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Ozempic and Cravings: How GLP-1 Drugs Work for Addiction · RECOVERable: Mental Health and Addiction Experts Answer Your Questions

• 0:13
  SPEAKER_01: This year, 10 to 12 percent of Americans will be on a GLP1.
• 0:17
  SPEAKER_01: Dr.
• 0:17
  SPEAKER_01: Stephen Klein, who specializes in addiction medicine, joins us to discuss innovative treatments, including the role of GLP1s in substance use disorder recovery.
• 0:27
  SPEAKER_00: Addiction is a problem with the brain, and now we have a really good medication to potentially change the brain, and that's going to change the way that we view addiction.
• 0:38
  SPEAKER_01: Welcome to Recoverable.
• 0:39
  SPEAKER_01: I'm your host, Terry McGuire.
• 0:41
  SPEAKER_01: The history of medicine is full of happy accidents, where a drug designed for one specific use ends up being used for something else and revolutionizing another field.
• 0:51
  SPEAKER_01: For instance, the hair growth drug rogaine was originally designed to treat high blood pressure, and Viagra was used to treat high blood pressure and chest pain.
• 1:01
  SPEAKER_01: This phenomenon is known as drug repurposing.
• 1:04
  SPEAKER_01: And it's exactly what we're seeing now with GLP1s.
• 1:07
  SPEAKER_01: Developed to manage type 2 diabetes.
• 1:10
  SPEAKER_01: They are now widely used for chronic weight management.
• 1:12
  SPEAKER_01: And today we're going to discuss the fact that they're also being used to treat addictions.
• 1:17
  SPEAKER_01: And joining us now is Dr.
• 1:19
  SPEAKER_01: Stephen Klein, who not only is an expert in this topic, but has lived experience with it as well.
• 1:24
  SPEAKER_01: Dr.
• 1:25
  SPEAKER_01: Klein, welcome back.
• 1:26
  SPEAKER_01: Thank you so much for having me.
• 1:27
  SPEAKER_01: Thank you.
• 1:28
  SPEAKER_01: So GLP ones, that's a that's a shift.
• 1:31
  SPEAKER_01: How did this come about?
• 1:32
  SPEAKER_01: And tell us how it has worked for you in your life.
• 1:34
  SPEAKER_00: Sure.
• 1:34
  SPEAKER_00: So I'll start with my story first.
• 1:36
  SPEAKER_00: Um, so like we covered a little bit in the last episode, I'm a person in long-term recovery.
• 1:41
  SPEAKER_00: I've been sober for the past nine years.
• 1:43
  SPEAKER_00: Part of my recovery journey was the pleasure of doing medical residency, sober.
• 1:49
  SPEAKER_00: Um, my medical residency was also during the global pandemic.
• 1:53
  SPEAKER_00: So as a resident in pediatrics in the inner city of Philadelphia, at that time it was very stressful to be in the hospital.
• 2:01
  SPEAKER_00: Many people saw this on the news, but really to live it, to go every day to the emergency room, not know what was going to happen, not know the right masks, the if it was the virus was surviving on the floors, on the patients, what would happen?
• 2:13
  SPEAKER_00: And we really didn't know how it was going to affect children.
• 2:15
  SPEAKER_00: And that was probably how it affected me the most.
• 2:17
  SPEAKER_00: But what was also really hard was that all of our coping mechanisms were taken away.
• 2:22
  SPEAKER_00: So we didn't have the gym, we didn't have dinner with friends, we didn't have, you know, things that we were doing to kind of maintain that balance.
• 2:29
  SPEAKER_00: And for me, as a person at that point, being four years sober, I really struggled uh with eating.
• 2:36
  SPEAKER_00: I just started to go to work.
• 2:38
  SPEAKER_00: I would come home, take off my scrubs, do the like laundry or whatever they were telling us to do at that time.
• 2:44
  SPEAKER_00: Um, and then I would order DoorDash, like a lot of people were doing in the lockdown.
• 2:49
  SPEAKER_00: Uh, but for me, that was really challenging because I started to put on a lot of weight.
• 2:53
  SPEAKER_00: And when the pandemic somewhat subsided, I went back to see my primary care doctor.
• 2:59
  SPEAKER_00: I really told her at that point I was struggling with about 35 to 40 pounds of extra weight.
• 3:04
  SPEAKER_00: And she said, you know, there are these new class of medications.
• 3:07
  SPEAKER_00: They're really effective.
• 3:08
  SPEAKER_00: Why don't I prescribe one for you?
• 3:09
  SPEAKER_00: And we'll see if we can get insurance to cover it.
• 3:12
  SPEAKER_00: And if so, great.
• 3:13
  SPEAKER_00: She prescribed me Bongiorno, which is now zEP-bound.
• 3:16
  SPEAKER_00: I started it and just had the most incredible transformative experience.
• 3:23
  SPEAKER_00: It made me realize that I was likely a food addict before I was a drug addict.
• 3:27
  SPEAKER_00: I had had a problematic relationship with food, my body image, and my weight my entire life, being a heavy child, losing weight in college, gaining weight again in medical school.
