We’re hiring a Director of Research to lead our scientific and clinical engagement. They will build partnerships, identify trial opportunities, and keep our policy work grounded in rigorous evidence. We’re also hiring a Director of Policy and a Policy Lead to advance our legislative agenda on Capitol Hill and beyond, including our proposals on NIH trial funding and online gambling addiction.

Full postings are below:

Director of Research: Idealist / Google Doc

Director of Policy: Idealist / Google Doc

Policy Lead: Idealist / Google Doc

If any of these sound like you, we’d love to hear from you. And if they don’t but you know someone who’d be a great fit — in health policy, addiction medicine, or clinical research — we’d be grateful if you passed this along.

• 50 State Rankings and Report Cards: Check your state’s score.

• Online Gambling Tax Rates for Each State: Ranging from 6% to 51%.

• Model Legislation for States: Policies to prevent new gambling addictions and bankruptcies.

In the past 8 years, dozens of states have legalized online gambling after intense lobbying from gambling companies. Without policies in place to prevent addiction and bankruptcy, the result has been terrible for their citizens. The only fig leaf of protection in most states are industry promoted post-addiction policies, like gambling hotlines or counseling. These are perfect tools for helping people after they’ve already lost everything to the gambling companies, but any real protections obviously need to happen before.

Predictably, states that have legalized gambling have seen a surge in gambling addiction: 24/7 gambling in your pocket is nothing like casual bets on a game with your friends. Even compared to casinos, which actually create jobs and economic activity inside a state, online gambling is a money vacuum, pulling dollars out of the state. This reduces economic activity and resulting tax generation within the state.

Best and Worst States

The top state in our rankings is Montana: online gambling is not legal and the state has sent a cease and desist to Kalshi to try to stop their illegal national sports betting ‘prediction app’, which ignores state law and pays no taxes to the states.

The lowest ranking state is Delaware, which earns an F-minus, a grade so low that school children still debate whether it even exists. Turns out it does! Delaware allows sports betting apps, allows even more addictive iCasino apps, has no anti-addiction protections for its citizens, and the state itself promotes gambling to its own citizens. A total disaster.

See the full list of 50 states here, including the full calculation of the scores, tax rates, and more.

What could states be doing better?

Policies that would prevent new gambling addictions and reduce bankruptcies include:

• Loss Limits: if someone loses more than $500 in a month, require users to take a 3 month pause to interrupt the addictive cycle

• Prohibit In-Game Microbets

• Block App-store gambling ads and app listings to minors.

• Require Spousal Consent for Joint Accounts

• Like alcohol, make it illegal to continue to serve bets to individuals demonstrative addictive gambling behaviors (loss chasing, escalating deposits).

• Waiting periods on deposits

• Raising the age limit to 25, closer to the age at which executive function is fully developed in men

In short, if online gambling is intended to be fun and entertaining, citizens should be protected against catastrophic losses. It should be illegal for online gambling companies to drain a family’s life savings in a matter of weeks, just because their app has successfully A/B tested its way to a hyper-addictive design.

All of these policies and more are in our resource of Model Legislation for State Regulation of Online Gambling.

Tomorrow morning CASPR will officially launch our new program, Life Savings, focused on online gambling addiction. We’re starting with the first-ever 50 state report cards and state rankings of online gambling policies.

Other organizations like AIBM and PHAI have big things coming soon as well. A coalition is forming to demand commonsense protections that have broad public support.

Love gambling? Now could be a great time to short DraftKings stock.

Instead of allowing this tragedy to needlessly grind forward, we should make suzetrigine low cost and first-line, through a public-private deal that would save payers money, ensure equal or better profits for the drugmaker Vertex, and reduce the number of opioid painkiller prescriptions written every year by up to 50%. This could be accomplished quickly.

Many, and maybe most, opioid addictions begin with prescriptions

Doctors and dentists in America prescribe about ~125M opioid pain prescriptions annually. While only a small percentage of these prescriptions lead to opioid addictions, that small percentage adds up to millions of people.

For any individual who develops an addiction after receiving a prescription, it’s impossible to know whether they would have eventually become addicted anyway. But we have good reasons to believe that prescribing is a primary cause for many. And not only do patients themselves become addicted, but 60% of post-surgical opioid tablets go unused and sit in a medicine cabinet, often becoming a source of first exposure for others.

For a sense of scale:

• A 2025 survey of 1,515 US adults who reported non-prescription opioid use, predominantly illicit fentanyl, found 75% had started with prescription opioids:

  • 39% first used opioids prescribed to them.

  • 36% first used opioids prescribed to someone else.

  • 25% first used illicit opioids, like heroin or non-prescribed fentanyl.

• ~80% of people with OUD in 2013 reported that their addiction started with prescription painkillers.

• These percentages have been fairly consistent since the 2000s.

• In 2023, 8.6 million Americans reported misusing prescription opioids.

• “Among US adults with any prescription opioid use in the past year, 7.0% met DSM‑5 criteria for prescription opioid use disorder” - Journal of Clinical Psychiatry 2024

Do we need to prescribe pain medicine at all?

Serious pain presents doctors and policymakers with a heart-wrenching dilemma. Pain can be life destroying. Should we err on the side of prescribing more opioids and accept addiction as a side effect? Or should we clamp down on prescribing and let more people live in pain? With suzetrigine reaching the market, the dilemma is closer to being resolved. There are several other non-addictive painkillers in pharma pipelines, so suzetrigine is likely the first of what will be a new generation of truly non-addictive pain medicines.

For milder and chronic pain, some experts, like Dr. Amy Baxter, make a compelling case that a) most post-operative pain passes quickly and does not need a painkiller prescription, b) medicalizing pain causes people to feel more pain, and c) opioids are not very effective for chronic pain or mild pain. On the science, she may right in many situations. And yet, we still live in a society where most doctors want to give patients something after a procedure. There is limited top-down control over prescribing (for example, American dentists prescribe opioids ~30X more often than British dentists).

Could American doctors go cold turkey and simply stop prescribing pills for mild or transient pain? Perhaps. Some doctors are doing this by recommending acetaminophen and ibuprofen, which are often equally or more effective than hydrocodone. But many, many doctors still prescribe opioids. Whether it is objectively “necessary” to write these pain prescriptions, we are much more likely to rapidly reduce opioid prescribing if doctors and patients have a non-addictive alternative.

Decent is excellent

The approval of suzetrigine is not a normal situation.

Typically, a new medication is better than existing options for the use it is prescribed for, in this case pain reduction. But suzetrigine is actually not better than existing options at pain reduction. Its magic lies in what it lacks: addictiveness. Our medical insurance systems are built to balance the efficacy and cost of new treatments. They simply aren’t structured to drive a rapid switch to a drug with higher cost and equivalent efficacy. That’s why this case calls for an unusual intervention.

Suzetrigine, which acts on sodium channel pain-signaling, is not the strongest painkiller in the world, but it’s about as strong as hydrocodone+acetaminophen (aka HB/APAP, aka Vicodin). It could replace many of, and perhaps even the majority, of opioid prescriptions. When a doctor or dentist feels compelled to give a patient something, suzetrigine can be that something.

As you can see above, while this is not a leap forward in pain reduction vs opioids, it is still a huge step for patient health: decent pain reduction with no addictive potential. In addition, the comparison here of suzetrigine vs hydrocodone+acetaminophen is a bit unfair: suzetrigine is also medically compatible with acetaminophen (the drugs work on different pathways) but was compared without acetaminophen. It is very likely that suzetrigine+acetaminophen would be even more effective than suzetrigine alone given its success in multimodal pain protocols. It’s an easy combination to try.

