Acceptability and Perceived Utility of Virtual Reality Among People Who Are Incarcerated Who Use Drugs

Abstract

People who are incarcerated are at heightened risk of overdose upon community reentry. Virtual reality (VR) may provide an innovative tool for overdose prevention intervention in corrections facilities. This mixed methods study sought to understand incarcerated individuals' perspectives on VR for overdose prevention and explore physiological arousal associated with use of VR equipment. Study participants were 20 individuals, stratified by gender, with an opioid use disorder at a county jail. Qualitative interviews assessed acceptability and perceived utility of VR in the jail setting. Thematic analysis indicated high levels of acceptability and potential utility in the following areas: (a) mental health and substance use interventions, (b) community reentry skills training, and (c) communication and conflict resolution skills. Heart rate variability (HRV) data were collected continuously during the interview and during VR exposure to explore whether exposure to the VR environment provoked arousal. Physiological data analyses showed a significant decrease in heart rate (HR) [b = −3.14, t(18) = −3.85, p < .01] and no arousal as measured by root mean square of successive RR interval differences (RMSSD) [b = −0.06, t(18) = −1.06, p = .30] and high frequency-HRV (HF-HRV) [b = −0.21, t(18) = −1.71, p = .10]. This study demonstrated high acceptability and decreased HR response of VR among incarcerated people who use drugs.

Introduction

Fatal overdoses remain a growing crisis in the United States, with over 100,000 people dying during the first 12-month period associated with the COVID-19 pandemic (Centers for Disease Control and Prevention, 2021). Illicit fentanyl and related compounds have dramatically accelerated the epidemic of overdose-related deaths. National trends in opioid prescribing, changes in policy, and the actions of pharmaceutical companies have contributed to large-scale transitions from licit prescription opioid use to illicit prescription opioid and heroin use (Biancuzzi et al., 2022). Consequently, many people with an opioid use disorder (OUD) come into contact with the criminal justice setting (National Institute on Drug Abuse, 2021).

The critical attributes of OUD are the development of tolerance (i.e., the need for progressively higher doses of the drug to achieve the same effect) and withdrawal, a combination of deeply aversive physical and psychological symptoms that, together, negatively reinforce drug-seeking behaviors. These attributes predict the natural history of this disorder. As people who use opioids develop tolerance, the financial resources required to acquire increasing amounts of the drug also increase. To acquire the desired drug effect and to avoid withdrawal symptoms, many people with OUD report engaging in illegal behaviors (e.g., commercial sex work, theft, or involvement in the drug trade; Biancuzzi et al., 2022).

These behaviors, along with the criminalization of simple drug possession in the United States, lead many people with OUD to involvement in the criminal justice system. Each year, an estimated 24% to 36% of all people who are addicted to heroin—over 200,000 people—pass through U.S. prisons and jails (Boutwell et al., 2007).

Although there is an elevated concentration of people with OUD in correctional settings, access to evidence-based treatment has been scarce (Vestal, 2018). Medication for OUD is the most effective evidence-based approach to address OUD and reduce overdose risk, but people who are incarcerated—a large, underserved, and particularly vulnerable population—have historically lacked access in the United States (Vestal, 2018).

For most people with OUD who are in prisons and jails, incarceration is a period of relative abstinence that diminishes drug tolerance. This reduced tolerance, paired with the absence of evidence-based treatment in correctional settings and poor linkage and access to treatment in the community, increases vulnerability to opioid overdose following release from incarceration. During the weeks that follow a period of incarceration, people with recent criminal justice involvement experience greatly elevated risk of opioid overdose (Binswanger et al., 2007, 2013; Farrell et al., 2008; Merrall et al., 2010). Risk of death is significantly heightened during the first 2 weeks following release. In the United States, postincarceration rates of overdose deaths are 129 times higher during the first week relative to subsequent weeks (Binswanger et al., 2007).

Given the growing opioid epidemic and the greatly elevated risk of opioid overdose among those with recent criminal justice involvement, there is an urgent need to address OUD in criminal justice-involved populations and develop interventions to prevent overdose upon community reentry. We have failed to fully harness the technological capabilities to facilitate prevention of deaths associated with drug overdoses. Virtual reality (VR) technology allows developers to create common scenarios of environmental trigger situations to elicit drug cravings, such as being exposed to places or locations that may elicit a drug craving (e.g., bar scenario, party scenario).

We know little about effective uses of VR technology among people with an OUD. Until recently, VR was significantly limited by its costs and the quality of multimedia content. VR has been most extensively investigated in the context of post-traumatic stress disorder (PTSD; Botella et al., 2015). Recently, it has gained traction for other environmental trigger disorders, such as phobias and substance use disorders (SUDs; Metcalf et al., 2018; Pla-Sanjuanelo et al., 2017). When combined with coping skills training, it allows participants to develop coping strategies to overcome cravings and urges in a controlled, safe environment to better prepare for real-world scenarios.

Wiederhold et al. (2014) discussed the potential for VR to reduce prescription opioid drug misuse. The authors noted the dearth of funding and research that has limited development and testing of evidence-based VR-assisted behavioral interventions for opioid use, highlighting that a majority of funding has been directed toward pharmacological treatment. Studies have demonstrated that VR affects both psychological and neurophysiological mechanisms; however, we have yet to explore these mechanisms among people with OUDs (Ferreri et al., 2018).

VR technology allows manipulation of both environmental and perceptual cues to trigger cravings in a controlled environment. This elicits cognitive and physiological reactions that are experienced in real-world environments upon exposure to these cues. VR-assisted behavioral intervention allows for patients to develop coping strategies and overcome maladaptive patterns of behavior, such as cravings and urges, in a clinical setting. Metcalf et al. (2018) noted that through VR technology we can “more accurately recreate individualized environments that [relate to the participant] to increase cravings and elicit other measurable physical responses.”

The use of VR to recreate trigger environments and social interactions through the use of avatars (e.g., representations of a person in digital reality) may better simulate the environment, use of the drug, or peer pressure that frequently accompanies drug use. These scenarios may prove superior to in vivo exposure methods, which are limited within a clinical environment (Marissen et al., 2007). VR-assisted therapies have proven to be acceptable and are more effective than standard treatment and waitlist control groups for people with serious mental illness, PTSD, and eating disorders (Ferreri et al., 2018; Välimäki et al., 2014). These disorders are similar to SUDs in that they involve cue exposure and response (PTSD) and impulse control (eating disorders).