• 3:38
  SPEAKER_00: And it really drew attention for me to the amount of mental equity I was expending, thinking about food, thinking about diet, thinking about what I was or wasn't eating, working, working not out, how I was burning things off.
• 3:52
  SPEAKER_00: And somewhat overnight, my relationship with food normalized.
• 3:56
  SPEAKER_00: Is that the chatter that we hear?
• 3:58
  SPEAKER_00: The food noise is what people talk about.
• 4:01
  SPEAKER_00: For me, yes, it was the food noise.
• 4:03
  SPEAKER_00: It was also just the control.
• 4:07
  SPEAKER_00: I used to feel so bad about myself after a day of like good, healthy eating to come home and ruin it all with, you know, Chinese food or something else.
• 4:16
  SPEAKER_00: I just felt there was parts of my life that were just out of control.
• 4:19
  SPEAKER_00: And not just the noise telling me what to eat and not what not to eat, but the feelings of failure.
• 4:25
  SPEAKER_00: The feelings of, oh, I can't keep to this diet, the feelings of, oh, diet start Monday.
• 4:30
  SPEAKER_00: Like all of those feelings were just this roller coaster of emotion that was so not sustainable from an energy expenditure point of view, especially mental energy.
• 4:40
  SPEAKER_00: So I started the medication and it was transformative for me.
• 4:44
  SPEAKER_00: That seemed to, again, go away almost overnight and has stayed away.
• 4:49
  SPEAKER_00: And it's been amazing.
• 4:51
  SPEAKER_01: In what other ways than your relationship to food have GLP once helped you?
• 4:56
  SPEAKER_00: I would honestly say it's it's impossible to distinguish.
• 4:59
  SPEAKER_00: I tell my patients all the time, at the beginning of every morning, you get a certain number of tokens.
• 5:05
  SPEAKER_00: I want you to decide what you do with those tokens.
• 5:07
  SPEAKER_00: So being on this medication has given me all of my tokens back.
• 5:11
  SPEAKER_00: So I can't distinguish where it has and hasn't helped me.
• 5:14
  SPEAKER_00: I have invested those tokens into my relationship to my husband, into the individual therapy work that I do, into my recovery, into the people that I sponsor's lives and now into my career.
• 5:25
  SPEAKER_00: I mean, it's really for me, it's made every part of my life better.
• 5:30
  SPEAKER_00: I feel healthier and I feel more in control of the way that I'm exerting my efforts and expending my energy.
• 5:38
  SPEAKER_01: You're using tokens as a metaphor for energy focus.
• 5:42
  SPEAKER_01: Pretty much all of them.
• 5:42
  SPEAKER_00: I think of it really as like emotional equity.
• 5:45
  SPEAKER_00: Okay.
• 5:45
  SPEAKER_00: Uh emotional equity and uh investing those tokens in things that will pay me dividends.
• 5:50
  SPEAKER_00: So things that I get something back from, this roller coaster of weight and dieting and cycling and always feeling like a failure and never a success never really paid me back anything.
• 6:02
  SPEAKER_01: You were unaware, you say before then, that you may have had an addiction with food.
• 6:07
  SPEAKER_01: Did that play into shame and all and some of the other things that can lead to some of your other addictions?
• 6:15
  SPEAKER_01: Absolutely.
• 6:16
  SPEAKER_00: I think, you know, the for me, the world of recovery has been really transformative in a few of my relationships.
• 6:25
  SPEAKER_00: I would say mostly my relationship to my body, my relationship romantically to other men, and my relationship to my career.
• 6:34
  SPEAKER_00: All of those things have changed in my recovery.
• 6:37
  SPEAKER_00: I would say GLP1s have had an effect in all of those.
• 6:41
  SPEAKER_01: So, how did GLP ones get on the radar for addiction treatment?
• 6:45
  SPEAKER_00: Yeah, it's a great question.
• 6:46
  SPEAKER_00: So these are really the the place to start is really that these medications, despite popular belief, are not all that new.
• 6:54
  SPEAKER_00: So they've been around since around 2005 when we had once daily injections for type 2 diabetes.
• 7:00
  SPEAKER_00: We've noticed then that people were losing large amounts of weight.
• 7:04
  SPEAKER_00: And the second, second-ish generation of these were once weekly medications.
• 7:08
  SPEAKER_00: Those were things like osempic, semaglutide.
• 7:11
  SPEAKER_00: And with that discovery that they were causing weight loss in the amount of 10 to 15, even 20% of body weight, huge amounts of people started taking them.
• 7:21
  SPEAKER_00: That's the contemporary real eruption of their use.
• 7:24
  SPEAKER_00: We started to hear anecdotally, so just from people taking them, that wine didn't look so good, whiskey didn't look as appetizing, they were drinking less, they were doing less smoking, they were doing less compulsive behaviors.
• 7:38
  SPEAKER_00: So some people started to study this.