How many opioid prescriptions could be avoided by switching to suzetrigine?

Here are some ballpark estimates that CASPR put together, exploring which opioid prescriptions could be replaced by suzetrigine prescriptions. Generally, the use cases for suzetrigine fall on the milder side of the pain scale, which is where replacement is most doable.

Hydrocodone + APAP (acetaminophen): ~68% substitutable (32M prescriptions per year)

• Primarily prescribed for short-term pain, which is suzetrigine’s FDA-approved indication.

• Phase 3 trials show equivalent efficacy to hydrocodone/acetaminophen.

• Suzetrigine can be combined with acetaminophen for potentially even higher efficacy.

Tramadol: ~55% substitutable (15M prescriptions per year)

• Tramadol is a weaker opioid often used for moderate pain where suzetrigine may suffice.

• Similar indication profile as suzetrigine (acute musculoskeletal, post-procedural pain).

• Not yet fully substitutable because a. suzetrigine is not yet approved for chronic pain and b.tramadol’s mechanism may work especially well for some patients.

Oxycodone (IR): ~45% substitutable (9M prescriptions per year)

• Immediate-release formulations are typically used for acute pain episodes.

• Post-surgical use overlaps with suzetrigine’s approval and phase 3 trials.

• However, oxycodone is clearly stronger than suzetrigine and is used in chronic pain.

Codeine Combinations: ~60% substitutable (3M prescriptions per year)

• Frequently prescribed for mild-moderate pain and dental procedures.

• Short duration use aligns with suzetrigine’s acute pain indication.

• Not a total substitute, because many codeine prescriptions are for cough suppression where suzetrigine is not likely to be effective.

These estimates are all based on the mix of acute vs chronic use of the milder opioid painkillers, given that suzetrigine is currently only approved for acute use. However, phase 3 trials of suzetrigine for chronic pain are currently in progress, and have a good chance at success, which would result in an approval in late 2026 or early 2027, greatly expanding the potential substitutability for opioids.

For now, we believe that about 50% of current opioid prescriptions are substitutable with suzetrigine. Medically, this is a massive opportunity.

Current state of suzetrigine access

Suzetrigine is an expensive on-patent drug. Payers have erected a number of barriers to discourage use of suzetrigine and encourage doctors to try opioids first. Coverage is inconsistent and often complex for prescribers.

Most commercial plans place suzetrigine on Tier 3, the highest-cost tier, meaning high copays or deductibles if patients can even manage to get past prescribing restrictions. In Medicaid, only 19 states have removed prior authorization and step-edits as of mid-October 2025. Copays range from nominal amounts up to 20% of the state’s cost (which can mean $50 for patients vs $5 for opioids). Medicare coverage is still being rolled out. VA access remains limited through clinical use rules.

For 2025, Vertex reported 500k suzetrigine prescriptions, a negligible fraction of the roughly 125M annual opioid prescriptions in the US. Use is growing, but only a small percentage of patients today (~2-3%) are receiving suzetrigine instead of opioids, and we are needlessly continuing this prescription-to-addiction pipeline.

Making suzetrigine first-line would prevent hundreds of thousands of new opioid addictions

By agreeing to offer suzetrigine at low or no-cost to all applicable patients, the federal government could negotiate a dramatically lower price per pill with Vertex. This would cost public and private insurance companies roughly the same as what they would already pay for suzetrigine under the status quo (few suzetrigine patients, but high cost per patient) while replacing as much as 50% of all opioid prescriptions. Making this switch would prevent hundreds of thousands of new opioid addictions while saving the government tens of billions of dollars a year in downstream costs from addiction.

For a very rough ballpark, using the numbers we’ve looked at above:

• If ~75% of opioid addictions begin with prescription opioids, and

• If ~50% of opioid prescriptions can be replaced with suzetrigine prescriptions, then

• Very approximately, suzetrigine could prevent ~37% of new opioid addictions, roughly ~160,000 of the ~435,000 new OUD cases in the US each year.

• Over a decade, this could be more than a million addictions avoided. Since opioid use and drug supply have significant network effects, the impact could be even larger, as prevalence becomes less common.

• The financial benefits would be tremendous. Roughly 5.7 million Americans have OUD. The economic and medical costs of the opioid epidemic are estimated to be well over $1 trillion per year. And the damage to families and communities goes far beyond what can be captured in economic numbers.

Making a deal

The current Administration has shown openness to deal-making that reduces costs or improves access to medicine, like the recent GLP‑1 pricing agreements with Novo Nordisk and Eli Lilly. The case for a suzetrigine deal is even stronger. By agreeing to offer suzetrigine at low or no cost to all applicable patients in government health systems, and with a structure to enable private insurance companies to do the same, the government could negotiate a far lower price per pill. It could rapidly bring an effective non-opioid option for acute pain to far more Americans, while holding patient out-of-pocket costs at zero and giving Vertex revenue equal or greater to their earnings without such an arrangement. Combined with a provider-awareness push, opioid prescribing could be dramatically reduced in a matter of months.

This deal would also serve as a template for the future, as additional non-addictive painkillers come to market, ensuring that the pharma development pipeline remains strong and pricing is competitive and fair for the public.

An agreement along these lines would cover:

• Federal delivery systems (VA, DoD, and IHS).

• Medicare fee-for-service and participating Medicare Advantage plans through a CMS Innovation Center model.

• Highly appealing for states to opt-in via a standardized Medicaid template.

• A buy-in option for private insurance to adopt a similar deal, with incentives to do so.

For each of these systems, there are structural nuances and details to negotiate in detail, but it would all flow naturally as long as it focuses on these core objectives:

• Broad first-line access for suzetrigine

  • Make it as easy or easier to prescribe than opioids.

  • Make it easy to access (no prior auths, no step therapy).

  • Make the co-pays as cheap or cheaper than opioids.

• Low price

  • In exchange for this massive increase in patient access, Vertex prices suzetrigine competitively with opioids (90-95% reduction from list price).

A Victory for Americans and for Vertex

Let’s run through some napkin math to make this all more concrete:

• Currently, the suzetrigine list price is $15.50 per pill vs ~$0.35 for generic hydrocodone+APAP. Therefore insurers put up barriers to reduce usage.

• In the status quo, Vertex is expected to earn $10B-$25B from suzetrigine over the next 14 years before it becomes generic in 2040, mostly depending on whether other non-addictive painkillers arrive to market and when. That $10B-$25B already gets paid by all of us, through insurance premiums and copays.

• Through a deal to make suzetrigine dramatically cheaper and easily available to everyone, Vertex can earn roughly the same revenue by reaching many more patients.

• Millions of opioid addictions will be prevented. This will save federal, state, and local governments billions a year in direct and indirect savings.

• The total economic burden of opioid addiction and overdose has been estimated at roughly $1.5-2.7 trillion annually for recent years (2017 and a rough extrapolation to 2023). Even a modest reduction in OUD prevalence would drive hundreds of billions in fiscal savings and reduced economic burden.

• The personal and emotional benefits for families and the social benefits to communities would be immeasurable.

Under this structure, Vertex doesn’t get a handout but does get a predictable revenue stream that is at least as attractive as the typical high-price but low volume pathway they are currently on. In the process, Vertex also gains a national showcase role as the company that led a transformation in rates of addiction.

The Administration, in turn, secures a groundbreaking deal that quickly and measurably drives down opioid use and new opioid addictions without raising costs and while increasing patient choice. This model could then be extended to other drug companies as additional new non-opioid painkillers come to market.