While VR-assisted therapies show promise, no research to date has examined the potential utility and acceptability of VR tools among people who are incarcerated. van Rijn et al. (2015) investigated the use of avatar-based therapy in a prison setting to improve mental health outcomes among participants. Qualitative results indicated better engagement with personal issues, empathy development, and improvements in relationships. However, the sample size (N = 4) was insufficient to make significant conclusions.

Incarcerated populations are vulnerable and, thus, require extra precautions when testing technology-delivered interventions. This population has higher levels of trauma and may experience heightened physiological arousal in scenarios that may be perceived as unsafe. VR may be an environment that increases physiological arousal and stress response among this population as it requires participants to engage in a virtual environment that requires wearing head gear that fully encloses a participant's vision within their environment.

Before developing VR-based interventions, it is imperative to understand perspectives of people who are incarcerated on the use of this technology in the jail setting and to evaluate potential negative consequences of use of this type of technology with this population, such as increasing stress and physiological arousal just through engaging with the equipment alone.

The present study aimed to explore perspectives among incarcerated people with an OUD on the use of VR tools for overdose prevention in the jail setting. In addition, we sought to conduct exploratory analyses to understand the potential of VR equipment to elicit heightened physiological arousal, an indicator of psychological stress (Immanuel et al., 2023). Our purpose was to provide a preliminary understanding of the psychological safety of using VR-based interventions among a vulnerable population that is at high risk for developing mental health disorders during incarceration.

Method

We used qualitative and quantitative methods to explore perspectives among people incarcerated at a Texas county jail on the use of VR in the jail setting. We explored the following qualitative research questions: (a) how acceptable is VR among people who are incarcerated? and (b) what is the perceived utility of VR interventions in the jail setting among the target population?

We also collected heart rate variability (HRV) data to assess possible physiological arousal during VR exposure. This is important to assess as people who are incarcerated are considered a vulnerable and protected population. We want to evaluate possible adverse effects associated with the VR tools. All procedures were developed in collaboration with the behavioral health team at the study site and approved by the University of Texas at Austin institutional review board.

Participants and Study Setting

We recruited men and women at a correctional facility who were classified as minimum custody. Participants were eligible if they (a) were at least 18 years of age, (b) had history of an SUD or currently met criteria for an SUD, (c) were incarcerated for at least 1 month, (d) were able to understand and speak English, and (e) were not pregnant. Participants were excluded if they were unable to provide written informed consent or were actively psychotic. We also excluded individuals with a diagnosis of epilepsy, schizophrenia, or a medical condition that caused susceptibility to dizziness and disorientation. Participants were not compensated for study participation, but received a 2-hour release from duties to participate.

The behavioral health team at the facility identified potentially eligible participants through their behavioral health records and briefly explained the study to them. Only two people who were invited to participate in the study declined. Individuals who were interested were taken to a private room in the behavioral health division at the jail to meet with two research staff.

Data Collection and Risk Management

Eligible and interested participants scheduled a time to complete the interview, which occurred in a small room without other visual or auditory distractions. At the interview, we gave participants the informed consent forms to read and verbally reviewed the informed consent; participants had an opportunity to ask questions. Participants were asked to complete a brief survey of demographics and measures about substance use, health, and life experiences. All interviews were audio-recorded and participants were made aware of this in the consent process. Individuals who chose to participate signed the informed consent form. The interview lasted approximately 120 minutes.

The study aimed to assess potential experience of stress as a byproduct of the VR experience among people who are incarcerated. To mitigate and quickly respond to potential adverse events, the VR experience was conducted in a private room in the behavioral health division. The director of the behavioral health division was on-call and nearby if an adverse event occurred. Additionally, one study investigator was a doctoral-level licensed clinical psychologist and another investigator was a doctoral-level social worker.

The qualitative interview guide consisted of two sections: pre-VR exposure and post-VR exposure. The pre-exposure questions asked participants about their experience and knowledge of VR and perspectives on the utility of VR in the jail setting. Utility was defined as the personal benefit or value from VR-delivered interventions. We assessed their level of interest and willingness in using VR at the jail both pre- and post-VR exposure.

Following the pre-exposure questions, participants were oriented to the VR equipment and scenario. Participants were instructed to “talk aloud” during their exposure to express their thoughts and feelings during the activity. They were given 10 minutes to engage in the VR experience without interruption or additional instruction (explained in detail in the VR Tools and Scenario section).

The post-exposure interview guide asked about participants' experiences including perceived ease of use, enjoyment/excitement, immersion, presence, interactivity, cybersickness, and feelings of safety and trust. The final section of the interview explored participants' perception on the utility of VR interventions among people who are incarcerated. We specifically probed for perceptions related to mental health, substance use, and overdose prevention interventions. Finally, we reassessed participant level of interest and willingness to participate in a VR intervention while incarcerated.

Surveys

Survey measures were used to describe the target population, particularly their psychological state and substance use behavior. Demographic data collected from study participants included age, sex at birth, gender identity, sexual orientation, race, ethnicity, living situation before incarceration, educational attainment, and employment status before incarceration.

Drug Use Prior to Incarceration

The timeline followback (TLFB) measure was used to assess drug use in the 30 days before incarceration. The TLFB measure is a calendar-assisted structured interview that provides a way to cue memory so that accurate recall is enhanced (Fals-Stewart et al., 2000; Robinson et al., 2014; Sobell & Sobell, 1992). A structured interview has been found to be the most reliable and valid method of assessing prior substance use. The 30-day TLFB has test–retest coefficients of up to 0.93 (Carey et al., 2004; Sacks et al., 2003).

The TLFB interview was administered to capture the number of days of drug use. Participants were asked, “did you use opioids yesterday? How much did you use?” The number of days used was recorded on a printed calendar and digitized using an Excel spreadsheet.

Opioid Overdose Knowledge

The Brief Opioid Overdose Knowledge (BOOK) questionnaire is a psychometrically sound, 12-item self-report measure (score range: 0 to 12) that is used to assess three domains: opioid knowledge, opioid overdose knowledge, and opioid overdose response knowledge (Dunn et al., 2016). Participants were instructed to answer “true,” “false,” or “I don't know” to questions such as “methadone is a long-acting opioid” and “trouble breathing is not related to opioid overdose.” The BOOK questionnaire was administered to capture participants' overall knowledge with regard to opioids.

