We’ve all likely heard of GLP-1s, the miracle Type 2 diabetes and weight loss drugs that slow digestion, control blood sugar, and signal satiation to the brain. The health effects of GLP-1-associated weight loss, as one might expect, are far-reaching and include reduced heart attack and stroke risk, better kidney and liver function, and improved sleep quality.
As it turns out, GLP-1s are also effective in curbing alcohol use and treating addiction. In the last two years, several scientific studies have shown GLP-1s to reduce cravings, decrease substance intake, and modulate addiction-related receptors in the brain.
These studies suggest great promise for GLP-1s in curing addiction. The New York Times, in bringing the good news to the public, called Ozempic a possible “breakthrough drug to conquer addiction.”
Such enthusiasm is understandable. Despite billions of dollars of federal, state, local, and private foundation funding, America’s struggles with addiction have deepened with each passing decade since the 1960s. Perhaps we’ve finally found the answer.
What History Says About Medical Cures for Addiction
There’s no disputing the science. GLP-1s work in curbing cravings and substance use for many of the people who take them. Given these findings, why would anyone want to rain on the GLP-1 parade? The answer is simple: We’ve seen this play and its encores before.
The first well-known drug treatment for alcohol use disorder was Antabuse (disulfiram). Antabuse causes an allergic-type reaction to drinking by blocking alcohol metabolism in the liver, with a resulting buildup of acetaldehyde, a toxin, in the body. Those who take Antabuse before drinking experience severe nausea, vomiting, flushing, and heavy sweating. These symptoms make Antabuse extremely effective in reducing alcohol intake.
Like GLP-1s, Antabuse was initially used for a different purpose—treating parasitic stomach infections—before its anti-alcohol use properties were discovered. Also like GLP-1s, Antabuse reduces cravings and has its own weight loss properties (albeit through different mechanisms), with associated improvements in organ function.
So why isn’t Antabuse, a drug that nearly abolishes alcohol intake in controlled studies, used regularly to treat alcohol use disorder? One reason is long-term side effects, but that’s true of common drugs used to treat a variety of physical ailments and mental health conditions.
More importantly, Antabuse only works for those who take it. Those who plan ahead of time to drink can stop taking Antabuse a few days beforehand. People like me, who work in the field, see this over and over again with Antabuse and other drug treatments for addiction. On the streets, where it counts most, drug treatments aren’t nearly as effective as they are in the lab. Suboxone, which I’ve written about elsewhere, provides another example.
Laboratory Versus Real-World Effectiveness
Two other drugs, naltrexone and acamprosate, were introduced in 1994 and 2004, respectively, to reduce cravings and treat addiction. Lab studies showed sizable reductions in alcohol cravings and alcohol use for both. A few years later, however, an analysis of 64 studies, including 10,933 people, found the effects of both drugs to be between negligible and small, as shown in the adjacent figure.
Other, non-pharmaceutical interventions have been framed as cures by our nation’s most senior public health officials: transcranial magnetic stimulation, deep brain stimulation, and low-intensity focused ultrasound. Effects in the lab are impressive, but on the streets the jury is still out. Why do we so often jump the gun in promising cures before testing our treatments in the real world?
What Lab Efficacy Doesn’t Capture
The difference between efficacy in the lab and effectiveness on the streets has been known to psychologists for decades. Why don’t highly effective treatments translate into real-world cures? In attempting to bridge the efficacy-to-effectiveness gap, medicine even invented a new field—implementation science. Progress, however, is limited.
Addiction Essential Reads
Weak translation of efficacy into effectiveness isn’t restricted to addiction. Medical science has highly potent treatments for hypertension and heart disease, for example, but these aren’t adhered to by most patients either. Even vaccines that are 100 percent effective in preventing life-threatening viruses are rejected by ever-larger swaths of the population.
GLP-1s present a special challenge because their side effects, including nausea, vomiting, diarrhea, constipation, and stomachaches, can be intolerable. Although such effects can usually be managed with dietary restrictions, many people won’t accept such restrictions, and only a third of people treated with GLP-1s for pre-diabetic weight loss are adherent at one year. How can we expect GLP-1 treatments for addiction to be any different?
Between the laboratory and the real-world lies the human being. Psychology, more than any other discipline, should recognize this. Blocking the physiological effects of substances and managing cravings are important, but no magnetic field, ultrasound, or pharmaceutical can bring deserted children back, reverse financial ruin, heal the wreckage of infidelity, or resurrect someone killed by one’s drunk driving.
Events like these, which are common in addiction, diminish self-worth and engender legitimate shame—well-documented and potent catalysts for sustained use and relapse. Working through these emotions takes time. Short of erasing human memory and blunting human emotion, medical interventions will likely never be enough to cure addiction alone.
Too often we psychologists cede our expertise where it’s needed the most. Addiction treatment is one of those places. Take it from someone who knows.