RESOURCES

This policy brief, CASPR 003: Negotiating First-Line Access to Non-Addictive Painkillers for All Americans, is also available here on the web and as a PDF on CASPR’s website.

ABOUT CASPR

Nicholas Reville is co-founder and Executive Director of the Center for Addiction Science, Policy, and Research (CASPR). CASPR has a mission to reduce addiction at a population scale by advancing strategic policy and breakthrough medicines. More at caspr.org.

Proposing an NIH High-Leverage Trials (HILT) Program

(CASPR Policy Brief 002)

And if you haven’t read our previous paper, published by CASPR and IFP, you can find that on our site as well: An Innovation Agenda for Addiction.

This Tuesday, CASPR is hosting an online briefing for state legislative offices and others interested in how states can effectively prevent addiction in an era of 24/7 gambling on our phones.

The online gambling industry pushes states to focus on ways to help people after they’ve become addicted to gambling while the gambling companies focus on ways to get more people addicted. This is, of course, an extremely ineffective public policy and is predictably destroying the financial futures for young men and families in every state that has legalized online gambling.

We will discuss policies that can actually prevent addictions and reduce bankruptcy rates. CASPR will soon be publishing draft legislation and offering other technical support to states.

Experts, from across the political spectrum, include:

• Charles Fain Lehman, Manhattan Institute

• Jonathan Cohen, American Institute for Boys and Men

• Harry Levant, PHAI

• Nicholas Reville, Center for Addiction, Policy, and Research

Please join us:

• Reducing Addiction and Bankruptcy from Online Gambling

• CASPR Expert Briefing for State Policymakers

• February 3rd at 3pm ET (Add to Gcal, Add to Outlook)

• Join on Zoom >

• Register here

Topics will include:

• Requiring spousal consent before gamblers connect shared bank accounts.

• Ways mobile gambling companies mislead and lie to states considering legalizing online gambling.

• Recent class action lawsuits against gambling apps.

• Tax rates across different states and net state outflows to gambling companies.

• Ways to cap losses to prevent addiction spirals.

• Detecting addictive gambling behaviors programatically.

• Closing the Kalshi / Robinhood ‘investment contract’ loophole.

• Advertising bans.

The event will last 60-90 minutes, including Q&A.

We will be announcing the launch of CASPRs new online gambling program very shortly!

Nearly every phase III trial is run by a biotech or pharma company, so if industry doesn’t test a medicine, we almost never really know if it works. Supplements and drugs with expired patents don’t get Phase III trials because there’s not enough incentive to run a trial on medicine without patent exclusivity. That means that hundreds of safe and effective treatments are sitting on the shelf, unstudied.

I’ve been frustrated and perplexed about this problem years, and there have been proposals to address it, but I think that through understanding how similar the obstacle is that supplements and off-patent therapeutics face, we can find a solution that is broadly appealing across the political spectrum:

To solve this gap and open up new treatments and dramatic cost savings, we propose the creation of an NIH High-Leverage Trials (HILT) Program for off-patent drug repurposing and supplements. HILT would fund and run definitive large scale trials and, when appropriate, advance regulatory approvals to ensure broad patient access.

The medical opportunity and cost savings potential are tremendous. Here’s my proposal, published with The Good Science Project:

The Good Science Project

Proposing an NIH High-Leverage Trials (HILT) Program: Large-scale Research for Repurposing and Supplements

This is a guest article from Nicholas Reville, the Executive Director and cofounder of the Center for Addiction Science, Policy, and Research. He authored the Innovation Agenda for Addiction and speaks internationally on addiction and health policy. CASPR advances research on breakthrough therapeutics and develops novel policy interventions to reduce ad…

Read more

3 months ago · 4 likes · Stuart Buck

Here’s a chart from the piece, based on data from CASPR advisor Maya Durvasula’s recent paper on new uses for existing drugs.

The full article is here: Proposing an NIH High-Leverage Trials (HILT) Program: Large-scale Research for Repurposing and Supplements.

Thank you to Stuart Buck of The Good Science Project for invaluable feedback and for publishing my paper today on his substack, which I highly recommend.

I called up the cultural anthropologist and NYU professor to to ask what, if anything, can be done to stop the rise of gambling, the ethical obligations of designers, and pathways for harm reduction.

You’ve explored how addiction design targets vulnerable psychological states. What does effective intervention look like when the problem is embedded in the design itself?

Addiction lives in the space between a substance or activity and a person engaging with it. It’s a relationship. If you are going to address a problem in the relationship, which is what addiction is, you have to look at the interaction.

Right now, we address addiction in different ways. There are individual solutions, like a drug intervention, or morally weighed approaches such as cultivation of responsibility.

Then there are policy approaches to addiction, like putting a label on a cigarette pack or putting warnings on different kinds of substances. You could carry that over to slot machines or betting apps. The idea is that you’re making appeals to the individual’s responsibility because you can’t expect someone to behave responsibly if they don’t know what’s going on. The idea is that if someone sees the odds on a slot machine, they will know how to interact with that device responsibly. That’s what the industry likes to talk about when it talks about helping deal with problems.

My emphasis is on that other end of the spectrum, tending to the problematic, dysfunctional aspects of the design. For example, we know that increasing the number of lines you can bet on increases addictive behavior, so let’s reduce the number of lines. The more spins you can do per minute, the more addictive the game becomes, so let’s slow down the game. And so on.

That carries over to online sports betting: We can reduce the number of opportunities to bet during the game. “In game betting” is one of the most problematic aspects of sports betting apps, allowing users to bet continuously as the game unfolds.

How did we get to a place where these apps are so addicting?

It’s not that any of today’s designers, or even the designers of slot machines that I wrote about, are sitting around rubbing their hands together, asking how they could addict people. It’s actually more insidious than that because it’s more endemic to our particular system of capitalism. The idea is how can we increase profits? How can we extract more from these encounters?

In the book, I have this idea of asymmetric collusion, which carries over to apps and sports betting as well. To some degree, people want to be in what I call the “Machine Zone.” They seek it out and collude with the machine or the app that’s addicting them.

The reason that I put “asymmetric” in front of the word “collusion” is that the players are trying to erase themselves or escape whereas the companies are trying to extract profit. You end up with an extractive drive along with an escapist drive. That’s what makes it asymmetric.

Does a link to a Responsible Gaming website or hotline help people who are potentially addicted? Is there a policy solution that the app makers would agree to or does it have to be forced on them?

I’m pretty cynical. I don’t see in the current system that we have any real incentives for companies to do anything other than hand wave at responsibility. Any actual change would have to be written into regulation. It has to be the stick, not the carrot, policywise.

There’s nothing illegal about addicting people to your app. That’s actually the goal.

One of the exciting new frontiers of regulation is what’s called pre-commitment devices and design. You see this in Canada, where the government runs most of the gambling and there’s a bit more due diligence on the part of the government to actually fill its role for taking care of the citizens. These pre-commitment devices might have you sign up ahead of time for the days you want to gamble or the days you don’t want to do so. You have a calendar. You’re making decisions from a position of responsibility and foresight to care for yourself in advance. When it’s your son’s birthday and you have said you don’t want to be gambling, you actually can’t. You can do the same with money. You pre-commit a certain amount of money, and after that, cut yourself off.

There are lots of examples of pre-commitment devices. It’s a way of giving people the responsibility to do what the casino or the app makers are not comfortable doing: cutting people off, locking them out, or being Big Brother. It’s saying, “here are some tools.” You can Big Brother yourself, in a way.

Do you think that is an effective mechanism?