Overdose Risk Behavior

The extant literature offers no gold standard by which to measure opioid overdose risk behavior (ORB) other than prior overdose, and more recent data suggest any illicit fentanyl use is a risk factor. Thus, we followed the same criteria as Pouget et al. (2017) and asked participants whether they had engaged in the following risk behaviors during the 30 days before incarceration: (a) using opioids while alone, (b) using opioids in conjunction with alcohol, and (c) using methadone that was not prescribed to them. Each of these behaviors is proven to increase the risk of overdose (Foglia et al., 2021).

For example, individuals who use opioids alone are at heightened risk of fatal overdose as a bystander is not available to administer naloxone in the event of an overdose. Using opioids in conjunction with alcohol has been shown to increase opioid overdose morbidity and mortality (Witkiewitz & Vowles, 2018).

Depression

Depression and trauma data were collected to characterize the study population and understand how generalizable the study population is comparable to other jail settings. The Center for Epidemiological Studies—Depression Scale (CES-D; Radloff, 1977) was used to measure the level of depressive symptoms. The scale has 20 items and asks how often during the past week participants have experienced symptoms of depression such as restless sleep, decreased appetite, feeling lonely, and trouble concentrating. Response options range from 0 (rarely or none of the time) to 3 (most or all of the time). The total score (range 0 to 60) is calculated as the sum of the scores for each item. This scale is widely used and has high Cronbach's alpha reliability values between 0.89 and 0.90 (Clark et al., 1981; Ensel, 1986).

Trauma

The Childhood Traumatic Events Scale (CTES; Pennebaker & Susman, 2013) is a self-report questionnaire used to assess the presence and impact of historical traumatic events before the age of 17 years. It asks six questions that correspond to six domains: (a) death of a family member or a very close friend, (b) parental divorce or separation, (c) traumatic sexual experience, (d) victim of violence, (e) been extremely ill or injured, and (f) other major upheaval.

For each question, the participant was asked about the age of trauma, perceived severity of the trauma (range: 1 = not traumatic at all to 7 = extremely traumatic), and whether the trauma was disclosed to others. The total severity score range is 6 to 42 (higher numbers indicate higher severity). The Recent Traumatic Events Scale (RTES; Pennebaker & Susman, 1988) covers the last 3 years and assesses the same domains with two differences: parental separation is replaced with separation/divorce from a spouse or significant other and a new category of job change is added (Lai et al., 2016).

Physiological Arousal

We used HRV data to investigate physiological arousal to the VR exposure using heart rate (HR) and variability indices. Ideally, to demonstrate the safety of this intervention, we want to minimize vagal nerve withdrawal in this stage of VR introduction. Increased HR and vagal nerve withdrawal in later stages of VR testing, in which a triggering stimulus is introduced, may be expected, but at this stage an increase in HR would indicate that VR is problematic.

HRV is a measure of the variation in time between heartbeats and HR is the number of beats per minute (McCraty, 2015). Both reflect control of cardiovascular processes by the autonomic nervous system (ANS; Bilchick & Berger; 2006; Shaffer & Ginsberg, 2017). The ANS has two divisions and arousal can be characterized by activation of the sympathetic division or suppression of the parasympathetic division (Brindle et al., 2014; Laborde et al., 2017).

For this study, we focus on HR and two HRV indices, RMSSD (root mean square of successive RR interval differences) and HF-HRV (high frequency-HRV). RMSSD and HF-HRV both capture the functioning of parasympathetic nervous system controlled by the vagus nerve. An increase in HR and decrease in RMSSD and HF-HRV indicate vagal withdrawal. Vagal withdrawal occurs in response to multiple environmental and emotional stimuli including but not limited to temperature (Jungmann et al., 2018), physical pain (Bar-Shalita et al., 2020), exercise (Fontolliet et al., 2018), and stress (Brindle et al., 2014). We obtained data from the Polar H10 Heart Rate Sensor (Polar Electro Oy, Kempele, Finland).

Before the interview began, participants were fitted with a chest strap that fixed the sensor to the center of their chest. We recorded HRV data continuously beginning with the interview through the end of the VR exposure—thus, the VR exposure was added during HRV measurement. The participants were sitting during both conditions (interview and VR exposure). Data from the sensor were captured on an iPad via Bluetooth connection using the EliteHRV 4.7.2 (Elite HRV LLC, Asheville, NC, USA) software for iOS devices.

VR Tools and Scenario

Two complete kits of equipment were used so that multiple participant sessions could be conducted in parallel in separate rooms. Each kit consisted of one laptop, one VR equipment set, and the software used during the sessions. The VR equipment was the Oculus Rift VR Set with one headset, two motion controllers, and two external motion sensors.

We worked in collaboration with the behavioral health team at the jail to develop the study protocol. Since no research has been conducted on VR with this population, we decided that a neutral VR exposure was a good starting point to examine acceptability and usability of VR among participants before exposing them to a potentially triggering stimulus. The Green Meadows scenario was used from the Nature Treks VR game. This scenario included an immersive three-dimensional experience in a green meadow. The experience allows the user to move through the environment and create different aspects to the experience, such as seeing animals, moving through water, and controlling the weather and time of day. Elements within the environments react procedurally to the audio and visual cues.

We hypothesized that exposure to the VR with the Green Meadows scenario will not increase physiological arousal (i.e., vagal withdrawal). An increase of vagal withdrawal during the VR exposure may indicate psychological stress and the experience of stress may decrease individuals' willingness to engage in a VR intervention.

Data Analysis

Qualitative Data

Interviews were audio-recorded and transcribed verbatim. Trained research assistants reviewed transcripts and recordings for errors. A preliminary coding structure was derived deductively from the interview guide. Data were coded and analyzed using applied thematic analysis (Guest et al., 2011). Two trained coders independently reviewed transcripts and applied specific subtype coding to the coding structure inductively as themes emerged from the data. A master codebook was finalized after three iterations. All transcripts were independently coded by the two coders. The coders met to review discrepancies and discuss code assignments. After consensus was reached for all codes, the final set of master codes was entered into NVivo. Themes were extracted related to the a priori research questions.

Quantitative Data: Surveys

Analyses were conducted in SPSS version 26. Univariate statistics for continuous and categorical variables were used to broadly examine the characteristics of the sample population. Psychometric scale scores were created as means or sums of scores, as appropriate.

Quantitative Data: Physiological Arousal

Kubios HRV Premium 3.2 software (Kubios Oy, Kuopio, Finland) was used to analyze the HRV data collected from the HR sensor and calculate three indices (HR, RMSSD, and HF-HRV). HRV data were collected continuously, and two 5-minute periods were chosen to assess physiological arousal—Time 1 (first 5 minutes of the interview) and Time 2 (first 5 minutes of VR exposure). HRV was measured at the beginning of each condition in order for researchers to have a baseline measure of psychological stress. Stress at this stage of the protocol is a bad sign for tolerance of the intervention at a later stage (i.e., when the trigger situations are introduced).