• 7:40
  SPEAKER_00: There was a study run at Karen treatment centers that looked at opioid use disorder with once daily lyriglutide that showed that people's cravings for opioids decreased by about 40%.
• 7:50
  SPEAKER_00: And then last year a study was run on alcohol use disorder.
• 7:53
  SPEAKER_00: It was published in JAMA Psychiatry that showed that people decrease their drinking by about 40%.
• 7:58
  SPEAKER_00: Pretty impressive data.
• 8:01
  SPEAKER_00: So it's been now the real push, I would say, the new frontier of addiction medicine is can these medications be repurposed as you opened for addiction or to treat other compulsive behaviors?
• 8:14
  SPEAKER_00: What's the answer?
• 8:16
  SPEAKER_00: I believe yes.
• 8:17
  SPEAKER_00: I think, you know, for me, I step back and I look at the data.
• 8:21
  SPEAKER_00: So I step back and I look at the studies that have come out, but maybe more nuanced.
• 8:28
  SPEAKER_00: I think most people with obesity, and I'm talking morbid obesity, where obesity is in BMI 35, 40, 45, those people really do have an addiction to food.
• 8:40
  SPEAKER_00: I think if you were to ask someone of a very high BMI, the DSM five criteria for alcohol use disorder and change the word alcohol with food, many of the answers would be yes, and their use would be severe.
• 8:52
  SPEAKER_00: I think based on that, they're already treating addiction.
• 8:56
  SPEAKER_00: For the first time, we may be getting to the actual core circuitry of addiction and not just treating the symptoms or the end receptors.
• 9:04
  SPEAKER_01: So the core circuitry of addiction, the significance of that, because if if that's what GLP1s do, there are a lot of addictions that could be well, I don't remedied is certainly not the word, but treated with it.
• 9:19
  SPEAKER_01: What sort of uses are you seeing?
• 9:21
  SPEAKER_00: Yeah.
• 9:21
  SPEAKER_00: So there was an amazing paper that came out about two weeks ago now in the British Medical Journal that showed that across multiple substances, GLP1s have an effect.
• 9:30
  SPEAKER_00: So this was opioid use disorder, cocaine use disorder, nicotine use disorder, and alcohol use disorder.
• 9:36
  SPEAKER_00: So actually, for the first time, this may be one of the only medications out there that seems to be substance agnostic.
• 9:43
  SPEAKER_00: So it can be used across the spectrum of addiction.
• 9:46
  SPEAKER_00: Again, because it's getting to more of the circuitry, less so the end product.
• 9:51
  SPEAKER_00: I also want to be really clear.
• 9:53
  SPEAKER_00: This is something that we touched on last week.
• 9:54
  SPEAKER_00: And I loved that part of our conversation.
• 9:57
  SPEAKER_00: These medications do take away cravings and desires for medication.
• 10:02
  SPEAKER_00: We still have to look at that why.
• 10:04
  SPEAKER_00: Yeah.
• 10:04
  SPEAKER_00: So I don't, I don't want to sell this as, you know, and these these medications are not yet FDA approved for the treatment of alcohol use disorder or opioid use disorder.
• 10:14
  SPEAKER_00: But again, we're talking about the treating of symptoms, which in this case is cravings.
• 10:19
  SPEAKER_00: I still am a firm believer that the treatment of addiction is recovery.
• 10:23
  SPEAKER_00: These medications may help people engage in recovery sooner.
• 10:27
  SPEAKER_01: Do GLP ones play a role, or do you think that in the future they could in behavioral addictions, gambling, sex addictions, those kinds of things?
• 10:34
  SPEAKER_00: Absolutely.
• 10:35
  SPEAKER_00: Um, from my own experience, I never had a problem with gambling in the sense that I never presented for help.
• 10:41
  SPEAKER_00: I never sought help.
• 10:43
  SPEAKER_00: Um, I do drive past a casino on my way to uh our place on the Jersey shore.
• 10:49
  SPEAKER_00: And I used to stop frequently just to play Blackjack, which was the game that I liked.
• 10:53
  SPEAKER_00: I liked the numbers and I would find myself playing, and I did like the rush of it.
• 10:57
  SPEAKER_00: I think it's a it's a fun pastime.
• 11:00
  SPEAKER_00: I had I did find that that slowed down and then completely stopped about a year after taking GLP1s.
• 11:06
  SPEAKER_00: So I do think they play a role in behavioral addictions, sex addiction, gambling addiction.
• 11:13
  SPEAKER_00: I think we're just scratching the surface.
• 11:15
  SPEAKER_00: Really, anything that can somewhat hijack our dopamine reward, what's called the mesolimbic system, is a potential candidate to be treated or at least mitigated by these medications.
• 11:28
  SPEAKER_01: So sounds like a miracle drug, kind of.
• 11:30
  SPEAKER_01: And and it may be in some ways, but there's always the other side.
• 11:35
  SPEAKER_01: I mean, you I used to do the the commercials and you talk really, really fast and just say, like, yeah, and you also might die.
• 11:42
  SPEAKER_01: So, what are the side effects of GLP1s that people need to be aware of?