It can be, but the problem is that too often the purveyors of whatever form of gambling are building exit ramps at every stage so that you can override the whole system. Then it doesn’t hold any weight.

Does the “skill” narrative around sports betting change the addiction dynamic?

When you actually watch the way that bets happen on these apps, I really don’t think skill comes into play. It’s moving so fast, and most people have so little knowledge to draw on. It’s not about that for them.

What makes mobile sports gambling potentially more or less harmful than casino gambling?

When I wrote my book, I started with the physical design of the casino. I learned that there’s a very strong logic of curving carpets, for instance. You don’t want to have a right angle. If you have a right angle, you put the person in a decision-making role where they suddenly have responsibility to move left or to move right. You’d rather just curve them where you want them to go. I kept seeing how that logic of curving was carrying over, not just to the carpets, but to the atmospherics, and most importantly, to the game, the math and the algorithms.

And this idea is so salient in the design of apps. Another way of describing the logic of curving is the removal of friction. Friction is something that you’re working against when you’re an app maker. The ongoing flow of in-game betting in online sports betting is one way to remove friction. The fact that there’s no ending to the game is also key; even after a game has ended, you can keep betting on a different game, on the same app interface. It’s seamless. And of course, there’s the use of digital confetti, colors, and engaging graphics… all of these things draw players into loops of play.

Attention is the thing that everyone is trying to get and keep.

My book could have been called Attention by Design. It’s a primer in how you hook and hold attention. It’s useful to distinguish between those two things because things that are really flashy and obvious and might be a big part of the hook are not actually the things that are holding you. These other things that aren’t so obvious are holding you there.

Your work sits at the intersection of anthropology, design and public health. What disciplinary blind spots do you see in how we study and address behavioral addiction?

The biggest one for me still is the actual design and the understanding that the behavior isn’t in a vacuum. Our behavior is being shaped by that which it is interacting with. We still don’t focus enough on the role that design, and by extension, designers, play. If we were to acknowledge that more, we would see that more people are implicated in this problem than we imagine.

Is there a pathway for harm reduction by design given the incentives and structures in play in a capitalist system?

We’re moving more and more towards gambling being everywhere. This means that everyone is potentially a regular gambler. What that means for the industry is that you can’t take all of everyone’s money, and then expect that there will be a market that continues to exist for you. You have to worry more about cultivating your market and not burning it out.

Twenty years ago, the gambling industry learned that if you let people sit longer at a machine and keep giving them back a little bit of what they put in, you will ultimately get more money from them. That was a big surprise to the industry. Before that, the logic was take as much as you can get immediately. You didn’t even give them, literally, a chair to sit in. But then they realized, no this other mode is more profitable: over a lifetime, you extract value from them, but do it under the cloak of caring. That’s actually creepier in the end, in my mind.

I think you’re going to see more of an attention to cultivating a market from which the industry can reliably extract money over time, and not burn them out. It’s equivalent to letting them sit longer.

That’s bleak in a completely different way.

Yep.

Both companies currently ban apps that ‘encourage’ consumption of alcohol or cigarette smoking. These types of apps are legal according to the government, but are being blocked by Apple and Google at their own discretion, ostensibly for user safety.

Meanwhile, both app stores currently allow online gambling apps (the gambling companies are required to block signup and use in locations where online gambling is banned) and they accept advertising from online gambling companies.

From a safety standpoint, this approach is completely backwards. Gambling apps aren’t just encouraging people to gamble, they are directly providing the addictive service. The risk of losing your life savings to gambling is caused by the app itself.

We need a public campaign to push Apple and Google to block gambling apps in the app stores. While online gambling would remain legal on websites, an app store ban would dramatically reduce the initial rate of exposure to online gambling and the number of people who develop gambling addictions.

It would also reduce Apple and Google’s potentially liability in class action lawsuits from families harmed by online gambling apps that are designed to be addictive and which pay to be promoted on these app stores. If public safety concerns won’t convince these companies, maybe liability will.

Suzetrigine, a novel non-opiod painkiller, will be FDA approved for acute pain in January 2025: 90% chance.

CORRECT: Suzetrigine was approved on January 30. Use of suzetrigine has been very limited because it is an expensive on-patent drug. This mean millions of unnecessary opioid prescriptions are continuing to be given to patients. I’ve written in the past that the federal government should make a deal with Vertex to reduce the price in exchange for vastly increased access, making suzetrigine a first-line pain treatment (and replacing most uses of Vicodin). This would rapidly reduce the number of new opioid prescriptions written every month, by up to 50%. We’ll be publishing a more detailed proposal about this soon.

Suzetrigine will be seen as a modest step forward for pain management but will spark excitement and vision towards a future of opioid-free outpatient pain management: 70% chance*.

CORRECT: The asterisk on this and other predictions means that the outcome is fuzzy and doesn’t have a clear objective answer. But I think this one is true— suzetrigine is an important step for the field and for opioid replacement, but we’ve heard that many prescribers just don’t think it’s strong enough to be worth the hassle of prescribing it vs ibuprofen / acetaminophen.

Two or more Phase 2 RCTs will report results showing a large drop in heavy drinking among people with AUD who take semaglutide or tirzepatide: 90% chance.

HALF WRONG: Christian Hendershot’s highly cited trial of low-dose semaglutide for AUD showed a big drop in heavy drinking but it was the only AUD sema / tirzep RCT released last year (that I know of). That said, there are a handful of AUD sema or trizep trials that have completed but not yet published results, so there should be more papers this year.

“Micro-dosing” GLP-1s (for weight, addiction, hormonal regulation, brain health, etc) will grow from a small niche to a large trend: 70% chance*. Micro-dosing will serve as the psychological bridge that lets alternative medicine advocates embrace GLP-1s. The trend could stall within the US if compounding of semaglutide is shut down.

MESSY: Microdosing GLP-1s is certainly growing in popularity (see the google trends chart below) but I think objectively it remains below the level of a ‘large trend’. That said, I think it will continue to grow and there has been a lot of coverage of the concept recently (here’s the Today Show).

Semaglutide compounding will be shutdown: 50% chance. The law and Novo’s business interests point to a shutdown, but Makary (upcoming FDA head) was CMO of a compounding service and the many millions of people who are currently taking compounded semaglutide will be driven to unregulated gray market alternatives from China if compounding is stopped.

MESSY: Most GLP-1 compounding shut down in 2025 but several services remain alive and well. Novo and Lilly continue to sue companies and try to stamp it out but there are ongoing court battles from compounders who argue that they are providing custom medications that people can’t get elsewhere. Compounding has played a big role in the price reductions for patients paying out of pocket.

At least one telehealth service will begin offering compounded semaglutide off-label for substance use disorders: 60% chance. (I would have a higher likelihood if it wasn’t for the risk of compounding being shut down at some point in 2025.)

MESSY: WorkIt Health temporarily launched a GLP-1 for addiction service but it is no longer active. That said, if I was making predictions again, I’d re-predict this for 2026. It’s coming one way or another.

Incretins as the future of addiction medicine will go from what was a niche belief at the beginning of 2024 to the mainstream position of addiction experts by the end of 2025: 70% chance*. But it will continue to take a long time for research in the field to pivot proportionally to the opportunity.

CORRECT: GLP-1s for addiction have had far more attention and adoption this year than any other novel addiction medicine and NIDA is increasing its funding of GLP-1 trials, though still far too slowly in my opinion. Eli Lilly has launched a GLP-1 for AUD phase 3 program with brenipatide, which is a major step towards mainstream access. CASPR is also working to launch a phase 3 program, I hope we’ll have more news here soon.

