VR-Choice operates using the HTC Vive XR Elite headset and Vive Ultimate Trackers for the left and right wrists. The VR-Choice experience has 2 components. First, participants are presented with a calming virtual environment, developed using the Unity 3D gaming platform (version 2022.3.57f1) [42] intended to induce positive affect and an open mindset; we focused on facilitating the emotion of awe, as it involves cognitive processes—appraisals of vastness, feelings of smallness and connectedness, and accommodation of new ideas—that overlap with the mechanisms within empirically supported interventions for substance use disorder (eg, mindfulness [43]). In this environment, participants proceeded through 4 scenes of increasing elevation to the top of a mountain (“Mountain Journey”). Subsequently, participants were presented with an array of virtual bubbles, each of which, when touched, allowed an immersive glimpse of a 180-degree video showing a positive representation of life after recovery (“Possible Worlds”).

Our process for developing the 2 components of the virtual experience was iterative. In phase 1, we developed the virtual environment for Mountain Journey, which was characterized by relaxation, awe, and forward momentum, modifying it iteratively based on feedback from the research team, academic labs, and interviews with participants with lived experience (LE), who were community members with past or current nonprescribed opioid use. In phase 2, we ideated, selected, storyboarded, and filmed nine 180-degree videos representing positive aspects of life during recovery for Possible Worlds, beginning with interviews with LE stakeholders. In phase 3, we collected feedback on the combined VR-Choice experience (Mountain Journey + Possible Worlds) from LE stakeholders (see Phase 3 Feedback Process for a detailed description of measures). Verbal consent was obtained from all potential stakeholders prior to obtaining feedback or audio recording VR sessions. We describe the process for each phase in Figure 2.

The research team consisted of clinicians, researchers, and developers from 4 different institutions, all based in the continental United States. Two members of the team were clinical investigators with expertise in substance use and MOUDs. They received funding for the project and directed the overall research team. Two team members headed VR laboratories specializing in clinically oriented VR interventions. They both engaged their laboratory trainees in the iterative evaluation of the VR environments. The development team consisted of 2 developers with experience in creating VR environments for clinical applications, focusing on pain and rehabilitation. The team met via Zoom weekly or semiweekly during the course of the project and shared stimuli by email and through Google Drive.

All procedures were reviewed and approved as exempt by the Baystate Medical Center Institutional Review Board, and all participants signed informed consent forms or consented verbally. Participants were compensated US $50 per hour, prorated by time (ie, if the interview lasted only half an hour, the participant received US $25). All data presented have been anonymized.

In addition to the content and composition of the videos, we also discussed how participants would navigate this part of the experience. The bubbles were laid out in a grid pattern on a slightly concave curvature to allow for easier viewing and reachability. The bubble videos are rendered at 720p and compressed to 360p on a slightly transparent material to allow for a less claustrophobic presentation while keeping the file sizes and processing overhead low enough to run 9 videos simultaneously without catastrophically plunging the framerate. Vignettes of each scene were visible within each “bubble” so that participants could preview the material and avoid selecting content that might be distressing for personal reasons. For example, some participants might choose to avoid viewing materials with children, animals, or religious imagery. Participants could select bubbles more than once and could view as many of the videos as they liked. A voiceover at the beginning of the scene suggests that participants view at least 3 bubbles and that they could leave any scene at any time.

This paper describes a 3-stage, iterative process that drew heavily on incorporating the experiences and perspectives of people with LE in all aspects of the design and refinement of the VR-Choice platform. VR-Choice was intended to address affect and motivation among patients admitted to the ED following overdose, with the goal of increasing their readiness to engage in SDM for treatment with MOUDs. VR-Choice consists of a VR journey up a mountain (“Mountain Journey”) culminating in the presentation of nine 180-degree videos showing different positive aspects of life during recovery (“Possible Worlds”). The bubble content reflects themes derived from LE interviews conducted across the country. In total, we were able to engage with 59 participants with past or current OUD during the design process. Of the 20 participants who experienced the final version of the platform, none reported more than slight motion sickness symptoms. Nineteen of 20 participants stated they liked the videos shown in the final version, considered it to be potentially helpful for patients in the emergency room after an opioid-involved overdose, and thought the experience should be offered to those patients. All participants agreed that the program was easy to use, and only 1 participant described it as confusing.

Both the context and patient population targeted by VR-Choice necessitated careful consideration of multiple ethical and design factors. Specific efforts were made to mitigate simulation sickness, given the likely physical state of patients following overdose or overdose treatment, which informed the design of transitions “up the mountain” and between scenes. Once the intervention is deployed clinically, participants will experience the virtual environment seated and under the observation of health care workers. The positive feedback from non–ED-based OUD stakeholders is encouraging but will need to be further examined within the specific context of postoverdose ED care.