The duration of the physiological measurements was determined by best practice guidelines proposed by HRV research scientists to capture sufficient data and promote consistency in study results across different laboratories (Laborde et al., 2017; Malik, 1996). Linear mixed models (LMMs) were created using SAS 9.4 software (SAS Institute, Cary, NC, USA) to determine physiological arousal to VR exposure. LMMs account for correlations in the measures due to repeated measurement (Time 1 and Time 2) from the same individual and random intercept in the models accounts for variability across the participants (Magezi, 2015). Gender and age were added as control variables in the models.

Results

Quantitative Data

Our sample consisted of 20 participants, with 50% female and 50% male. Participants were predominantly heterosexual (65%). The sample was mostly White (75%) with almost half of Hispanic origin (45%). More than half of participants were married or cohabited (55%) followed by single (25%). Seventy percent had children and 70% had an education level of General Equivalency Diploma or higher. Sixty-five percent had a full-time or part-time job. See Table 1 for participant characteristics.

Table 1.

Participant Characteristics

Variable	N (%)
Age, mean (SD)
18 Years or older	32.47 (8.369)
Gender identity
Male	10 (50.0)
Female	10 (50.0)
Sexual orientation
Exclusively homosexual	0 (0)
Homosexual with some heterosexual experience	1 (5.0)
Bisexual	3 (15.0)
Heterosexual with some homosexual experience	3 (15.0)
Exclusively heterosexual	13 (65.0)
Race (check all that apply)
African American or Black	3 (15.0)
Asian	1 (5.0)
White	15 (75.0)
Native American	1 (5.0)
Native Hawaiian or Pacific Islander	0 (0)
Other	3 (15.0)
Ethnicity
Hispanic or Latino	9 (45.0)
Not Hispanic	9 (45.0)
Religion
Catholic	2 (10.0)
Protestant	2 (10.0)
Jewish	1 (5.0)
Islamic	0 (0)
None	6 (30.0)
Other	9 (45.0)
Relationship status
Married or cohabitating	11 (55.0)
Noncohabitating relationship	2 (10.0)
Single	5 (25.0)
Divorced or separated	2 (10.0)
Loss of long-term partner or widowed	0 (0)
Children
Yes	14 (70.0)
No	6 (30.0)
Who you live with (check all that apply)
Self	7 (35.0)
Partner or spouse	9 (45.0)
Roommates	2 (10.0)
Children	5 (25.0)
Group home or residential treatment	0 (0)
Other	3 (15.0)
Education level
Eighth grade or lower	0 (0)
Partial high school	3 (15.0)
High school graduate	3 (15.0)
GED	6 (30.0)
Partial college	5 (25.0)
College graduate	2 (10.0)
Partial graduate school	1 (5.0)
Graduate school degree	0 (0)
Work/school
Full-time work	9 (45.0)
Part-time work	4 (20.0)
Full or part time in school	0 (0)
Neither work nor school	3 (15.0)
On disability	0 (0)
Other	3 (15.0)

The mean number of days participants used drugs within the past 30 days prior to incarceration was 18.68. As shown in Table 2, mean scores generated for each domain of the BOOK questionnaire, which measures opioid overdose knowledge, were 2.47 for opioid knowledge, 2.73 for opioid overdose knowledge, and 1.57 for opioid overdose response knowledge. Since the possible range of scores was 0 to 4, the sample's mean scores were mid-range (except for the last domain). The total BOOK score for this sample was 6.78, also mid-range (possible range of scores is 0 to 12).

Table 2.

Survey Measures

Measure	Description/domains	Score
Brief Opioid Overdose Knowledge (N = 19)		Mean
	Book 1: General Opioid Knowledge	2.47
	Book 2: General Opioid Overdose Knowledge	2.73
	Book 3: Specific Opioid Overdose Knowledge	1.57
	Book total	6.78
Overdose Risk Behaviora(N = 19)		Mean
	ORB1. Use opioids alone	1.31
	ORB2. Use opioids and alcohol at the same time	1.00
	ORB3. Use methadone that was not prescribed to you	1.05
	Total score	3.36
		No. (%)
	ORB1. Yes	7 (35.0)
	ORB1. No	11 (55.0)
	ORB1. I don't know	1 (5.0)
	ORB2. Yes	2 (10.0)
	ORB2. No	15 (75.0)
	ORB2. I don't know	2 (10.0)
	ORB3. Yes	2 (10.0)
	ORB3. No	16 (80.0)
	ORB3. I don't know	1 (5.0)
Center for Epidemiologic Studies Depression Scaleb(N = 20)		Mean
		17.20
Childhood Traumatic Events Scalec,d(N = 20)		Mean
	Death of a very close friend or family members	3.25
	Major upheaval between your parents	2.85
	Traumatic sexual experience	2.20
	Victim of violence	1.60
	Been extremely ill or injuries	1.00
	Other major upheaval that you think may have shaped your life or personality significantly	2.60
	Childhood traumatic burden (sum of the above ratings)	13.50
Recent Traumatic Events Scaled(N = 20)		Mean
	Death of a very close friend or family members	2.65
	Major upheaval between your parents	1.75
	Traumatic sexual experience	0.35
	Victim of violence	2.40
	Been extremely ill or injuries	2.60
	Major change in the kind of work you do	0.70
	Other major upheaval that you think may have shaped your life or personality significantly	2.65
	Recent traumatic burden (sum of the above ratings)	13.10

^aAnswer options: Yes = 2, No = 1, I don't know = 0.

^bPossible range of scores is 0 to 60, with higher scores indicating the presence of more symptomatology.

^cSummed up the ratings on each of the six domains on the CTES to derive a score (childhood traumatic burden) that ranged from 0 to 42 (6 domains × rating up to 7 for each domain).

^dSubsample of participants who responded “Yes” to each domain.

Results from three ORB questions (possible range of scores is 0 to 2) indicated that participants were engaged in overdose-related risky behaviors: (a) score of 1.31 for using opioids while alone, (b) score of 1 for using opioids in conjunction with alcohol, and (c) score of 1.05 for using methadone that was not prescribed to them. The mean total score for the sample was 3.36/6.

The mean score generated for the CES-D scale was 17.2, demonstrating very low level of depressive symptoms in our sample (possible range of scores is 0 to 60).