• 11:46
  SPEAKER_00: Sure.
• 11:46
  SPEAKER_00: So the major side effects that I counsel all patients that I prescribe GLP1s for are GI side effects.
• 11:52
  SPEAKER_00: So nausea and vomiting being the most common.
• 11:55
  SPEAKER_00: I think with longer-term use, constipation is pretty common.
• 11:58
  SPEAKER_00: That's probably a combination of decreased intake, so you're not eating as much potentially, and also the delayed gastric emptying.
• 12:05
  SPEAKER_00: So stomach food comes out of the stomach slower in littler amounts that can decrease kind of stool bulk.
• 12:11
  SPEAKER_01: And that's on purpose.
• 12:12
  SPEAKER_01: That's part of the medication to make you feel full longer, correct?
• 12:15
  SPEAKER_00: Right.
• 12:15
  SPEAKER_00: But it can also be a somewhat uncomfortable side effect.
• 12:17
  SPEAKER_00: So I counsel most patients that, you know, these are things that can be mostly managed either behaviorally or by things that can be prescribed or even just bought over the counter.
• 12:26
  SPEAKER_00: Okay.
• 12:26
  SPEAKER_00: Muralx, metamusil, things like that are really helpful for the constipation side point.
• 12:31
  SPEAKER_00: The nausea, actually, I find is pretty self-limiting.
• 12:34
  SPEAKER_00: It depends on the which medication you're using and the dose.
• 12:38
  SPEAKER_00: Luckily for addiction, we use a smaller dose, especially in people not trying to lose weight.
• 12:43
  SPEAKER_00: And the the number of patients that we've prescribed to the amount that need to stop due to these side effects is very, very small.
• 12:50
  SPEAKER_01: You had already stopped drinking before you started taking GLP ones.
• 12:54
  SPEAKER_01: Have GLP ones changed the way your mind talks to you?
• 13:00
  SPEAKER_00: I would say really it's it's around food and kind of food experiences and getting back to just how much time I was investing in kind of meal prepping, dieting, things like that.
• 13:10
  SPEAKER_00: You know, I love food.
• 13:13
  SPEAKER_00: I'm I'm an Italian geo from New York.
• 13:15
  SPEAKER_00: Food is a huge part of my life.
• 13:17
  SPEAKER_00: I still love food.
• 13:18
  SPEAKER_00: But now when I'm sitting down to dinner across from my husband, I'm present.
• 13:23
  SPEAKER_00: I'm not thinking about what I'm having for dessert to what I'm having after dessert for like a midnight stack.
• 13:27
  SPEAKER_00: When I look at a menu, I'm not daunted by the fact that there's a burger and chicken fingers, but the society in my mind telling me that I should have a Caesar salad because I'm overweight is what I hear the most of.
• 13:40
  SPEAKER_00: And then I feel bad because I've had a moment where I order something that I think I shouldn't be eating.
• 13:46
  SPEAKER_00: My my food decisions just seem to be on autopilot.
• 13:50
  SPEAKER_00: And that to me has been the most amazing effect.
• 13:55
  SPEAKER_01: So GLP ones can not only make drug use less pleasurable, but make abstinence less painful too.
• 14:01
  SPEAKER_01: Is that correct?
• 14:02
  SPEAKER_00: I wouldn't say that's how I characterize their effect.
• 14:06
  SPEAKER_00: I would say it's a way of saying it.
• 14:08
  SPEAKER_00: So abstinence less painful.
• 14:10
  SPEAKER_00: I think about these medications as really somewhat changing the rheostat or the the level, the tuning of noise volume.
• 14:20
  SPEAKER_00: So how loud are the noises in our in our minds, how loud are the cravings, but also potentially having us feel better, more complete, more uh satiated with less input.
• 14:34
  SPEAKER_00: So I think that's really where the language and the correlation with food is really interesting.
• 14:40
  SPEAKER_00: So I think when we talk about food, we talk about appetite, hunger, and then we talk about satiation, fullness, feeling content.
• 14:48
  SPEAKER_00: Then we talk about addiction, appetite gets replaced with craving, urge, longing, desire, lust, all of those adjectives.
• 14:59
  SPEAKER_00: And then when we talk about the opposite of that, it's contentment, serenity, quietude, stillness.
• 15:07
  SPEAKER_00: So I think about those as kind of changing the baseline that a patient is feeling.
• 15:12
  SPEAKER_00: So if someone is used to craving opioids day in and day out, and that is the noise in their mind, if we can lessen that noise, yes, I would say abstinence or letting go of the substance, not having those cravings can be less painful.
• 15:29
  SPEAKER_00: Okay, be more tolerable.
• 15:31
  SPEAKER_01: So the top question asked on the internet is how do GLP1 drugs work or addictions?
• 15:38
  SPEAKER_00: Yeah.
• 15:38
  SPEAKER_00: So in a very kind of simple way, I think when we talk about GLP1s, we have to talk about three organ systems.
• 15:45
  SPEAKER_00: Okay.