Overdose deaths will continue to drop in 2025 vs 2024, by at least 5%: 75% chance.

CORRECT: Overdose deaths had another huge drop in 2025, down by 20.6%. Wonderful.

Why did deaths keep dropping? We still don’t know. I wrote last year about the possibility that the drop was driven by a trend away from injecting fentanyl towards smoking fentanyl, others have proposed that the gradual increase in availability of naloxone and buprenorphine has been making an impact, and others suggest the huge overdose surge during covid is just leveling off. An excellent paper in Science last week suggests that a ‘China shock’ of new restrictions on fentanyl precursors caused a drop in the strength of street fentanyl that corresponded closely with the drop in overdose deaths.

This correlation seems pretty convincing to me, though the other theories remain plausible and contributory to various degrees.

Like me, the vast majority of addiction medicine experts and professionals are not in favor of the drug war and are skeptical that the opioid crisis can be solved on the supply side. I think supply shocks like this will be hard to maintain and other countries will fill in the precursor gaps if China continues a crackdown. It’s just too easy to make fentanyl. But despite this justified skepticism of supply-side restrictions it’s important to remain open-minded to the role that supply plays and to be open about our uncertainty. It is certainly possible that the right international coordination could choke fentanyl supply significantly, leading to a big rise in prices and a drop in purity and a reduction in deaths. Again, I think it’s unlikely, but we should “follow the science” on this and everything.

The overdose death drop from 2024 to 2025 will be lower in percent terms than the drop from 2023 to 2024: 70% chance.

CORRECT: The 2023 to 2024 drop was 26.9%, and this year’s drop was 20.6%.

Someone you know personally will tell you that they drink a lot less since starting a GLP-1: 96% chance.

CORRECT? You’ll have to answer this one yourself. It happened to me about 6-7 times in 2025 but I am constantly having these conversations.

Novo Nordisk’s EVOKE trials of semaglutide for Alzheimer’s report positive results in late 2025 or 2026. They will show reduced Alzheimer’s incidence in people taking semaglutide, including individuals without diabetes or obesity: 80% chance.

WRONG: “While treatment with semaglutide resulted in improvement of Alzheimer’s disease-related biomarkers in both trials, this did not translate into a delay of disease progression.” - Novo Nordisk press release. I hope Novo will release more details of their results, including subgroups, but overall the trials clearly failed. Long-term I still suspect that for people with diabetes or obesity, we will see strong evidence that GLP-1s reduce Alzheimer’s incidence. But it’s virtually impossible to run a 10 or 20 year RCT prevention trial (this is a problem for all Alzheimer’s research).

Success of EVOKE will eliminate most of the remaining resistance towards GLP-1s as a ‘crutch’ or ‘bandaid’ for people with diabetes or obesity: 70% chance*.

WRONG: The trials failed! That said, I think that GLP-1 skepticism and resistance is continuing to drop rapidly as the popularity grows, people see their friends having success, and more data shows broad health benefits and reduced mortality.

So how did I do?

I think I did… decent? On the bigger trends I was mostly right, with some details and timings off, and too much hopefulness on Alzheimer’s, where I have a lot of family history.

I still have a few more predictions pending for 2027 and beyond.

The past few months I’ve been overloaded with new policy and research projects that CASPR is preparing to launch and my head has not been in mindset to make new predictions. That said, 2026 will certainly be a big year for GLP-1s in addiction medicine as more trials announce results and industry activity grows, getting us closer to an eventual FDA approval.

Download this image here and share widely.

An in-depth piece presenting a winnable strategy to stop the gambling app takeover is coming soon.

We will be speaking about our work to advance GLP-1 pilot programs and research, as well as strategic policy interventions to reduce addiction at scale. Please see CASPR.org for more about our work.

EVENT INFO

• Tuesday January 13, 2026 — 9:30–10:30 AM

• Rayburn House Office Building, Room 2168 (Gold Room), 45 Independence Ave SW, Washington, DC 20515

• Morning reception with light refreshments

• Panelists:

  • Nicholas Reville (CASPR) — Moderator

  • Steve D. Klein, MD/PhD — Addiction Medicine Physician, Caron Treatment Centers

  • Jessica Massarone — Addiction survivor, OpenDoors GLP-1 client

  • Nick Horton — Co-Executive Director, Open Doors

Please come! And RSVP here if you have a chance.

These programs have already been covered by STAT and the New York Times, but the Washington Post reaches a DC audience that is, of course, particularly influential in addiction policy, and there are high leverage policy opportunities to get better medicines, including GLP-1s, to patients sooner.

So far, the experiences of patients in our programs have been extremely compelling. From the article:

“We see how hard it is for people to maintain their recovery long-term after they leave the support of our housing,” Open Doors Co-Executive Director Nick Horton said. “But with this medicine, I’m hopeful.”

Regina Roberts, a 41-year-old alcoholic in recovery, is living at an Open Doors facility after stints in rehab and a family court program after she lost custody of her teenage son. She has been sober since 2023 with the help of 12-step programs, therapy and life-skills classes. But she faced frequent reminders of her past: walking past a liquor store, smelling alcohol on someone’s breath, cigarette smoke wafting in the air. When Open Doors told her about the promise of GLP-1s several months ago, she agreed.

“I figured, why not try it?” Roberts said. “I’ll take anything to help me stay on my road to sobriety.”

With her cravings dialed back, Roberts hopes to reunite with her teenage son and move out of Open Doors in a few months. But she’s unsure whether she can keep taking the medication; she can’t afford to pay out of pocket and Medicaid might not cover it.

Three other quick updates:

• I’m speaking today in Halifax at CCSA’s Issues of Substance Conference at 11am, if you are in town. I’ll be talking about the emergence of GLP-1s for addiction and the particular opportunity that Canada has for advancing both clinical and real-world research as semaglutide (ozempic) becomes genaeric in Canada in less than two months (it won’t be generic in the US / EU for another 7 years). If you are around, please say hi! Can also email me.

• The retrospective study on GLP-1s and overdose among veterans that we funded at the VA has been submitted for publication. Results are very promising, more soon.

• Our website for CASPR.org has been updated recently. Check it out.

“Micro bets” are a wager on specific actions — will this pitcher throw a curveball to this batter? Will this player commit a foul in this quarter? More generally, prop bets, which include micro bets and things like “Will this team score more than 2 runs in this inning?” are extremely profitable for sports betting apps because they often offer worse odds to bettors, can string actions together into ‘parlay’ bets, and, most of all, because prop bets create hundreds of potential betting moments throughout a game— are a way to keep bettors constantly engaged and continuously betting.

Prop bets are addiction engines and betting companies make the majority of profits from the 10% of bettors who are the most addicted.

Prop bets also encourage players to cheat. The rise of sports gambling apps has created huge incentives for professional athletes to intentionally manipulate specific game actions. While it can be difficult and risky for one player to attempt to throw an entire game, it’s easy for a player to do specific things at the right time: nothing seems suspicious about throwing a certain type of pitch in a certain inning to a certain batter.

The obvious fix, one that should be supported by law and order types, sports fans who want games to be fair, and anyone who worries about people being pulled into gambling addictions, is this: ban prop bets.

Prop bet bans could be passed in individual states or at a national level. Gov. Mike Dewine in Ohio has pushed to limit prop bets, though instead of passing good legislation he appears to be settling for a deal with gambling app companies to restrict prop bets over $100, which may help to some extent on the corruption side (it makes it harder to place huge bets on a manipulated outcome) but won’t help addicted gamblers: a couple dozen $100 bets per game can drain someone’s life savings in a matter of days.