The mean score generated for six domains of the CTES ranged between 1 and 3.25 (possible range of scores is 0 to 7), where being “a victim of violence” or “extremely ill” was reported less frequently and “death of a very close friend or family members” was the most commonly reported traumatic event. The total childhood traumatic burden among our sample was 13.50, which was very low as the possible range of scores is 0 to 42.

With regard to physiological arousal, our analysis shows a significant decrease in HR [b = −3.14, t(18) = −3.85, p < .01] during the VR exposure, but no significant outcomes for RMSSD [b = −0.06, t(18) = −1.06, p = .30] or HF-HRV [b = −0.21, t(18) = −1.71, p = .10]. Thus, one of our three measures indicates that our participants experienced reduced physiological arousal.

Qualitative Data

See Table 3 for emergent themes and representative quotes.

Table 3.

Emergent Themes and Subthemes From Qualitative Data

Emergent themes and subthemes and representative quotes
Acceptability of VR
High interest
• I think other people would show up. They'll probably be more into it than coming to class and just hurrying up trying to get a certificate and get out, like they would actually do something with their time because it has something to do with technology, compared to just paper and a word, and somebody talking, and they're not. (101, female)
• They want to escape, even if you know—even if it's just for a minute, even if it's just people researching them. A lot of people are missing their kids, a lot of people are not leaving here, a lot of people are looking at like 10 years. You know so if this is their chance to get out of here just for a little bit, and maybe relax and not worry about everything, and not have to stress, and not have to worry, even if it's for 10 minutes, I think anybody would be down. (115, female)
• …people get frustrated in here…They want to fight and argue…but like, if we're all like you know doing virtual reality, and like you saw how like I smiled as soon as I put it on. You know, like it was cool. So like, the next person's going to be like anxious to do it and then be excited to do it and the whole time everybody's excited, energy's good. Being excited is never a bad thing. I'm pretty sure everybody smiled who put on that virtual reality headset. You know, it's just something, it's just cool. You know. Makes everybody go, “What'd you see? What'd you see?” And then everybody can watch the monitor while you're doing that and they see and they're like, “Now I want to do that, I want to do that.” And then they get all excited and then you know it—But I think having it in the tank would also be good though, because it's always going to be there. You know what I'm saying? Because when I go back to tank, I'm going to be like, “Oh man, I wish I still had that virtual reality.” (114, male)
Low interest
• …it was kinda hard—the hand things…and there wasn't much to do. I wish I could have seen animals and stuff like that. (107, female)
• Maybe if they liked it, or if it made them feel so good that afterwards, they were kind of like, “Dang, now I'm back in here,” you know what I mean? What if it makes it worse, you know what I mean? It's like somebody letting you out for a day and then coming back. And now you're gonna do five years, you know what I'm saying? Might as well just stay … keep my mind where I'm at, you know what I mean? A lot of people have that mindset, you know what I mean? They don't wanna hear from that, they don't wanna make calls, they don't wanna talk to anybody outside. A lot of people are like that, ‘cause they don't wanna I mean experience or, like if you have that feeling of anxiousness from getting to talk to somebody out there, whatever, and then coming right back in here… (112, male)
• I'm sure it could trigger people have had traumatic events… people with PTSD. Obviously, people that have seizures. (103, female)
• Just a lot of people that don't believe in doing right as far as thieves and people who hurt people… I think there should be limited virtual reality use. (109, female)
Perceived utility of VR
Reentry skills training
Vocational skills
• Education would be great. Like electrical school or welding school or something like that ‘cause you could do hands on with that type stuff. Vocation would be great. I mean if I was able to study that. Part of it was learning how to do landscape design. So they had us on computers in landscape design. That would be great for something like that. Move trees. Design a piece of property. A lot of these guys if you don't know, they sit in their cells and they design their own homes. It's part of… not really wasting time but kinda getting out of here and doing something constructive, like oh this is what I want to do when I get out. (110, male)
• …kind of puts you there, kind of practice before you're put in a real situation. I mean I'm sure there's many industries where they use something where you're simulated before you're really doing. (106, male)
• A lot of people would [be open to VR,] especially if there were vocational courses. I think a lot of people would be—it'd probably be a list to get in there. (112, male)
Skills to obtain job
• I feel like training for like a job, and they do the job readiness, the reentry [training], all that. But even as far as like taking a test, the GED test or a trade or something, some kind of learning. I feel like not everybody does good reading and on paper, so being able to see it and it's kind of like the hand–eye coordination thing. I do better with show me one time and I'm going to catch it, as to where you're probably going to have to explain it to me five times. (105, female)
Communication and conflict resolution skills
• Instead of just wanting to beat each other up, what are other ways you can connect or you can figure it out and talk? I think it'll help a lot of different ways, and even just with everything, it just knocks out all the negative and it's a positive in every kind of aspect, every kind of way. (105, female)
• I know a lot of ways, I mean I feel like maybe if they were to give you an obstacle and how you would do something different, maybe this could kind of help you plan out how will you get out there and you're faced with it. It could help in that way…. Maybe like behavioral or substance abuse, just everything. Everything that leads you to being in this environment right here. Maybe if you had that, it's like the what would you do if you were given the chance right now to go out there, what would you do different that you were doing before you got in here? … Like obviously in a video game if you lose it's game over, you got to start all over and try again and figure it out. So kind of in that kind of way, if you do that go way and go and buy some drugs or get on it, then game over. Start over. What would you do different to make sure that when you are able to be released to go out there and be successful and not just fall into the same habit or same ways you were doing before? (105, female)
Mental health
Anger and stress management
• [The jail] used to have a guitar class. They used to have just a bunch of different stuff and I guess the classes just get thrown out…. I feel like they should have things that just make it easier, you know? Because that's where the depression comes in and people get aggravated and want to fight people. The attitudes come because there's nothing to do but be negative… [with VR there may be] less depression…I mean, just something to get the girls up and wanting to do something instead of just being in there and crying because they're not going to go home or they got really sad or mad…but when you have things to look forward to like the classes…it's like almost escaping from the pod. But if there was more, more exciting classes, I'm pretty sure everybody would be on board with getting up early, staying in classes, going back, and that way when you go back you can actually share with “Oh this is what I learned today, this is what we did over here” instead of being there “Oh, can you believe this girl's been talking about me?” It blocks out all negative and it'll be more positive, more entertaining, more… instead of watching somebody fight you'll be able to come and do stuff like this. (105, female)
• I just feel like you should be able to talk to when you need to talk to them, not have to fill in a slip and get called two weeks later and you know, you've already beat somebody up and went to lockdown because you had all this built in you. Maybe even for that, maybe even some kind of stress relieving or breathing or you know some kind of, I don't know. Maybe even something in there that could sit there and tell you what to do, like if you have an issue or different ways to go about it. I think that would be cool too. (105, female)
• Like have a fake jail in there and somebody on the phone and immediately you're going to want to smack the guy. You kind of have to smack him. That might be a good way to desensitize people to fight or flight reaction or something like that… I think it'd be real enough. (118, male)
Mindfulness and meditation
• Like if you're looking to help somebody relax or be more at ease or something, like I can see that being beneficial. I really like being outside anyway, so I was kind of actually getting into the whole, I can move around and go check stuff out, kind of thing. (102, male)
• Mentally, it keeps you away. That's really what it is in here. When you're in jail, most of it is mentally. Everything that brings you down is mentally. Even a relapse is all mental. It's all in our head. So being able to distract ourselves mentally is going to help you in any type of aspect. (119, female)
• Yeah, I think so, because even without it, it was really calming for me and I feel like being able to hear a soft voice tell you “Breathe, it's okay, touch the water,” I think that'd be real helping. (105, female)
• I think the biggest thing is that because it did make a big impact on me. It made a bigger impact than I thought. It was just neat. It really made me feel like I wasn't in this situation. Being able to have a positive environment around you, it triggers your mentality, and you start thinking in a clearer manner. It helps. Your environment always does help…When you start being in a good, positive environment that's making you feel good, you start thinking about everything, not just in … Excuse my language, “I don't give a fuck anyway” mentality. It's more like the prize at the end of the line. Once you get there, and what are you really working for? What do you really want? What's that saying? You can't do the same thing expecting a different outcome. It gets you to think. (119, female)
Therapy-based experiences
• Definitely like meditation, or like some kind of art, if they can be painting, or some kind of therapy, like pet therapy, even just like virtual pets would be cool. (115, female)
• A lot of times in groups, nobody wants to open up because they're so worried about what the hell the next person is going to think about them. And if they could go through some type of therapy session or a class and do this every day, but do it on their own, by themselves and they can feel more safer. Like it's more confidential that way. (103, female)
• You know how there's some people that have pet allergies? [Veterans] could have pet allergies. You know, to dogs? They're good for [therapy]. That [a virtual pet] would be another thing that this would be good for. (119, female)
Substance use
Education
• Maybe if you had something that could show the damage you were doing to your body by doing drugs in a virtual sense. Like, there's a lot of people in here that have had pig valves in their hearts and stuff from diseases from improper needle usage. People are cutting heroin with tootsie rolls and god knows what else. (118, male)
• So maybe if [my mom] would've seen a video and how [overdose] does to you and the video be virtual reality and she herself in that scenario, maybe she wouldn't have done it or maybe she would've been mind-strong and, “Hey, well this is going to happen to me if I do this another step.” …But if you could see yourself in that position before you think about taking another step into drug life, you know, I think that would… Yes, that would be very helpful. (109, female)
Overdose and relapse prevention
• Helping to prevent relapse…if there is something in this virtual reality that can trigger something in the brain that could help people to not relapse, that would be like a cure to AIDS…because it's an epidemic and it's serious and if that can help, I'm all for it. (103, female)
12-Step programs
• Go to meetings, or like, have virtual reality meetings or something. ‘cause I don't have a car, I don't have a license, it'd be hard to get to a meeting or something. Something like that. ‘Cause I know with like recovery, you have to chase your recovery the way you chased your drug, and it's hard when you don't have transportation, or support or—’cause my mom does drugs. (115, female)
• I would think Alcoholics Anonymous or Narcotics Anonymous. They can use it, you know, because a lot of them, even in this environment, being in here, there's still a lot of people that talk about their drug use. Mentally, a lot of people still relapsed while they're in jail. Being able to like get into virtual reality, I think maybe they could, depending on what they use to keep off their mind. Some people, they do get into a gospel not to relapse. They get into their Bible. Being able to hear someone, their testimony, or any other type of therapy. Like I said, pet therapy, you know, to keep their mind from it. I think that could help. (119, female)
Virtual therapy sessions
• Like have virtual reality meetings or something…’cause with recovery you have to chase recovery the way you chased your drug and it's hard when you don't have transportation or support [upon community reentry]. While you're [in jail] go see those triggers…and prepare them for that situation. (115, female)
• If you were to do a virtual reality counseling thing, I think that that would be good as well because again, some people don't like to open up to other people, they don't get it all out and versing something in a computer, they're not going to judge you, they're not going to go back and tell your business, they're not going to say this and that about you. Because we're having that problem right now in a brave class that somebody is telling somebody else's business and stuff so if it was kind of one-on-one virtual reality, they're giving you that comfort, you know that somebody's listening but they're not going to go back and voice what's going on with you. I think that would be great, too. (109, female)