• 15:46
  SPEAKER_00: First organ system is the pancreas.
• 15:48
  SPEAKER_00: In the pancreas, they basically increase the release of insulin.
• 15:52
  SPEAKER_00: That treats type 2 diabetes, pretty straightforward.
• 15:54
  SPEAKER_00: In the stomach, it's a second organ system.
• 15:57
  SPEAKER_00: They de decrease gastric emptying.
• 15:59
  SPEAKER_00: So it's delayed gastric emptying, slows the transit of food.
• 16:03
  SPEAKER_00: People feel full longer, weight loss.
• 16:06
  SPEAKER_00: Now let's talk about the brain.
• 16:08
  SPEAKER_00: The brain is really where I spend a lot of my time thinking.
• 16:12
  SPEAKER_01: I love how you light up about it.
• 16:13
  SPEAKER_01: It's like really careful.
• 16:15
  SPEAKER_00: It's fascinating because, like, you know, in every other disease model, we talk about the organ and we talk about the pancreas and the in diabetes.
• 16:22
  SPEAKER_00: We talk about the stomach and obesity.
• 16:24
  SPEAKER_00: In addiction, for some reason, we've always talked about the whole person.
• 16:27
  SPEAKER_00: You know, you are the person.
• 16:29
  SPEAKER_00: It's your issue.
• 16:31
  SPEAKER_00: It's not.
• 16:31
  SPEAKER_00: It's it's a disease of the brain.
• 16:34
  SPEAKER_00: And the fact that all of the brain regions that control addiction, the mesolimbic system again, have GLP1 receptors.
• 16:42
  SPEAKER_00: And we know now because of the rodent evidence, the animal models, that using GLP1s modulate that system in such a way that could be beneficial for addiction, it really starts to break down that stigma that addiction is a problem with you as a whole person.
• 17:01
  SPEAKER_00: Addiction is a problem with the brain.
• 17:03
  SPEAKER_00: And now we have a really good medication to change, potentially change the brain.
• 17:07
  SPEAKER_00: And that's going to change the way that we view addiction.
• 17:11
  SPEAKER_01: So when you talk about the other symptoms, the pancreas and the stomach, uh, and the way they're affected by GLP1s, I'm assuming it's only the brain part that works toward the addiction.
• 17:21
  SPEAKER_00: It's hard to know exactly.
• 17:22
  SPEAKER_00: These are really there, there we're enters, we're entering a really interesting phase of more understanding the gut brain access.
• 17:30
  SPEAKER_00: There's a lot of communication.
• 17:31
  SPEAKER_00: At the end of the day, GLP1s are naturally made peptides that the body makes.
• 17:36
  SPEAKER_00: They're cleaved in different places and bind in different places.
• 17:40
  SPEAKER_00: The thing that I focus on is the brain and the brain signaling.
• 17:43
  SPEAKER_00: Can I say that's completely in isolation from the stomach and other parts of the body?
• 17:48
  SPEAKER_00: No, overwhelmingly, I think that that's the effect that they have on the brain, the in that the injections that we're giving patients, it's a synthetic form of the naturally occurring hormone.
• 17:59
  SPEAKER_00: It's the remaking of that peptide that really kind of changes the volume and changes the playing field.
• 18:06
  SPEAKER_01: So the changes in the brain or rewiring, as people like to say, is that only while they're on a GLP one, or is that going to continue after they go off?
• 18:18
  SPEAKER_00: It's a great question.
• 18:19
  SPEAKER_00: That's probably the biggest area that we don't know right now.
• 18:22
  SPEAKER_00: Okay.
• 18:22
  SPEAKER_00: I will tell you my favorite expression and analogy for the question that you just asked, which is that addiction is like there is a record playing in your mind.
• 18:30
  SPEAKER_00: That record always ends in drug use.
• 18:33
  SPEAKER_00: Something good happens, use drugs, something bad happens, use drugs.
• 18:36
  SPEAKER_00: It's Saturday, Sunday, or Monday, use drugs.
• 18:40
  SPEAKER_00: These medications, I believe, pick the needle off that record long enough that we can teach you another song.
• 18:48
  SPEAKER_00: So I believe that these medications can really break the chains of addiction from a behavioral standpoint.
• 18:57
  SPEAKER_00: I also am a real believer that new behaviors and new reward loops can be built.
• 19:04
  SPEAKER_00: That's something that's going to take more time to prove.
• 19:07
  SPEAKER_00: Those are harder, more nuanced outcomes.
• 19:10
  SPEAKER_01: Tell me about the other paths, the other ways to get your needs and desires met that are not through harmful addictions.
• 19:19
  SPEAKER_00: Sure.
• 19:19
  SPEAKER_00: So this gets kind of down to dopamine gain.
• 19:22
  SPEAKER_00: Another expression, sorry, I use a lot of expressions.
• 19:25
  SPEAKER_00: That's all right, you're a doctor.
• 19:26
  SPEAKER_00: One that I really like is uh if you are raised on a battlefield, it's very hard to hear the tinkering of bells.