Instead, we should pass complete bans on prop bets and parlays.

This, like other gambling policies that we’ve been writing about, is achievable consensus politics: it doesn’t ban gambling but it would end the most addictive and manipulative elements that lead to ruined lives.

For more of our gambling and addiction writing, see our writing on how dependent gambling apps are on the most addicted users and how these apps are designed to encourage addictive behaviors.

Maia Szalavitz has a great article in the New York Times today covering the Open Doors / CASPR program, SheThrives, which is offering GLP-1s to women with substance use disorder history who are in post-incarceration housing. We are very proud of the program, the team at OpenDoors, and the women who are participating.

One of those, Jessica Massarone, is the focus of the Times piece:

In May, she began taking a drug similar to Ozempic while living at Open Doors, a Rhode Island nonprofit for formerly incarcerated and homeless people. She gets the medication, called a GLP-1, free through a pilot program testing the weight loss and obesity drugs as a treatment for addiction. Fifteen patients have started on the medication so far.

The drug helped Ms. Massarone, who had also battled obesity, lose 17 pounds. Critically, it also allowed her to overcome drug cravings in situations that had once defeated her.

This video from OpenDoors features Dr. Steve Klein and Jessica, on the impact of GLP-1s on her cravings:

Nick Horton, who runs the program and has spent decades managing transitional housing, says, “In so many cases, we are out of tools when it comes to dealing with addiction, even when we offer every other resource we can. Now, this seems to be making a difference where we otherwise were out of options. The women in our recovery houses want to enroll in this treatment, are staying on the medication, and are saying it is helping them. That makes us feel more and more confident that this is not only worth doing, but that we and others need to explore this treatment more widely.”

“I’ve gotten stronger in my recovery—I used to have a pit in my stomach when I thought about drugs. I had drug dreams. Those are gone,” Jessica reported. Another patient in the program, Kaley, also described her drug dreams vanishing on GLP-1 treatment, “I stopped having drug dreams. It hadn’t even occurred to me until someone asked me about my cravings, but I used to have these dreams where I was using opiates and then I’d wake up and want them. I don’t have those anymore.”

OpenDoors and CASPR are currently seeking funding to expand this pilot program into a randomized trial.

A chance to dramatically reduce the number of women in prison

We are, of course, delighted that this effort is helping the women in the OpenDoors program, and the broader vision is to understand how next-generation addiction medicine can create new paths to stability for people exiting prison.

The downstream consequences of addictions are often even worse than the direct medical effects — families torn apart, crime, poverty, abuse, lost jobs, lost futures, orphaned children, and more. Addiction is one of the rare factors that is truly a root causes of so much suffering and alienation.

Consider:

• Roughly half of reported crimes are related to drug or alcohol use or sale.

• 58% of women in state prison met DSM‑IV criteria for a substance use disorder in the previous 12 months (DOJ).

• 63% of women released from prison will be re-arrested within 5 years (DOJ).

Numbers are similar for men (slightly lower SUD rates but slightly higher re-arrest rates). Effective, maintainable addiction treatment that can begin during or just after prison will reduce crime, will vastly improve the lives of these women and men, and help protect the families and communities around them.

We already know that treating opioid use disorder in prison reduces rates of overdose when people are released. But many people with substance use disorders won’t accept methadone or buperenorphine treatment— after becoming sober from opioids in prison, they are often reluctant to begin an opioid agonist therapy. And for those with addictions to cocaine or methamphetamine, there are zero FDA approved treatments to offer.

In fact, only 3% of Americans with a substance use disorder currently receive medication to treat it, and you can’t make a lasting population-level impact at that level of adoption. GLP-1s can transform addiction treatment, in and out of prison, not just because they are effective, but because they are appealing. GLP-1s are extremely safe, easy to initiate, easy to self-dose, work across substances, are combinable with all existing SUD medications, and help people lose weight (which is highly motivating for adherence to treatment). Here’s more on GLP-1s and addiction.

To reach a broad population and get coverage from health care programs, GLP-1 medications need large scale clinical trials in substance use disorder indications; making that happen is one of our core missions at CASPR.

Finally, I want to thank the public and private donors to CASPR who have made it possible for us to develop and support programs like this. STAT also recently covered our GLP-1 program at Caron, which provides medication free of charge for an in-patient recovery program.

This is a seismic change from the past. Before 2018, betting on sports legally generally required physically going to a sportsbook, which were located in a handful of locations like Nevada and Atlantic City, New Jersey. Betting, in other words, required commitment and effort. (One could also bet illegally with a bookie, a thriving industry for sure but one with an even larger entry barrier.)

In 2025, however, betting on sports is everywhere. So are betting company ads, as anyone with a passing familiarity with sports media will tell you. The biggest growth area is online sports betting. Download an app, fund your account, bet away. It’s nearly effortless, and addicting by design. This rapid growth has lead to a surge in bankruptcies among young men who have become addicted to online gambling. Nicholas wrote recently on political strategy to protect users and weaken the industry’s growing grip on sports culture.

Betting apps use ideas described and developed by Stanford professor BJ Fogg, creator of Behavior Design, as well as the Hooked Model championed by Fogg acolyte Nir Eyal and described in his book Hooked: How to Build Habit-Forming Products. These apps drive addiction with the same strategies deployed by TikTok, Instagram, X, and virtually every other download at the top of the app store. (Plenty of now famous names passed through Fogg’s lab before building their highly addictive products.)

Eyal’s book details the four steps required to “spark interest and attention”: Trigger, Action, Variable Reward, Investment. To understand the success of modern sports betting, it’s helpful to break these categories down individually:

1. Trigger—External or internal cues that prompt action.

2. Action—Getting the user to do a simple, easy thing; a quick win.

3. Variable Reward—Study after study show uncertain rewards lead to more addicting behavior.

4. Investment—Make the user work a little and they will feel attached, wanting to return.

The result: In less than a decade, sports gambling went from a thing that happened at a handful of sportsbooks across the country (mostly inside casinos) to an activity done by millions of people every day.

Here are some examples of how sports gambling apps systematically pull users into addictive betting habits.

Note: We took representative screenshots from DraftKings and BetMGM, two of the apps that are available in New York state.

The Trigger: Getting users attention

These opening offers give new bettors bonus bets if they win their first bet, leading to “safe” plays and easy wins. Wins are highly reinforcing to bettors, even if the amount won is small because the bet was high probability.

And most importantly, these offers give new users a strong incentive to make a bet in their first user session, rather than just cautiously exploring the app and eventually deciding not to bet or getting distracted. Once a user places their first bet, the apps are confident they will stay engaged to see how the bet does.

***

Once you start using the a betting app, the iPhone home screen notifications never stop. In our testing, it wasn’t clear what the red numbers actually refer to—it wasn’t the number of live events to bet on or bets we had placed or anything we could figure out. The only function of the number seemed to be to draw the user’s attention.

After placing a bet, it’s easy to share it or create a group to exchange picks between friends. Social engagement is highly motivating for retention in any app.

***

An example of how the apps highlight live betting inside the app. Drawing players into real-time interaction will increase their time in the app and the number of bets they place, building and deepening the habit.

***

Apps like DraftKings give new players a percentage of the money they deposit while also promising referral bonuses. The user must opt into the offers, reinforcing interaction between new gamer and platform. There’s also a referral bonus for bringing friends on board.

Action: starting with a simple quick win

Placing a bet is so easy. Three clicks. We even had a surprise boost to use. Go Tigers. (They lost.)

***

Odds change constantly in live betting, with green and red borders indicting updated figures. This keeps users in the app, capturing more attention and mindshare.

