The Diabetes Drug That Could Offer Help with Addiction Treatment Highlights the Importance of Comprehensive Behavioral Healthcare Approaches

Pharmaceutical innovations continue improving the quality and longevity of life, even when beneficial side effects of these medicines are discovered unexpectedly. Numerous medications created to treat specific illnesses have found new applications because they were found to be effective at addressing completely different problems. One example is Prazosin, a medication originally developed to treat hypertension. After its FDA approval for use in 1988, the drug was found to reduce nightmares associated with Post-Traumatic Stress Disorder (PTSD), and is now sometimes prescribed for this purpose.

Ozempic (semaglutide) a diabetes drug introduced in 2017, was later FDA-approved to help people with diabetes and obesity lose weight. Recent reporting suggests that the drug could help people lose more than the desire to overeat. It may also reduce people’s desire to overuse substances, making it a promising target for treating addiction.

Semaglutide is a GLP-1 receptor agonist, mimicking the action of the human incretin glucagon-like peptide-1 (GLP-1), thereby increasing insulin secretion and blood sugar disposal and improving glycemic control. Side effects include nausea, vomiting, diarrhea, abdominal pain, and constipation.

As semaglutide increased in popularity (as a weight-loss medication), patients have been sharing interesting effects beyond appetite suppression. “They have reported losing interest in a range of addictive and compulsive behaviors: drinking, smoking, shopping, biting nails, picking at skin,” wrote Sarah Zhang in The Atlantic. “Not everyone on the drug experiences these positive effects, to be clear, but enough that addiction researchers are paying attention.”

Some physicians report that the effect of reduced alcohol use is the most common thing they hear from people taking Ozempic or similar drugs. Lorenzo Leggio has been studying the phenomenon at the National Institutes of Health. His team recently published a study indicating that semaglutide can reduce alcohol drinking in rodents (this effect has not yet been studied in humans).

“GLP-1 analogs like semaglutide may influence interest in psychoactive substances such as alcohol because they have an effect not just in the gut but in the brain, Leggio told CNN. “We believe that at least one of the mechanisms of how these drugs reduce alcohol drinking is by reducing the rewarding effects of alcohol, such as those related to a neurotransmitter in our brain, which is dopamine” he said. “So these medications are likely to make alcohol less rewarding.”

Asim Shah, a professor in the Menninger Department of Psychiatry and Behavioral Sciences at Baylor University, heard similar things from people he treats. “Patients do say that they feel a benefit on their addiction, whether it’s alcohol or smoking or anything like that. People are even saying they’ve decreased their gambling,” Shah told the Houston Chronicle. “Is it true or not? We don’t have proof.”

Should that proof emerge in future research, it would yield further support for the disease model of addiction. “Discovering how the new weight loss medications alter appetite and the compulsive behavior that can be associated with it could offer new insight into the nature of pleasure and addictions,” addiction expert Maia Szalavitz wrote in The New York Times. “Adjusting brain systems that regulate desire may also affect the stigma that society pins on people with conditions that can lead to loss of control. When drugs can significantly ease weight loss or addiction recovery, it’s hard to argue that the problem is moral rather than medical.”

In her influential book Unbroken Brain, Szalavitz explained that desire comes in two flavors: the “pleasures of the hunt” and the “pleasures of the feast,” also described as “wanting” and “liking.”  Drugs such as cocaine and methamphetamines engage the wanting circuits of the brain, while heroin and alcohol are about sedation and satisfaction.

“The positive side of wanting is feeling empowered and focused on getting what you desire; the negative side, of course, is craving that goes unsatiated,” Szalavitz explained in The New York Times op-ed. “The second kind of pleasure [liking]...  is linked with the satisfaction and comfort of having achieved your goal.”

The wanting circuits tend to rely on the neurotransmitter dopamine, while liking is more associated with the brain’s natural opioids and serotonin. Having these common currencies of emotion allows our brains to modulate what we want, depending on what it perceives as our most pressing needs.

Szalavitz explains how medication-assisted treatment utilizing opioid agonists such as buprenorphine or methadone satiates “opioid craving by providing a consistent level of a drug similar to the one that is wanted, without the chaos that can prevent people with addiction from living well.”

Other medications, like naltrexone, do the opposite and prevent opioid receptor activation. These medicines, however, can reduce the experience of pleasure overall. GLP-1 drugs act differently. They modulate the motivational dopamine systems but apparently without depressing desire overall. So far, the data on using GLP-1 drugs for substance addictions are mixed. Some studies showed positive results in animals and humans, but others found no effect.