• 19:34
  SPEAKER_00: So from this, it's really the background of trauma.
• 19:37
  SPEAKER_00: It's the background of things that cause huge dopamine release.
• 19:41
  SPEAKER_00: It's the background of someone who's used to doing methamphetamines, which increase our basal dopamine from 100 to 1,000.
• 19:48
  SPEAKER_00: In context, eating your favorite food may increase your basal dopamine from 100 to 150.
• 19:53
  SPEAKER_00: Wow.
• 19:54
  SPEAKER_00: So when I talk about the rewiring of the brain, it's really to relearn to not be on a battlefield.
• 20:01
  SPEAKER_00: It's to re-equilibrate our hearing so that we can hear the tinkering of bells.
• 20:06
  SPEAKER_00: If you're used to only the input of drugs, giving you the dopamine necessary to feel even normal, what chance does a good conversation with a friend stand or the sunlight on your face, seeing someone that you love after a week of them being away?
• 20:21
  SPEAKER_00: Those things are smaller, more nuanced dopamine signals.
• 20:24
  SPEAKER_00: I think abstinence is the gateway to relearning that actually life is full of beautiful things and wonder when we're in the depths of our addiction.
• 20:33
  SPEAKER_00: We forget that.
• 20:35
  SPEAKER_01: The second most common question on the internet is: are there specific addictions that GLP ones are the most helpful in treating?
• 20:42
  SPEAKER_00: We don't yet know.
• 20:43
  SPEAKER_00: We can only say what the data shows.
• 20:45
  SPEAKER_00: So the data right now for GLP ones, there's two main categories of data.
• 20:49
  SPEAKER_00: One is observational and the other is prospective.
• 20:52
  SPEAKER_00: For observational studies, we have huge, I'm talking hundreds of thousands of patients in big healthcare systems that are prescribed these for either weight loss or type 2 diabetes.
• 21:01
  SPEAKER_00: And then we make retrospective observational accounts of what's happening.
• 21:05
  SPEAKER_00: And those studies, the biggest ones that have emerged are opioid use disorder, alcohol use disorder, and nicotine use.
• 21:11
  SPEAKER_00: Then prospectively, that's when we take patients and randomize them to either get semaglutidozempic or uh placebo.
• 21:19
  SPEAKER_00: That's kind of the gold standard of medical interventions.
• 21:23
  SPEAKER_00: Those are emerging the most, in my opinion, the strongest evidence is in alcohol use disorder.
• 21:28
  SPEAKER_00: It's what affects the most people and what's easiest to fund.
• 21:32
  SPEAKER_00: So from that perspective, it's where the data is.
• 21:35
  SPEAKER_00: Again, this larger study that came out that was actually 600,000 US veterans, showed an effect across so many substances that I think we're just scratching the surface.
• 21:46
  SPEAKER_00: What difference can all this make?
• 21:48
  SPEAKER_00: Huge.
• 21:49
  SPEAKER_00: Um, I think about the treatment center where I'm fortunate enough to work is is really a place where I wish everyone had access to that.
• 22:02
  SPEAKER_00: I wish everyone had access to incredible therapy, wraparound clinical services, group therapy, spiritual uh therapy, things like that.
• 22:09
  SPEAKER_00: But it's just it's not the way that our medical system is set up and it's not reasonable.
• 22:13
  SPEAKER_00: Reasonable to think that that's accessible to all people today.
• 22:16
  SPEAKER_00: I think where these medications have incredible promise is one, if we can get over the accessibility barriers to these medications themselves, they could potentially be scalable addiction treatments that people could take on their own, mitigate their risk, decrease their risk of overuse, overdose, things like that.
• 22:36
  SPEAKER_00: But also, I think there's an incredible untapped population where we may be able to divert people from ever crossing the line into alcoholism or drug addiction.
• 22:49
  SPEAKER_00: So if someone is having a relationship with alcohol or opioids or nicotine that, again, takes away from their agency, they're not able to do things that align with their value system.
• 22:59
  SPEAKER_00: Could they start one of these medications earlier?
• 23:02
  SPEAKER_00: Is there a lower risk of overdose for people in GLP ones?
• 23:06
  SPEAKER_00: What these big observational studies show is yes, the British Medical Journal paper showed a decrease in 50% of all cause substance use-related mortality, over 600,000 people taking them.
• 23:19
  SPEAKER_00: So let's 50%.
• 23:20
  SPEAKER_00: 50%.
• 23:24
  SPEAKER_00: So alcohol-related hospitalizations, alcohol-related relapse, almost 20% in all of those, but then jumped to 50 for all-cause mortality related to substance use.
• 23:34
  SPEAKER_00: So I would say yes, the idea is that patients are doing less of the substances that potentially can affect them negatively while on these medications.
• 23:44
  SPEAKER_00: Again, those are observational studies.
• 23:45
  SPEAKER_00: So those are people who are on them for weight loss or type 2 diabetes.
• 23:48
  SPEAKER_00: We don't yet have the longitudinal study largely because it's not yet FDA approved to follow patients, say, who are leaving care and treatment centers on a GLP 1 long-term, what their relapse rates are.