A majority of male and female participants expressed high levels of interest and willingness to use VR both pre- and post-VR exposure. Several participants noted mild adverse experiences with the equipment. These included mild headache from the headset being too tight, difficulty navigating the virtual environment using the hand tools, and difficulty understanding how to navigate the virtual environment.

Only one participant reported having a negative experience overall as a result of the environment being “blurry” and that “it was kinda hard—the hand things…and there wasn't much to do. I wish I could have seen animals and stuff like that” (Participant ID: 107, female). Following the VR exposure, she reported not being interested at all in using VR; however, she said she would still be willing to use a VR intervention during incarceration, as she believed this type of program would prepare her for community reentry:

Because this is where it starts before you go into the world…like me, my attitude is real bad. I got a bad temper. But in here, I like calm myself down. I look at it like is it really worth it and I say, ‘Nah, it ain't?’…it's just getting me ready for the world. [With VR] I can separate myself from different people. In [jail] you're just here. You're trapped. You can't walk nowhere else. Going through [the VR environment] makes it more better to go in the world and deal with situations like this. (Participant ID: 107, female)

Participants noted that preferences for using VR will vary among incarcerated people and may not be a useful delivery mechanism for some; however, the technology may improve attendance and engagement in programs:

I think other people would show up. They'll probably be more into it than coming to class and just hurrying up trying to get a certificate and get out, like they would actually do something with their time because it has something to do with technology, compared to just paper and a word, and somebody talking. (Participant ID: 101, female)

Participants noted that VR may not be a useful tool for some people who are incarcerated, specifically individuals with medical conditions, such as epilepsy and seizures; people with mental health conditions, such as claustrophobia and PTSD; and people with violent tendencies. Concerns about VR included the potential that people may become jealous over VR usage and fights may occur over the VR equipment, as well as adverse reactions to the VR scenarios such as triggering PTSD symptoms or causing relapse to substance use.

