GLP-1: Is Addiction Treatment and Recovery the Next Frontier?: Lori Beerman

Glucagon-like peptide-1 receptor agonists — or as you probably know them, GLP-1s — have taken the weight loss and healthcare industries by storm. I’m guessing you’ve seen the commercials? Experts believe that GLP-1s will soon expand into other areas of chronic condition management (Quantum Health). This includes addition, or substance use disorder (SUD).

In a recent interview with STAT, Nora Volkow — director, National Institute on Drug Abuse — called the early data on GLP-1s to treat addiction is “very, very exciting.” 

But how do we get from excitement to treatment and how quickly — especially when no pharmaceutical companies are studying the issue? To change this, we have to address what Volkow calls “structural problems”: Apathy, coverage and cost. 

We also have to address their root cause: stigma. But first . . .

How GLP-1s Could Work for Addiction

When we eat, the GLP-1 hormone is secreted to help release the insulin that lowers our glucose levels. This process is disrupted for people with diabetes. GLP-1 receptor analogs — or simply GLP-1s as we’ve come to know them — are an effective, FDA-approved treatment. 

GLP-1s are also FDA-approved for obesity. They work by interrupting the brain’s cravings for food. Could these drugs interrupt the brain’s cravings for alcohol, opioids and other substances? Volkow notes that such a mechanism could interfere “with that incentive, motivational drive, that consumption reinforces and generates in our brain — it just blocks it.”

“That is of course extremely important for drugs, because that’s what drugs do: Immediately activates a system, and you just want more and more and more and it escalates. So if you can interfere with that system, this could be a mechanism that would reduce the binging that you see with drug-taking.”

This leads us to the GLP-1 SUD data that Volkow finds so exciting — and the first of many questions and challenges.

Promising Data on GLP-1s for Addiction

A 2024 review identified two randomized control trials that showed a “significant effect of GLP-1RA on decreasing SUD.” The details:

• One study pertained to alcohol, the other to nicotine
• In the alcohol study, participants drank 29% less compared to their baseline intake (Probst et al., 2023) dulaglutide once a week for 12 weeks
• A third study only showed SUD results (alcohol) for patients who were also obese (Klausen et al., 2022) 
• In this study, one GLP-1 (Exenatide) decreased total intake and the number of heavy drinking days by almost 24% once a week for 26 weeks

The 2024 review concludes that GLP-1s have a “a potential role” in SUD. To fulfill that role, more research will be needed — but even that won’t be enough. As Volkow stresses, drug companies (“Big Pharma”) has a “moral imperative to develop new addiction treatments” but don’t.

Example? Let’s compare two conditions: high blood pressure (HBP) and addiction. For HBP, there are 11 drug categories alone, with Drugs.com listing 214 individual drugs to treat the condition. Contrast this with just five primary medications that treat the cravings, chemical imbalances and withdrawals associated with SUD (SAMHSA): 

• Acamprosate, disulfiram, and naltrexone for alcohol use disorder
• Buprenorphine, methadone — and again naltrexone — for opioid use disorder

In the STAT article, Volkow adds that “in other disease spaces, like depression or hypertension, researchers and public health officials would never be content with just two or three effective treatment options.” She cites the “structural problem” responsible for far fewer medication assisted therapy (MAT) drugs for addiction: That manufacturers don’t develop them and payers don’t pay for them.

Problem #1: Apathy

Drug companies don’t focus on addiction.

“The pharmaceutical industry has never spontaneously embraced us and said, ‘We want to help develop treatments.’ No, no, no. We go to them …. and say, please, please, we have an obligation,” says Volkow.

“[They’ve] never considered addiction as a disease that is worthwhile to invest in, despite the very high rate of mortality,” she adds.

While the opioid crisis and the SUD epidemic more broadly is creating some movement, change is happening slowly.

Problem #2: Lack of Coverage

Big Pharma’s profits flow from healthcare “payers”: the government, health insurance companies and employers. Their willingness to cover and pay for GLP-1s for current conditions hint at what we can expect for SUD.

• Medicare does not cover GLP-1s for weight loss. The Biden Administration was seeking to change that but the Biden Administration is now no more. 
• Private Medicare Advantage and other commercial health plans DO cover GLP-1s but mainly for diabetes or other conditions that weight loss can improve.
• Many large employers (44%) covered GLP-1s for obesity in 2024 (Mercer).

Even the parts of this picture that sound promising are at risk due to another structural problem: the massive cost of GLP-1s, especially in the U.S.

Problem #3: Cost and U.S. Healthcare Economics

USA Today reports that Americans often spend more than $800 per month on GLP-1s for weight loss. This is compared to $140 in Germany and $92 in the United Kingdom (for the GLP-1 Wegovy). Despite this, a Yale University study found that weight-loss medications cost just $22 to make.  

The impact on consumers as well as payers is substantial:

• Medicare spending for just three GLP-1s spiked from $57 million in 2018 to $5.7 billion in 2022 (KFF). That is 100x growth — far more than the 9% inflation that caused us to lose our collective minds during the pandemic.
• Sen. Bernie Sanders has warned that the cost of GLP-1s has the potential “to bankrupt Medicare, Medicaid and our entire health care system.”
• For employers, GLP-1 costs led to an 8.4% increase in their 2023 prescription drug spending (USA Today).

This is unpredictable and unsustainable.

“Employers. . . can’t just let it be open season,” says James Gelfand — president and CEO of the ERISA Industry Committee (USA Today). In response, employers and other payers are trying to curb use in multiple ways, including denying coverage altogether.

Supply-and-demand just isn’t working with GLP-1s. Normally, demand drives competition which drives costs down. Yes, consumers have spoken: “Show us the GLP-1s!” But so have pharmaceutical and insurance companies. Their profit motive is more like a compulsion — and they don’t just want a little profit, they want a lot.

Welcome to the messed-up economics of the U.S. healthcare system.

None of this bodes well for the development, coverage and payment of GLP-1s for SUD treatment. Health insurance benefits to treat addiction are already skimpy compared to other chronic conditions.