• 24:00
  SPEAKER_00: I imagine that data will be forthcoming.
• 24:03
  SPEAKER_01: So you just address this.
• 24:08
  SPEAKER_01: What does that mean, though?
• 24:09
  SPEAKER_00: So basically, the FDA is the governing body in the United States that basically says the medical literature has reached a point that we can now use this medication to treat X.
• 24:20
  SPEAKER_00: So big studies showed that these medications were effective in weight loss.
• 24:24
  SPEAKER_00: Two major studies came out in the New England Journal that then after that the FDA followed with the treatment of uh WAGO, the approval of WAIGOV for weight loss and Zetbound for weight loss.
• 24:35
  SPEAKER_00: So by their stance currently, the data has not reached that threshold.
• 24:40
  SPEAKER_00: It needs a few more clinical trials, more prospective data, like we were mentioning.
• 24:44
  SPEAKER_00: What's quite interesting is that doesn't mean they can't be prescribed.
• 24:48
  SPEAKER_00: So just because something is an FDA approved doesn't mean that it can't be repurposed.
• 24:52
  SPEAKER_00: Getting back to your opening of the second off-label.
• 24:55
  SPEAKER_00: Right, off-label.
• 24:56
  SPEAKER_00: Yeah, off-label.
• 24:56
  SPEAKER_00: So in fact, in addiction medicine, off-label prescribing is no mystery to us.
• 25:03
  SPEAKER_00: There is no FDA-approved medication for cocaine use disorder.
• 25:08
  SPEAKER_00: There is no FDA-approved medication for methamphetamine use disorder.
• 25:12
  SPEAKER_00: That does not mean we don't treat those people.
• 25:15
  SPEAKER_00: So there's a lot of repurposing that already happens.
• 25:17
  SPEAKER_00: I treat a lot of my patients with methamphetamine use disorder with naltrexone.
• 25:21
  SPEAKER_00: We talked about it last episode, as well as buprenorphine, something called well butrin.
• 25:26
  SPEAKER_00: Uh, it's there's one paper that shows that that's quite effective.
• 25:29
  SPEAKER_00: Um, and for cocaine use disorder, it's also a lot of off-label prescribing.
• 25:33
  SPEAKER_00: But there's nothing illegal, unethical, anything about off-label prescribing.
• 25:40
  SPEAKER_00: It's just a doctor's analysis of the data and then a very careful risk-benefit calculus of this, if it can help the patient in front of them.
• 25:50
  SPEAKER_01: So if GLP ones are not FDA approved for treating addictions, does that mean insurance won't cover them?
• 25:55
  SPEAKER_01: Yes.
• 25:56
  SPEAKER_00: Largely, yes.
• 25:57
  SPEAKER_00: And what's hard about the way that our insurance system is currently set up is someone like me who's meeting a patient for a 28-day residential treatment stay, it's almost impossible for me to even prescribe them for FDA approved indications.
• 26:11
  SPEAKER_00: So currently, if you want to be prescribed a GLP one for weight loss, many insurances will deny until you can prove three to six months of failed weight loss on diet and exercise.
• 26:23
  SPEAKER_00: Okay.
• 26:23
  SPEAKER_00: I have don't have that data as someone who's meeting a patient for the first time and taking care of them for 28 to 30 days.
• 26:29
  SPEAKER_00: Right.
• 26:30
  SPEAKER_00: It's become a way that insurance companies can deny access to these medications because they're very expensive and because so many Americans are overweight.
• 26:38
  SPEAKER_00: So many people qualify who can't even get them for the FDA approved indications.
• 26:43
  SPEAKER_01: So in this instance, being overweight could actually be helpful in terms of having access to the medication that somebody else might be denied?
• 26:50
  SPEAKER_00: Sure.
• 26:51
  SPEAKER_00: It's definitely a possibility.
• 26:52
  SPEAKER_00: Insurance company could approve for a patient in under my care if their BMI was 35.
• 26:57
  SPEAKER_00: They may approve Ozempic, WAGO, more likely WAGO V or ZEP bound for that patient.
• 27:03
  SPEAKER_00: Um, and they may deny it for a patient whose BMI is under 30.
• 27:07
  SPEAKER_01: So looking specifically at mental health, if GLP ones make someone lose interest in drugs, alcohol, or other addictive behaviors, can it make them lose interest in everything?
• 27:16
  SPEAKER_01: I think of that word anhedonia, where you just don't experience joy.
• 27:21
  SPEAKER_00: There is kind of a feared reporting of this that people become anhedonic or really lose interest in all things.
• 27:28
  SPEAKER_00: I don't see it.
• 27:30
  SPEAKER_00: I also haven't experienced it myself.
• 27:32
  SPEAKER_00: I wouldn't say it's a common side effect.
• 27:35
  SPEAKER_00: I would also say at this point, we're crossing the threshold of these medications are so widely used this year.
• 27:40
  SPEAKER_00: 10 to 12% of Americans will be on a GLP one.