One participant noted that the virtual experience might remind people of the real world and have unintended negative consequences:

What if it makes it worse, you know what I mean? It's like somebody letting you out for a day and then coming back…Might as well just stay … keep my mind where I'm at, you know what I mean? A lot of people have that mindset, you know what I mean? They don't wanna hear from that, they don't wanna make calls, they don't wanna talk to anybody outside. (Participant ID: 112, male)

As to the perceived utility of VR programs in the jail setting, emergent themes pertaining to potential usefulness encompassed the following domains: reentry skills training, mental health, and substance use. Almost half of the participants discussed the utility of VR tools to facilitate job training and increase readiness upon community reentry. Male participants noted interest in virtual scenarios that would help them develop a skillset for a trade such as welding, HVAC, electrical work, horticulture, and landscape design.

Education would be great. Like electrical school or welding school or something like that ‘cause you could do hands on with that type stuff. Vocation would be great. I mean if I was able to study [landscape design]… that would be great for something like [VR]. Move trees. Design a piece of property…It's part of… not really wasting time but kinda getting out of here and doing something constructive, like oh this is what I want to do when I get out. (Participant ID: 110, male)

Male and female participants noted the use of VR to improve skills for obtaining a job, such as interviewing scenarios and GED test preparation.

I feel like training for like a job, and they do the job readiness, the reentry [training], all that. But even as far as like taking a test, the GED test or a trade or something, some kind of learning. I feel like not everybody does good reading and on paper, so being able to see it and it's kind of like the hand–eye coordination thing. I do better with show me one time and I'm going to catch it, as to where you're probably going to have to explain it to me five times. (Participant ID: 105, female)

Several of the female participants noted how VR may be used to develop communication and conflict resolutions skills. A couple of participants noted potential of VR to teach people how to drive; however, they also noted concerns about learning this type of skill in a virtual environment instead of in a real-world scenario as the virtual skills may not fully represent a real-world driving scenario.

All participants indicated that VR has the potential to improve the mental health functioning of people during incarceration. The most common emergent themes included anger and stress management, mindfulness and meditation, and a variety of therapy-based experiences. One participant indicated that VR may reduce depression and fights among people housed in the jail:

[The jail] used to have a guitar class. They used to have just a bunch of different stuff and I guess the classes just get thrown out …I know you mess up, it's not supposed to be fun being in jail, but … you're already in jail, you're not going to be able to go home, you're having to deal with who you are and coming off of whatever you're coming off of, and just dealing with your own personal issues…Because that's where the depression comes in and people get aggravated and want to fight people. The attitudes come because there's nothing to do but be negative… [with VR there may be] less depression…I mean, just something to get the girls up and wanting to do something instead of just being in there and crying because they're not going to go home or they got really sad or mad…but when you have things to look forward to like the classes…it's like almost escaping from the pod…It blocks out all negative and it'll be more positive, more entertaining, more… instead of watching somebody fight you'll be able to come and do stuff like this. (Participant ID: 105, female)

Almost all participants indicated that the VR nature scenario was relaxing and calming, providing an “escape.” Female participants described a variety of therapy options including art therapy, pet/animal therapy, and traditional psychotherapy options. “Definitely like meditation, or like some kind of art, if they can be painting, or some kind of therapy, like pet therapy, even just like virtual pets would be cool” (Participant ID: 115, female).

Male and female participants noted challenges to engaging in mental health treatment and existing programs delivered in the jail. Several participants reported not engaging in therapy because it is currently delivered by people employed in the jail system. They noted that this created concerns related to privacy and confidentiality of the information shared with jail staff. “If they could go through some type of therapy session or a class and do this every day, but do it on their own, by themselves, and they can feel more safer. Like it's more confidential that way” (Participant ID: 103, female). Furthermore, they reported not wanting to establish a relationship with a temporary therapist in the jail and then have to change to a therapist in the community upon release.

Participants noted that virtual counseling sessions with a community-based therapist while incarcerated would alleviate these barriers to establishing mental health care while incarcerated. This type of mental health delivery would allow them to establish a therapeutic relationship with a treatment provider during incarceration and increase the likelihood that they would continue therapy with the same provider following incarceration. They also indicated that there would be less concern about privacy and confidentiality breeches, as the therapist would not be associated with the jail and would not be aware of what happens in the jail; thus, the therapist may be less biased and more committed to the patient's health and well-being.

All participants noted that VR may be useful for people with SUDs who are incarcerated. Themes emerged related to substance use and addiction education, overdose and relapse prevention, 12-step programs, and virtual therapy sessions.

A few participants noted that VR may be a tool used to provide more in-depth information for substance use education. Education topics of interest included the health effects of substance use on the physical body, what experiencing an overdose is like, and coping with triggers. One participant said,

Maybe if you had something that could show the damage you were doing to your body by doing drugs in a virtual sense. Like, there's a lot of people in here that have had pig valves in their hearts and stuff from diseases from improper needle usage. People are cutting heroin with tootsie rolls and god knows what else. (Participant ID: 118, male)

A majority of participants noted that VR tools may effectively reduce overdose and substance use relapse upon community reentry if an effective treatment program is delivered during incarceration.

Helping to prevent relapse…if there is something in this virtual reality that can trigger something in the brain that could help people to not relapse, that would be like a cure to AIDS…because it's an epidemic and it's serious and if that can help, I'm all for it. (Participant ID: 103, female)

Participants noted the following key features of this type of program: virtual trigger scenarios that elicit drug cravings, decision-making skills building activities for avoiding relapse, and identifying emotional states that lead to relapse.

A few participants noted that having Alcoholics Anonymous (AA) and Narcotics Anonymous (NA) meetings through VR would be beneficial to some people. One participant indicated a preference for virtual AA/NA meetings upon community reentry, as she experiences barriers to attending in-person meetings including lack of transportation and lack of social support.