In order to mitigate the risk of psychological distress in a vulnerable population, substantial attention was given to the content of Possible Worlds bubbles, balancing the inclusion of themes endorsed as meaningful by stakeholders (eg, caring for children) with sensitivity to content that could be personally triggering. To that end, the content of each bubble is made readily apparent to viewers (visible inside the bubble) to inform participants’ selection, and mechanisms were incorporated to allow for a quick and easy exit if desired. All content was carefully curated to be positive. While the development of the administration protocol draws heavily on input from LE experts, including individuals with OUD and ED personnel, issues around informed consent remain relevant given the potential differences in states of readiness among ED patients during an opioid-related visit. For future evaluations of VR-Choice involving patients in the ED, the informed consent process will include a detailed screening to ensure patients are not altered in mental status, feeling sick, or in significant distress prior to the experience. Consent will also include an overview of VR-Choice—including the content of the Possible Worlds bubbles—and a clear emphasis that patients may remove the headset and stop the experience at any time, for any reason. Following preliminary evidence supporting the feasibility and efficacy of VR-Choice within the ED, future large-scale studies should incorporate implementation metrics, including the integration of VR-Choice within ED workflows and evaluation of the intervention’s cost-effectiveness.

This experience was limited by both technical factors and constraints in the co-design process. In terms of technical limitations, there was no interactivity, personalization, or embodiment in any of the VR or 180-degree video scenes. Participants could not reach out and touch or manipulate objects. In the video scenes, while we did our best to simulate a sense of social presence, the actors were only pretending to make eye contact and engage with an imaginary speaker and as such could not respond to any behavior on the part of the participants. Because the camera was set at a height of 5′5″, it did not necessarily match participants’ actual height. Similarly, neither hands nor body were portrayed in any of the scenes to avoid a mismatch with participants’ actual bodies. Therefore, when participants looked down, they would see only empty space. As technology continues to advance, we expect to eventually gain the ability to rapidly create avatars of a user and integrate them into digital scenes; current platforms capable of this, such as the Apple Vision Pro, remain prohibitively expensive and technically demanding for the purposes of this project.

In addition, there were challenges in working with our target population. First, obtaining a representative sample of participants with LE was especially challenging. Participants were often difficult to contact, so follow-up interviews were challenging to conduct. Second, many people do not have personal experience with VR, meaning that for many stakeholders, including many clinical members of the research team, it was challenging to imagine possible outcomes. Future work developing in this area could consider how to provide a sample VR experience before asking people to comment on screenshots or other nonimmersive content. However, this brings other issues, including the fact that the novelty of participants’ “first VR experience” might create an anchoring effect.

Next steps will include feasibility, acceptability, and preliminary efficacy testing in the actual ED setting with the population of interest (individuals following opioid-involved overdose). The data collected from this work will subsequently inform the planning of a larger randomized controlled trial testing the VR-Choice intervention against a standard intervention type.

Future studies may further explore mechanisms of change and participant responses, drawing on both EIC theory and established models of health behavior adoption. For instance, the ability to choose elements within the VR intervention aligns with principles of self-determination theory by potentially enhancing autonomy and competence through interactive engagement with the Possible Worlds bubbles [49]. Similarly, the intervention incorporates aspects of the transtheoretical model of change [50] by targeting the precontemplation and contemplation stages through visualization of recovery-related benefits. Given the acute nature of the ED setting, such questions will likely be best addressed through collaboration with laboratory-based human testing. Pragmatic considerations will ultimately include conducting a cost-benefit analysis comparing the VR-Choice platform with more established (but, as noted, potentially insufficient) approaches, such as motivational interviewing, contingency management, and peer recovery coaching, to highlight the unique contribution of the VR approach. Future studies may also wish to examine combining VR-Choice with more traditional approaches for a potential synergistic impact.

The potential applications of this intervention are wide, including acute treatment programs (detoxification centers), outpatient intake assessments, or harm reduction sites, with appropriate modifications to address the specific barriers relevant to each context. In addition to applications for substance use, it may be valuable to explore the use of such motivationally oriented VR experiences in other health behavior change contexts, such as smoking cessation, eating disorders, and physical activity promotion.

In this paper, we present VR-Choice, a virtual environment designed to improve affect and motivation among patients with OUD in the ED following an overdose and to increase their readiness to engage in shared decision-making for treatment with MOUDs. While the efficacy of this app has not yet been tested, initial feedback from participants with LE points to the feasibility of VR as a way to engage patients undergoing an extremely difficult experience in a challenging environment. This work contributes to the growing body of innovative nonpharmacological approaches for addressing the opioid crisis. Our VR intervention should be positioned within the spectrum of novel digital health interventions being developed for substance use disorders, highlighting how it addresses specific gaps in existing approaches for engaging patients in the critical ED setting.