Editor Charles Ward
Virtual Reality-Based Cue Exposure and Aversion Therapy for Alcohol Dependence: A Randomized Controlled Trial
Zhao et al., in: Addiction Biology, May 2026, Vol 6 (31:e70166),
Key Messages
● Combining virtual reality cue exposure therapy (VR-CET) and aversion therapy (AT) significantly reduced short-term alcohol cravings among a cohort of 80 patients with alcohol use disorder (AUD).
● As hardware costs drop, immersive VR offers a highly scalable method of delivering advanced addiction therapy.
● Despite craving reductions, the VR interventions did not translate into lower relapse rates at 4 or 12 weeks.
● Severe loss to follow-up obscured long-term efficacy, reinforcing the message that post-discharge adherence to treatment remains the greatest predictor of AUD recovery.
Article Summary
This was a single centre randomised controlled trial conducted by a team from Henan Medical University, Henan, China, assessing the effect of virtual reality cue exposure therapy (VR-CET) and aversion therapy (VR-AT) on alcohol craving, emotional state, sleep quality, attention span and relapse rate among a group of 80 male patients with diagnosed alcohol use disorder (AUD). Inclusion criteria were meeting diagnostic criteria for AUD, male sex, age between 18 - 60, no significant withdrawal symptoms and ability to co-operate with VR treatment and complete follow-up assessment.
Immersive cue therapy relies on attenuating alcohol craving through repeated exposure to alcohol-related stimuli without allowing consumption. This was conducted in the VR environment by the placement of a wide variety of alcohol products in the virtual space that the participant was able to interact with, while a small amount of liquor aroma was perfused into the space to provide olfactory stimulation. Aversion therapy aims to eliminate alcohol-seeking behaviour by providing an adverse stimulus or discomfort, which in this case was produced by participants taking part in an immersive virtual experience lasting approximately 10 minutes, simulating specific scenarios such as “arguing with a partner”, “hypothermia after drinking”, “cycling accidents” and “vomiting”.
Patients were assigned to either a control group receiving a standard treatment pathway, or were given 8 sessions of VR-CET, VR-AT or combined treatment over 15 days. Patients were assessed before and after treatment using a visual analogue scale for self-reported alcohol craving, along with the Pennsylvania Alcohol Craving Scale, the Hamilton Depression Scale, the Hamilton Anxiety Scale and the Pittsburgh Sleep Quality Index. Attention span was measured using eye tracking and grasping indices while in the virtual environment.
The authors found that all groups (including the control) showed significant improvement against all metrics. VR groups, especially the combined VR-CET and VR-AT group showed substantial improvement in reduction of alcohol craving assessed post treatment on a visual analogue scale. Nevertheless, this did not translate into any measurable improvement in relapse rate at four and twelve weeks among the cohort. Across the cohort, the authors saw substantial loss to follow-up, which prevented a fuller picture of the effects of their programme.
Commentary
Traditionally, aversive therapy consisted of electric shocks and other noxious stimuli, however this has largely been retired owing to safety risks and poor adherence. While pharmacological aversion via disulfiram (which causes vomiting, vertigo, anxiety and nausea with alcohol) continues to be prescribed worldwide, modern practice has largely shifted toward anti-craving mechanisms like naltrexone and acamprosate which do not suffer from the compliance issues common with aversive treatment.
The use of a VR environment to provide aversive stimuli is certainly novel, although a similar strategy was employed by Sadeghi et al in their 2025 study assessing craving and depression among patients using methadone maintenance treatment. They too noted that VR strategies provided short-term benefits in terms of reduction of cravings, drug-seeking behaviour and a reduction of self-reported depressive mood, although they did not report the effects of their VR-based treatment on relapse or adherence to follow-up, and so direct comparison between the two studies is difficult [2]. Nevertheless, the finding of Zhao et al that all groups (including the control group that did not receive VR treatment) benefited suggest that inpatient treatment and routine care alone can provide substantial benefits in AUD.
Why Is This Important?
This was a fascinating study to read and it certainly provided an interesting and thoroughly innovative approach to AUD treatment. The recent proliferation of affordable VR devices has undoubtedly made such virtual treatment environments possible at scale and conceivably, they could in the near future provide both a potent method of treatment and a means of provisioning treatment to remote or poorly served areas. It is quite likely that we are going to be seeing a lot more of this over the coming years.
Sadly, as is typical of many studies into AUD the authors noted high loss to follow-up. A number of studies have determined that, by a large margin, the strongest predictor of successful treatment of AUD among inpatient cohorts is consistent attendance at follow-up and aftercare appointments [3]. While novel strategies fielded by Zhao et al provide a novel approach to AUD, finding some means of increasing adherence to treatment should be a key priority for alcohol treatment studies moving forward.
References
1. Zhao H, Ying X, Du X, Ren G, Deng H, Li W, Wang J, Chen M, Shao Z, Zhang J, Liu L, Zhang J, Cui P, Li C, Wang X, Xu Y, Zhang J, Wang D, Wang C. Virtual Reality–Based Cue Exposure and Aversion Therapy for Alcohol Dependence: A Randomized Controlled Trial. Addict Biol. 2026 May 6;31:e70166. doi:10.1111/adb.70166 PubMed PMID: 42091202; PubMed Central PMCID: PMC13148881.
2. Sadeghi N, Mousavinasab ES, Sharifi E, Ghoreishi FS, Ghaderi A, Omidi A. The Effect of Aversive Therapy Using Virtual Reality on Craving, Depression, and Self-Efficacy: A Pilot Study in Patients Under Methadone Maintenance Treatment. Brain Behav. 2025 Oct;15(10):e70953. doi:10.1002/brb3.70953 PubMed PMID: 41076546; PubMed Central PMCID: PMC12515104.
3. Farren CK, McElroy S. Predictive factors for relapse after an integrated inpatient treatment programme for unipolar depressed and bipolar alcoholics. Alcohol Alcohol. 2010;45(6):527–33. doi:10.1093/alcalc/agq060 PubMed PMID: 20855410.
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