***

The apps learn your habits and preferences to make personalized recommendations that are most likely to get you to places more and bigger bets.

Variable Reward: always be changing

Every time you log on, there are new and seemingly random Profit Boosts and other “deals.”

***

The UX displays auto-created parlays (a single bet that combines multiple event wagers), showing how many other people placed the same bet. FOMO is strong.

Investment: now you’re committed

After placing a bet, a person doesn’t need to wait until the event ends to cash out. If the game starts trending in your direction, you can take your gains early. In these screenshots, you can see how the payout offered immediately after placing a bet (image 1) was the same for both sides of the bet. When the bet started trending Fenerbahce’s way, the payout offered for that bet increased while the payout offered for Aluinvent Miskolc decreased (image 2), until it wasn’t offered anymore (image 3). At the conclusion of the game, the Fenerbahce bet cashed, paying out $9.34, while the Aluinvent Miskolc bet went to $0. Had we cashed out the Aluinvent Miskolc when DraftKings offered us $1.31, we would have taken that amount back, a loss of $3.69 ($5 initial bet minus $1.31) but it might have felt like a profit since we didn’t lose all the money as we did when Aluinvent Miskolc lost by more than the 11.5-point spread.

(Yes, we were live betting on a Euroleague Women’s basketball game at noon on a Thursday afternoon. )

***

BetMGM and DraftKings offer their own rewards programs, some combination of cash back, future bets, and membership cards that can be used at digital and physical locations. The goal is to keep users in the app’s ecosystem, getting them dedicated not only to sports betting generally, but to the individual provider specifically.

As the gambling infrastructure, rules, and regulations develop and different aspects become legal in different states, providers will seek to drive users to more products. For example, DraftKings already offers multiple gambling apps in addition to its sportsbook—Daily Fantasy Sports, Casino, Pick 6, DK Horse—although they can only be used by users in some states. (Sports gambling was legal in New Jersey before New York. One could, if one wanted, take a ferry from Lower Manhattan to Jersey City, betting on an app as soon the geolocation recognized that the ferry had crossed the state line in the middle of the Hudson, then take the next ferry back.)

Since the Supreme Court ended the national ban on sports betting, the floodgates have opened. Legal sports betting is now available in 38 states, plus DC and Puerto Rico. Roughly 30 states allow mobile / online apps, with some gray areas in certain states. In 2024, US companies made about $13.78B in revenue on $149.9B in bets. Incredibly, 48% of American men 18-49 have online gambling accounts.

Gambling is, of course, highly addictive for many people and quietly destroys lives and families, with limited personal or social benefits (and I do think ‘fun’ is a valid upside to consider). Research has started to arrive showing serious harms since legalization, including a big increase in bankruptcies, delinquencies, and debt collections in states that legalized online gambling vs those that didn’t. In states that did, bankruptcies rose by about 10% overall, and for people who are actually betting authors estimate the rate is 5X-10X higher than that.

I’ve started doing some work on this issue recently because I believe the online gambling industry is much more vulnerable than most people realize. While it may be hard to fully ban online gambling in the states that have already legalized it, there are smarter, politically achievable paths to eliminate most of the acute harms and end the industry’s cultural takeover.

Fundamentally, the online gambling industry is built on exploitation of a small slice of the population: the top 10% of online gamblers, “whales”, generate 80% of industry revenues and the top 1% generate 36% (report). These are also the people experiencing the most acute harms.

David Sasaki works on gambling issues at the American Institute of Boys and Men. He writes, “Sports betting is fairly harmless for most users, but incredibly harmful for the minority who develop an addiction they can’t afford.”

Unlike the morass of the drug war, online gambling is highly susceptible to policy intervention. What happens to the industry’s power if you provide even the most basic protections to these people and their families?

Gambling has taken over sports broadcasts

Sports broadcasts now often include betting odds and ads encouraging betting on individual moments of the game. In the short-term, these ads drive app downloads and bets and in the long-term they build the idea that the activity of watching sports should include betting.

Many sports fans find the sudden turn of professional sports toward gambling to be a tragic development. A friend told me recently that all the in-game gambling promotion ‘has crowded out so much of the fun of following sports for me’.

JR Moehringer published a piece the other day about sports gambling in the NYTimes, The Tragedy That Has Befallen Baseball:

Virtually overnight, Major League Baseball entered multiple partnerships with the gambling industry, permitted stadiums to be plastered with ads for gambling entities and betting apps, and even allowed sports books to operate at some of our most sacrosanct baseball cathedrals, including Wrigley Field, which is like nailing slot machines around the rim of the Grand Canyon.

When an industry rises like this, it drives a spiral of increasing power— huge revenues lead to more advertising and more industry lobbying and campaign donations. Ad revenues flow to sports teams, stadiums, and broadcasters while taxes flow to state governments, all of which aligns everyone in the same direction: more, more, more. The dramatic growth in the past few years could make you think this juggernaut has become unstoppable— “If we ban gambling in our state, we’ll lose millions in funding for schools!”

But as Charles Fain Lehman recently wrote on his substack, there is a backlash arriving:

Americans are growing more concerned about what sports gambling is doing to their country. In one recent poll, 58 percent wanted the federal government to “aggressively” regulate betting. Nearly two-thirds backed the SAFE Bet Act, a proposal from Democrats Rep. Paul Tonko and Sen. Richard Blumenthal that would impose stringent federal oversight. While a majority still favor legal sports betting, they also say that it should be illegal to bet on college sports, according to a recent AP-NORC poll.

Sports gambling momentum is more precarious than it seems

Advertising is always an auction. The seller has viewers or users they can put ads in front of and whoever pays them the most gets their ad shown.

For online ads, the auctions happen in real-time, with everyone who might want to reach a user competing to see who is willing to pay the most. The same dynamic is true for TV ads, billboards, and all the places in televised sports where a logo can be squeezed in.

When an online gambling service buys ad space, they are bidding against everyone else: car commercials, soap brands, insurance companies. To win the slot, the business must expect more value from that placement than its rivals do.

I spent years developing mobile apps and the user acquisition side of the business is brutal. If an app earns $6 on average per download, you will often have to bid $5.75 or sometimes even $6 to get a download— doing so is the rational path to growth, as painful as it is to have nearly all your income going out to ad sellers (And this explains why app stores and ad sellers like Meta and Google suck up most of the potential profits from app businesses.) The same dynamic is true for advertising physical products online and buying TV ads.

Now put yourself in the shoes of an online gambling app, trying to grow users and increase betting rates: you want to bid enough to get your ad out there without losing money. So if you are willing to pay $5.00 for a download or $500,000 for a TV placement, you must expect to generate at least that much value from those ads. If an insurance company sees a higher ROI from their TV placements than yours, they will bid $550,000 to get that in-game placement instead of you.

Online gambling companies spend hundreds of millions a year on ads and their gross profit margins are only around 10-15%. That means that even a modest increase in ad cost or decrease in revenue per user will make national ad buys unprofitable. And crucially, online gambling is still banned in a 12 states, including the two biggest markets, California and Texas. That means the ability for online gambling companies to run national TV campaigns and in-broadcast placements is very precarious: they are paying to run ads that appear even in states where their service is blocked. They are carrying substantial dead weight already.

If these companies lose access to a few more key states or if revenue per user drops even modestly, their ability to outbid other industries for national ad placements will end, and so will the financial engine that’s driving the cultural adoption of gambling as a core activity of sports fandom. Online ads, which are targeted to specific user locations, don’t have the deadweight problem of advertising to ineligible users, but they are just as sensitive to revenue per user: a small decline in expected earnings per download could make most of the user acquisition activity of online gambling companies unprofitable.

