This pilot study aims to evaluate the feasibility and acceptability of a VR-based chronic pain management intervention with a virtual AI coach for patients with Opioid misuse and opioid use disorder (OM/OUD). The intervention is a single-day 45-minute VR intervention which is subdivided into three smaller sessions:

Session 1: A 15-minute AI check-in to ask questions about biopsychosocial health, Session 2: A 20-minute Pain Coping Skills Training (PCST) session offering psychoeducation on managing chronic pain Session 3: A 10-minute stress reduction exercise.

The VR sessions will be conducted using hardware (VR Headset Device - Meta Quest 3) and software developed by AugMend Health Company.

The study will be conducted in a clinical setting at the Montefiore Multidisciplinary Pain Medicine Program (MMPP), a Pain Medicine outpatient specialty practice within a major urban medical center. MMPP providers see thousands of patients every month, some of which have concurrent opioid misuse or OM/OUD.

Opioid misuse and opioid use disorder (OM/OUD) constitute a persistent public health emergency that is projected to escalate. In 2018, about 2 million individuals in the US had an OM/OUD, associated with a high mortality rate of approximately 130 daily deaths, comorbid psychiatric disorders, and other poor health outcomes. Further interventions are needed to reduce the impact of opioid misuse, OM/OUD, and overdose. Chronic pain affects over 100 million individuals in the United States, and opioids prescribed to treat pain can increase risks of misuse, physiological dependence, and OM/OUD. Research indicates that 64.4% of OM/OUD patients report chronic pain, which can trigger relapse, reduce adherence to OM/OUD treatment, and diminish quality of life. Standard care for OM/OUD includes medication, such as methadone maintenance therapy (MMT), and psychosocial treatment. Given the adverse effects of chronic pain among patients with OM/OUD, there is an unmet need for complementary approaches to assist OM/OUD patients with pain.

In patients with OM/OUD and Chronic pain, psychosocial treatment is provided using a variety of approaches, one of which is Cognitive behavioral therapy (CBT). CBT is an evidence-based treatment that has been shown to be effective in managing both chronic pain and OM/OUD by helping patients develop coping strategies and alter maladaptive thought patterns. However, traditional CBT faces challenges such as limited accessibility due to geographic, socioeconomic, and psychological barriers, and high dropout rates due to its repetitive nature. Studies show patient-reported barriers to use of non-pharmacological treatments in chronic pain included high cost, transportation problems and low motivation, while top-ranked facilitators included availability of a wider array of options and a team-based approach that included follow-up. For this reason, more readily available and accessible options are needed.

VR technology offers an innovative treatment paradigm for patients with OM/OUD and chronic pain. A recent study showed that a VR meditative intervention can modulate pain and modify neurobiological markers in patients with OM/OUD. The immersive environment can significantly enhance patient engagement, making sessions more interactive and enjoyable, while providing pain relief. Furthermore, by providing a captivating virtual experience, VR-based psychosocial check ins can improve retention rates and ensure patients complete their therapeutic programs.

A significant innovation of VR-based biopsychosocial check-ins is its potential to make psychosocial interventions more accessible and tailored to individual needs. Traditional face-to-face CBT can be inaccessible due to geographic, socioeconomic, and psychological barriers. VR can overcome these barriers by providing a flexible treatment option within the clinical setting. Moreover, VR environments can be customized to accommodate patients with varying literacy levels, using visual aids and interactive elements to ensure comprehension and engagement, particularly for those with a third-grade reading level. VR provides an experiential learning platform where patients can practice biopsychosocial skills in a controlled, simulated environment. This method allows for repeated practice of coping strategies and pain management techniques, which is crucial for skill acquisition and generalization to real-world settings. The ability to engage in realistic scenarios within VR can enhance the transfer of these skills to daily life, improving patients' ability to manage pain and opioid cravings outside the clinical setting.

Few studies have previously utilized VR and AI to deliver conversational biopsychosocial check ins and lifestyle education specifically targeting the combined treatment of chronic pain and OM/OUD. There are limited studies on the efficacy of AI tools in mental health. Mental Health America has an AI-powered tool which allows users to type their negative thoughts, and the program assists them in reframing the thoughts. This novel application not only addresses the limitations of traditional CBT but also explores the potential of VR and AI as a versatile and effective medium for treating co-occurring conditions. The integration of VR and AI represents a promising approach that could significantly enhance therapeutic outcomes for patients with these complex conditions. The AI virtual coach is designed to provide a non-judgmental, empathetic, and supportive environment. By interacting with an AI coach, patients may feel more comfortable discussing sensitive issues without fear of judgment or bias, which can reduce internalized stigma and encourage openness. Additionally, some patients find it easier to disclose information to AI-based avatars. AI systems can enhance patient support by providing adaptive treatment recommendations based on patient feedback, effectively supporting patients and optimizing healthcare resources. Moreover, AI allows the adaptivity of the difficulty level to the demographic specificity of the patient, ensuring a more personalized and effective treatment approach. Research has shown that interactive and immersive environments can significantly enhance user engagement, leading to better adherence to treatment protocols. To promote equitable access to our VR intervention, the investigator team anticipates expanding its availability for in-home use in future phases and larger studies as part of the research. By developing portable and user-friendly VR systems, the study team aims to overcome barriers such as transportation difficulties and limited access to clinical facilities, particularly for underserved populations. This approach aligns with research indicating that home-based VR interventions can effectively reach diverse patient populations and improve accessibility to care.

The VR software has been determined to be non-significant risk by the Institutional Review Board (IRB) based on the 21st Century Cures Act. Section 520(o)(1) of the Food Drug and Cosmetic (FD&C) Act specifically excludes certain software functions from medical device classification.

Inclusion Criteria:

• Patients with opioid misuse or International Classification of Diseases 10th revision (ICD-10) diagnosis of opioid use disorder
• Patients with Chronic pain of at least moderate intensity (>4 Pain Intensity Score) with no pain medication changes in 14 days
• Ability to understand written/spoken instruction and provide informed consent in English
• Ability and willingness to participate in all components of the study

Exclusion Criteria:

• History of severe motion sickness, cybersickness, or conditions that could make participation in VR hazardous or cause adverse effects
• Conditions that could prevent proper use of VR headset (such as vision problems that cannot be corrected by contact lenses or glasses that fit in VR, Significant hearing impairments that cannot be corrected by a hearing device)
• History of seizures or seizure disorder
• Acute exacerbation of psychiatric conditions such as self-injurious behaviors or suicidal risk that preclude the ability to participate in the study