How an addiction medicine doctor has made GLP-1s like Ozempic central to his practice
How an addiction medicine doctor has made GLP-1s like Ozempic central to his practice
“I’m now offering GLP-1s to nearly all my substance use disorder patients.”
We’ve been speaking with doctors who have made GLP-1RAs like Ozempic, Wegovy, Mounjaro, and Zepbound part of their practice of addiction medicine. If you are a prescriber and would like to share your experience, please be in touch.
A surge of interest in GLP-1s for addiction
Addiction specialists and family physicians around the country are rapidly adopting GLP-1s like Ozempic, Wegovy, Mounjaro, and Zepbound for patients with substance use disorders (SUD). The overwhelmingly positive reports from patients and providers combined with rapidly growing medical evidence is driving this transformation of practice. Doctors and addiction centers are seeing dramatic results.
“I’m now offering GLP-1s to nearly all my substance use disorder patients.”
Patient-driven requests are a big part of this story, as people on GLP-1s spread word about the remarkable reductions in cravings for alcohol, opioids, and stimulants they have experienced. (Here’s a reddit group where people discuss their use of GLP-1s to reduce their drinking). As a medication that reduces addictive drive and which patients are actively seeking out, GLP-1s could drive a population-level decrease in untreated addictions.
GLP-1s are becoming a draw for rehabs. The Livengrin Foundation, a rehab center outside of Philadelphia, recently ran a sponsored article suggesting that their patients are being offered GLP-1s during treatment: Connections between new weight loss drugs and alcoholism treatment comes from Philly’s Livengrin Foundation.
Prescribing GLP-1s to SUD patients, on- and off-label
While we urgently need large-scale trials to achieve an FDA indication and insurance coverage, doctors are seeing sustained positive outcomes for many patients in treatment. They prescribe GLP-1s for SUD patients either on-label for other health conditions (diabetes, obesity, and soon sleep apnea and several others) or off-label (unlikely to be covered by insurance).
Off-label uses are not unusual in addiction medicine. Several other medications are frequently prescribed in this manner for SUD treatment, either for cost savings or due to the lack of pharma industry interest in pursuing FDA approvals for effective medications. Clonidine, for example, is very commonly used off-label for opioid withdrawal management. Several other medications, including ondansetron, baclofen, clonidine, divalproex, gabapentin, and topiramate are also popular off-label prescriptions for addiction medicine providers and family physicians.
One of the largest obstacles to patient recovery for SUDs is adherence to medication. GLP-1s, which are more appealing to many patients than existing options, may encourage patients to keep taking their medication. Last week, we spoke to a doctor at Stanford Health Care. They described an alcohol use disorder patient who had failed previous interventions but was eagerly calling each week for their next GLP-1 dose, excited about the craving reductions as well as weight loss and other health benefits.
GLP-1s in addiction medicine practice
Mo Sarhan, MD is an addiction medicine specialist who works at Caron Treatment Centers, a large rehabilitation and treatment service provider with facilities in multiple states. Caron is a leader in addiction research and treatment adoption, and served as the study location for the recent Penn State randomized trial that demonstrated large reductions in cravings for opioids among patients receiving a GLP-1.
Dr. Sarhan is in recovery himself and initially became interested in using GLP-1s for treatment after talking with friends in the recovery community. “I started hearing so many stories of people who were put on Ozempic or Mounjaro for diabetes or weight loss, and as soon as they started the medication, their cravings for alcohol or stimulants like cocaine and amphetamine disappeared,” he said.
A couple dozen patients later, he is even more convinced. He’s seen patients who had been unable to stop the cycle of returning to use until going on GLP-1s. This includes patients who were admitted to the relapse unit, started GLP-1s, and are now in the longest period of recovery that they’ve ever had. “I’m now offering GLP-1s to nearly all my substance use disorder patients,” Sarhan said.
Only patients with qualifying conditions like diabetes or obesity are able to receive insurance coverage. In Caron’s inpatient system, where Dr. Sarhan works, all patients are fully detoxed, and begin a GLP-1, if prescribed, around day 10 due to the delay requesting prior authorization from insurance companies. Patients receiving GLP-1s for opioid use disorder are also receiving Suboxone. Patients are understandably concerned about nausea when beginning a GLP-1, and Dr. Sarhan said he has been leaning towards tirzepatide rather than semaglutide because of fewer reported side effects in the literature.
A growing trend among addiction specialists
Dr. Sarhan described growing utilization of GLP-1s among the new generation of specialists, signaling what may be the next major shift in addiction medicine practice. "It’s amazing how quickly things can change in terms of medication adoption,” he said. “I personally was a patient 10 years ago. When I was here, no one got put on maintenance Suboxone. People with opioid use disorder got put on Vivitrol if they wanted it. Doctors almost never used medications for treatment of alcohol use disorder. It’s totally different today.”
Crucially, GLP-1s are additive to and compatible with all existing SUD medications and show reductions in cravings across substances. Because only 3% of people with substance use disorders are able or willing to take existing medications, there is an urgent need for new options such as GLP-1s that are more appealing to patients, have lower side effects, increased efficacy, and broad health benefits and mortality reductions.
This is the first in a series of articles we will be doing on providers who are innovating in addiction medicine practice. Are you a provider who has used GLP-1s with your patients? We’d love to hear your story.
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These medications are super interesting but the effect on addiction makes me wonder what negative side effects they have we don't understand yet. After all, cravings and other drug use behaviors leverage quite general mechanisms of reward, pleasure and desire in the brain and it's hard to imagine tuning those mechanisms won't affect other, potentially desierable behaviors. I certainly know that some people report anhedonia and it would be great if that could be validated or rejected with an RCT.
Those impacts aren't any reason to panic or warn people away -- there is alot of interpersonal variation in psychological traits and if consciously adjusting them helps someone live a better life great -- but I unfortunately suspect there is no free lunch here (just some good bargains).