Common sense is the shiv

At CASPR, we’ve started talking with a coalition of organizations and individuals who are interested in preventing the most severe harms of online gambling.

We can win if we lead with politically appealing proposals that focus on common sense reforms rather than blanket bans. Nothing sounds more boring than the phrase ‘common sense reforms’, but strategically this will achieve more progress, faster— it is not a path of compromise. Proposing broad access bans or blanket ad bans will, in most states, stoke fears of lost tax revenue, draw in armies of lobbyists from gambling companies and sports teams, and pull you into a ‘prohibition vs freedom’ debate that will distract from the reality of the devastating spirals that are happening every day in homes around the country.

What makes this strategy so effective is that ‘common sense’ is firmly on our side. If you apply any common sense to the online gambling industry, it will shrink to a fraction of it’s current scale and lose its cultural power along the way.

Again, the top 10% of online gambling spenders drive 80% of the revenue and suffer the most harm. Reform campaigns should focus specifically on preventing harms to the heaviest users.

Just take a few of the pieces below and think about how they might fit together:

• Most states allow credit cards to be used for online gambling apps. Why?

• Most states don’t require people to prove they are the sole owner of a bank account in order to connect that account to a gambling service. This loophole means that joint bank accounts can be drained rapidly without mutual notification or permission. How many marriages would be saved if this were fixed?

• In most states, there are no requirements to intervene when users show addictive, escalating betting behaviors, there are no caps on how much people can bet per day or per week, and no cooling off periods after bettors experience significant losses. Basic guardrails would benefit everyone, particularly users at risk of escalating their betting beyond what they can afford.

• There are currently no caps on what percent of your bank balance can be spent at an online gambling app in given day or a week. Banks should be required to create limits.

How many politicians would vote against basic protections for the families being most harmed? How many voters would vote against a ballot measure that provided protections? Not many. And each time you pass a reasonable reform, the size of the industry will shrink and the next reform will become even easier to pass.

But there is some promising news from the FDA, and a policy win for our efforts to accelerate the development of new addiction medicines: the new National Priority Voucher (NPV) program. Based on statements from the administration about fentanyl and addiction, we expect that this program will include addiction medicine as a ‘national priority’ and could significantly accelerate the approval process for addiction drugs, potentially saving 10 months on drug approval timelines.

CASPR was the first organization to propose a priority review voucher for addiction medicines, we’ve met with dozens of Congressional offices to support a program, and Joe Lonsdale included our PRV recommendation in the influential ‘Make the FDA Great Again!’ paper. This new FDA effort delivers many (but not all) of the benefits that we believe can draw more companies into addiction medicine development.

Does 10 months faster matter?

In a disease area like addiction, which is profoundly lacking in late stage drug candidates and FDA approvals, speeding drug approval might seem pointless– getting nothing approved 10 months sooner is still nothing. But the potential to save 10 months on a drug development program matters tremendously to drug developers and investors who decide whether to launch a new medication program.

Despite a massive burden of disease, addiction medicine is currently a desert for innovation. The core thesis of our policy work is that this neglected disease area needs new incentives to jumpstart innovation. Last fall, CASPR published our Innovation Agenda for Addiction along with the Institute for Progress and with the Federation of American Scientists. It proposes actionable steps to accelerate breakthroughs in addiction medicine.

The Agenda introduced a novel proposal to expand the FDA’s Priority Review Voucher (PRV) program to incentivize medications targeting substance use disorders. The existing FDA PRV program has been very successful in spurring innovation in other neglected disease areas, and we believe it can work here as well.

Since publication, passage of a PRV has been our top policy goal and we have been actively engaging lawmakers and policymakers on the topic. This new National Priority Voucher is being created at the FDA without a new law being passed and, likely for this reason, does not go off the same benefits as the existing PRV programs, which allow resale of earned priority review vouchers. Selling these vouchers is a vital source of funding for biotechs working in neglected disease areas, as each voucher is worth over $100M. We will continue our work to advance legislation for a full addiction PRV program in Congress.

Still, the introduction of the NPV is a potentially huge step forward and is a recognition of the need to give special incentives to disease areas with high social externalities. Addictions cause tremendous harms within families, relationships, society, and the economy– it makes sense for the government to prioritize development of better treatments.

A backdrop of painful cuts

The overall political and policy strategy behind our Innovation Agenda for Addiction is to advance nonpartisan policies that can lead to medications that can reduce substance use disorder at a population scale. Families, doctors, and politicians on both sides of the aisle want better medicines for addiction, making this a policy path that can side-step the entrenched ‘drug war vs harm reduction’ debates that have lead to policy paralysis.

We count this NPV as a good step towards supporting innovation but it comes at a time when funding cuts are destroying addiction research programs at universities and research centers. This is counter-productive, both medically and fiscally: anything that slows down our ability to make progress against addiction is tremendously expensive to both the heart and purse of our country. New medicines begin with basic science– if we lose that, we could face many more decades of woefully insufficient medications for addiction.

But why this big drop now? A few theories:

1. Maybe the long-term trend of lower drinking among younger people is peeking out from under a short-lived pandemic-era upswing in stress drinking.

2. “For the first time in Gallup’s trend, a majority of Americans, 53%, say drinking in moderation, or ‘one or two drinks a day,’ is bad for one’s health.” There’s been a new medical consensus in the past couple years that no amount of alcohol is beneficial and maybe that’s been sinking in with the public.

3. Drinking could be dropping as GLP-1 use continues to rise— with 12% of adults having taken a GLP-1, we might be seeing some population-level downward pressure on alcohol consumption.

But the most intriguing part of the Gallup findings is that Republicans reported a huge 19% drop in drinking since 2023, going from 65% to 46%, and apparently driving the vast majority of the overall drop in Adults who report drinking. I’d generally be skeptical of a big drop within such an established cultural practice, but the data shows two consecutive years of big drops for Republicans, so maybe it’s real.

Why are Republicans in particular suddenly less likely to drink?

• Is this the influence of RFK Jr. / MAHA / right-wing health influencers? The Gallup details say that Republicans are less likely to believe that drinking is bad for health, but there still could be a shift happening there from before.

• New and more conservative beliefs around drinking? Trump doesn’t drink (though neither did Biden).

• Less conservative GOP beliefs about cannabis? The right seems to be quickly opening up to cannabis and psychedelics. Perhaps this is driving replacement of alcohol with cannabis, though Gallup notes that overall cannabis use has been flat the past few years (after big increases in the previous decade).

Any other theories?

In recent months, doctors at Caron Treatment Centers, an elite nonprofit rehab facility, have begun prescribing semaglutide to patients not to address obesity or diabetes but to help treat the addictions that brought them here in the first place.

…

To Sarhan, two things already seem clear: Patients are interested in GLP-1s, and the medications are producing results unlike any he’s seen.

“GLP-1 medications are all-around more attractive to patients: They’re new, they’re sexy, they cause weight loss, they jump-start wellness,” he said.

“I’ve never had a person who I’ve started on naltrexone turn around and tell me that their cravings have been obliterated,” he added, referencing a common treatment for alcohol and opioid addiction. “Whereas I have had that happen with people who’ve been started on GLP-1 medications.”

The Caron Program is one of two real-world pilot projects that CASPR is supporting to develop case studies and lay groundwork for new clinical trials. The other program, at OpenDoors in Providence RI, has launched recently as well, providing semaglutide to women with SUD in a post-incarceration transitional housing program (background here).