Nora Volkow, the director of the National Institute on Drug Abuse (NIDA), is funding research on these medications for drug addictions. Szalavitz quotes Dr. Volkow as saying they might work “by interfering with that urge to have more.” It will be fascinating to determine whether it is possible to alter or even create a set point that signals that “enough” drugs have been taken. People with alcohol use issues seem to lack such an off switch, while those who drink moderately report knowing when to stop.

Szalavitz hopes the research will eventually yield medications that help people “change with ease” after years of struggling. The experience with methadone—first studied as a treatment for opioid addiction in the 1950s and 60s—shows that full recovery from addiction usually takes much more than just taking a single medication.  

While medications that can help stem the desire to use substances or reduce their ellative effects can be highly effective treatment aids, experienced medical and behavioral health providers know that substance use disorders and their co-occurring mental health conditions can result from complex underlying issues that cannot be resolved with medicines alone. Essentially, reducing the effect of a substance does not necessarily address the factors leading that person to seek substance-induced relief. When considering messages promoting the promise of medications, it is important to include the fundamental concept that addictive disorders have biological, psychological, and sociological components that can lead to their development and exacerbation. Stopping people from feeling the effects of substances or being able to stop taking them does not always mean that the underlying issues causing them to misuse the substance are reduced. Creating the perception that a medication alone can comprehensively “cure” addiction should be carefully avoided.

Foundry Treatment Center Steamboat, like other experienced behavioral healthcare providers, avails clients of psychiatric medications to help control cravings and restore mental health while taking a holistic approach that considers the bigger picture affecting clients. As a program that emphasizes the outsized roles that trauma and family system issues play in developing a range of health problems, including addiction and mental illnesses, Foundry Steamboat clinicians suggest taking a judicious approach to the role of medications in personalized treatment plans.

“The problems our clients are facing are often the underlying reasons that they developed substance use disorders in the first place,” says Chief Clinical Officer Michael Barnes, Ph.D. “Medication can certainly help people feel better and help them establish a baseline from which they can deal with underlying problems, but medication is very rarely a complete answer to this very complex disease.”

Medication-assisted treatment (MAT), which has been promoted as the gold standard for addiction treatment and has been used for decades, is a case in point. While medication-assisted treatment tremendously benefits many people, others relapse and overdose, divert their medications, or change the substances they use to achieve a high. This is not because MAT is ineffective or without merit, but because many of the people prescribed medicines to reduce their ability to feel the elative effects of alcohol or opioids still face daunting problems that make them feel deeply stressed, anxious, and depressed. Problems such as family estrangement and divorce, abandonment, housing insecurity, financial instability, legal entanglements, physical health problems, and victimization are some of the many reasons that people have difficulty entering and maintaining recovery, regardless of medications they may be prescribed.

“The potential benefits of semaglutide are certainly welcomed, if studies prove its efficacy to safely reduce cravings. We need as many tools in the toolbox as we can get,” says Foundry Chief Medical Officer Dr. Jim Shuler. “But when treating addictive disorders cohesively and fully, we need to consider social determinants of health, medical and trauma histories, and lifestyle factors and treat for these. Medication, while potentially very helpful, doesn’t treat these issues. These take a different set of therapies, skills, and supports. We do not want to instill the idea that medicine is the answer because, in the vast majority of cases, the answer lies in identifying and addressing a much deeper set of issues than one’s inability to stop using substances despite wanting to. In other words, medication is just one spoke that can help keep the entire wheel of the patient round.”

“In some cases, not even the most well-tuned medication plan is going to help a person dealing with the profound effects of trauma and negative life experiences,” says Dr. Barnes. “Some problems simply cannot be medicated away. Many people simply do not have the ability to regulate their autonomic nervous response to stress naturally, and without that ability, they will either always be dependent upon medications that attempt to control it or will not experience relief. The answer, in these cases, is to teach them how to achieve homeostasis and make important lifestyle changes that moderate stressors.”

Foundry Steamboat takes a holistic approach to treating substance use and co-occurring mental health disorders, including trauma. Psychiatric prescribing, which is provided to clients in the program’s residential and intensive outpatient programs, makes a significant difference to many clients. However, the program employs thoughtful assessment, psychotherapy, fitness and nutrition support, recreation and wellness services, and specialized trauma therapies with the aim of helping clients develop recovery-supportive lifestyles and learn to reduce the potential triggers of substance use disorder.

‍