Several participants indicated a preference for virtual therapy sessions with a community-based counselor over in-person sessions with a counselor employed by the jail. They noted that this delivery modality may increase confidence in privacy and confidentiality for session content, reduce bias during the session as the community clinician would be unaware of events that occur in the jail, and facilitate linkage to treatment upon community reentry as this relationship and treatment would already be established. One participant noted a combined approach of relapse prevention and community-based meetings through VR during incarceration:

Like have virtual reality meetings or something…’cause with recovery you have to chase recovery the way you chased your drug and it's hard when you don't have transportation or support [upon community reentry]. While you're [in jail] go see those triggers…and prepare them for that situation. (Participant ID: 115, female)

Discussion

This mixed-methods study aimed to understand perceptions among people who are incarcerated on the use of VR-delivered interventions for people housed in a minimum-security jail setting. Overall, our study demonstrated high levels of acceptability of VR tools. We sought to preliminarily assess whether VR tools would heighten physiological arousal, considering the nature of this vulnerable population being incarcerated. We found low physiological arousal indicated by a decrease in HR as a result of exposure to the VR environment. This is an important preliminary finding as it lays the foundation for future work in the use of VR with people who are incarcerated who use illicit drugs.

Evidence-based interventions targeting mental health and substance use are quite limited for people who are incarcerated in the United States (Batastini et al., 2021). Batastini et al. (2021) recently found that most facilities for incarcerated populations do not provide structured, manualized interventions and few interventions are tailored to the unique needs of people who are incarcerated. Our study sought to understand perspectives from this population on interventions they would like to see developed using VR.

Specifically, VR-based interventions for reentry skills training, mental health concerns, and substance use treatment and relapse prevention were priorities of intervention development and delivery for our study sample. Our participants noted the utility of VR to engage in programs such as AA or community-based therapy. It may be possible to create an AA VR scenario that allows participants to experience that support group-type setting in a VR setting where avatars represent other group members. It also may be that using Zoom or another telehealth platform to allow individuals to engage in a virtual community-based AA meeting is preferable.

In light of the worsening overdose crisis, immediate attention should be given to the development of overdose prevention interventions using VR tools. VR may prove to be an effective means of eliciting drug cravings while in the jail setting when combined with evidence-based relapse prevention interventions. It is essential that participants who complete a VR intervention that involves triggering scenarios are immediately taught skills to reduce and manage these cravings and are closely monitored following the triggering exposure to avoid potential adverse effects.

Combining these interventions with a virtual “warm hand-off” via Zoom or another telehealth platform, and linkage in the jail setting to a community-based clinician prior to community reentry, may facilitate treatment engagement and reduce overdose and relapse risk following incarceration.

This target population is uniquely positioned to benefit from tailored interventions, as incarceration may provide a window of opportunity to intervene that may be limited in the community. However, research and development of effective behavioral interventions for people who are incarcerated are lacking due to insufficient funding allocated to advancing science among this vulnerable and high-risk population (Belcher, 2013). Funders and researchers should prioritize development of efficacious mental health and overdose prevention interventions to facilitate success of reentry and reduce recidivism rates.

Using innovative technologies, like VR, may increase engagement and retention in such programs. Furthermore, it provides an alternative educational method that may particularly benefit kinesthetic learners. It is imperative that we prioritize the mental and behavioral health of people who are incarcerated.

Findings from this study should be taken in light of several limitations. This study was exploratory in nature and primarily focused on the qualitative research questions. As such, our sample size was small for the physiological outcome measures and should be interpreted with caution. Our study laid the preliminary foundation for future studies to examine the safety and physiological response to VR scenarios among this vulnerable population.

Furthermore, survey data are presented to describe the study sample. Future studies should use a larger sample size to examine these quantitative metrics. Another consideration is that the data for HRV were recorded using technology that measures the time between heartbeats (RR intervals) instead of an electrocardiogram (ECG) signal. Research using ECG data has a longer history of empirical support than RR intervals.

However, emerging empirical evidence documents a high correlation between HRV data collected using wireless HR monitors (e.g., Polar chest straps) and ECG data (Plews et al., 2017). Wireless HR monitors have the advantage of being more unobtrusive than ECG systems. This feature was particularly important for our study because our aim was to measure physiological arousal due to VR exposure. Possible participant anxiety and discomfort with ECG electrodes, wires, and monitors may have compromised our results.

This study was conducted in the Travis County Correctional Complex in Texas, which is a county jail that primarily holds pretrial individuals. Consequently, data from these interviews may not be generalizable to medium- or maximum-security facilities.

These are important findings; however, our participants reported minimal trauma exposure in childhood and recently. Thus, these findings may not extrapolate to trauma-exposed populations. Future studies should evaluate stress response among trauma-exposed samples, as the virtual experience, particularly wearing the headset that prevents seeing your surroundings, may serve as a trigger for symptoms of PTSD.

Furthermore, future studies should evaluate the feasibility of VR in custodial settings. This study highlighted interesting suggestions from people who are incarcerated for the utility of VR including conducting AA/NA meetings, virtual meetings with community-based providers, education-based programming, and mental health/substance use relapse prevention and treatment interventions. Researchers should assess implementation barriers and facilitators prior to and during the intervention development process to ensure feasibility and sustainability in these settings.

Although participants in the present study did not experience adverse events or increased stress response as a result of the VR exposure, future studies should have a risk management plan to mitigate negative outcomes should an incident occur. Investigators should develop a risk management plan in conjunction with the behavioral health division of the custodial setting. This is critical when testing potentially triggering VR scenarios for substance use relapse and overdose prevention. Investigators should accompany triggering scenarios with evidence-based relapse prevention strategies and stress management strategies.

Conclusions

This study highlighted the potential utility of VR-delivered interventions in the jail setting, particularly among individuals who have an SUD. Evidence-based interventions should be adapted to VR scenarios and tested among people who are incarcerated. Researchers should use a community-engaged research approach in the development of tailored VR behavioral interventions for this population. Cue exposure and response prevention interventions may prove to be more effective in a virtual environment relative to existing in vivo exposure protocols.

Furthermore, VR-delivered interventions may prove to enhance access to evidence-based interventions in these low-resourced settings. Future studies are needed to further explore physiological arousal during drug cue exposure to develop VR scenarios that can generally trigger a drug craving reaction. These scenarios, paired with relapse prevention treatment, may be an effective program to prevent substance use relapse upon community reentry following incarceration.

Authors' Contributions

K.R.C. is the principal investigator for the study and led the conceptualization of the study, qualitative data collection, and analysis. F.C. is a coinvestigator and contributed to conceptualization of the study, psychophysiology data collection and analysis, and writing successive drafts of the article. K.R.C., F.C., and L.N. completed data analysis and developed a first draft of the article. All authors read and approved the final article.

Author Disclosure Statement

The authors disclosed no conflicts of interest with respect to the research, authorship, or publication of this article.

Funding Information

K.R.C.'s effort is supported, in part, by NIDA K23DA039037.