, or fMRI, they hope to use the resulting brain images to determine exactly which parts of the brain are activated when a former addict continues to experience a craving.

Preliminary results from a brain imaging study of nicotine addicts conducted by Steve Baumann, virtual reality/fMRI project manager for Psychology Software Tools, a private Pittsburgh company, reveal the feasibility of this technique. His results show brain activation in areas previously reported to be involved in drug craving and cigarette smoking, such as the amygdala, hippocampus and prefrontal cortex. These results lay the groundwork for a controlled virtual reality smoking study in the fMRI and open the way for expansion to cocaine and alcohol addiction studies.

The goal of such integrated systems is to provide investigators and clinicians with flexible programs that can be tailored to their needs. Ultimately the technology won’t provide all the answers to the difficulties inherent in treating drug addiction, but it will add to the arsenal of available treatments. “Virtual reality programs don’t do the treatment by themselves, the therapist does the treatment,” Graap says, “but these are the tools.”