• 27:44
  SPEAKER_01: 10 to 12% of Americans.
• 27:46
  SPEAKER_00: 10 to 12% of Americans.
• 27:47
  SPEAKER_00: Wow.
• 27:47
  SPEAKER_00: So if something like that was even happening in 0.01%, we're talking about tens or hundreds of thousands of people, if not millions.
• 27:56
  SPEAKER_00: So it's not a report that is something that we see time and time again.
• 27:59
  SPEAKER_00: It's not something that I'm hearing from my patients kind of boots on the ground.
• 28:03
  SPEAKER_00: I will say, you know, the reward system is very interconnected with emotional well-being.
• 28:10
  SPEAKER_00: For example, there were some early reports of depression in people using GLP1s.
• 28:15
  SPEAKER_00: I question if it's causing depression or if these are people who were addicted to food and using food as a coping skill who no longer had their coping skill.
• 28:25
  SPEAKER_00: Interesting.
• 28:26
  SPEAKER_00: So there's some nuance there.
• 28:27
  SPEAKER_00: I think we have to be careful about saying that things are causative or if it's just happening.
• 28:33
  SPEAKER_00: There's a lot of neuroplasticity and neural remodulation that happens in early recovery.
• 28:39
  SPEAKER_00: I don't know if we'll ever be able to parse apart exactly what the effect of individual things are.
• 28:45
  SPEAKER_00: I think for right now we're on the macro level.
• 28:47
  SPEAKER_00: The more research will show more of the micro changes.
• 28:50
  SPEAKER_01: This may be a similar answer to the one you just did, but another question is that some studies suggest the risk of suicidal thoughts and behaviors can increase significantly using GLP ones.
• 29:00
  SPEAKER_00: Yeah, I think it's largely that.
• 29:02
  SPEAKER_00: I think that's really where I kind of land, which is yes, we're taking away the cravings, but you know, my my expression from last episode, drugs and alcohol are not the answer, but they make us forget the question.
• 29:15
  SPEAKER_00: If you take away drugs or alcohol, that question may still be there.
• 29:19
  SPEAKER_00: That may be unresolved trauma, unresolved depression, unresolved issues with integration and authenticity.
• 29:26
  SPEAKER_00: If you remove someone's coping skills, they may have an increase in mental health symptomatology because of that.
• 29:33
  SPEAKER_01: And if somebody listening is having that experience, what should they do?
• 29:38
  SPEAKER_00: I would say, in my opinion, these medications, especially in the realm of addiction, should not be used in a kind of vacuum.
• 29:46
  SPEAKER_00: I think, especially if you're having severe alcohol use disorder, severe opioid use disorder, and you're thinking about or using GLP1s as part of that treatment, that you're really engaged with mental health professionals.
• 29:58
  SPEAKER_00: The degree is up to you if you need outpatient therapy or something like we offer at care and treatment centers with really intensive inpatient therapies.
• 30:06
  SPEAKER_00: But I think, again, the idea of learning a different song is really important with these medications and just doing one thing.
• 30:14
  SPEAKER_00: And we're actually seeing that with weight loss too.
• 30:16
  SPEAKER_00: If people use the time on these medications to learn new healthy lifestyles, they can actually build health in a different way in a different direction.
• 30:24
  SPEAKER_00: I think that correlation also exists in the addiction and mental health space.
• 30:28
  SPEAKER_01: I think it can help just to hear that it can be a possible side effect so that if it happens, A, you don't feel, you know, condemned by it or stigmatized about it or afraid to tell anyone.
• 30:37
  SPEAKER_01: You walk in and say, I'm having, you know, I get a rash from this lotion.
• 30:41
  SPEAKER_01: You know, I'm getting, I'm having suicidal thoughts or I'm I'm my depression's acting up, whether I knew I had it or not, as a result of, or in in conjunction with being on this medication.
• 30:52
  SPEAKER_01: Is it that or me or life?
• 30:54
  SPEAKER_00: Or yeah, I I would encourage everyone, my mantras of trust and and and also honesty, like with their healthcare providers, really share what's going on, what your experience is.
• 31:06
  SPEAKER_00: These medications in every person's journey is going to be unique.
• 31:10
  SPEAKER_00: And I think the more that patients are sharing with their doctors, the more that we can respond and help both treat symptoms and also guide therapy into maybe we need to add something or take away something or lean into something a little bit more.
• 31:23
  SPEAKER_00: I think that's the way medicine should be, highly personalized and highly patient focused.
• 31:30
  SPEAKER_01: Another top internet question is will my cravings return if I stop taking GLP ones, just like some people regain lost weight.
• 31:37
  SPEAKER_00: Yeah, that's this all kind of builds off the same conversation.
• 31:41
  SPEAKER_00: Back to the record analogy, I think it really depends on if you learn a different song.
• 31:45
  SPEAKER_00: So with the with the weight loss, I think we're showing now that if patients use that time to really understand their habits, build healthier habits around exercise, food choice, protein intake, and really focus on maintaining some degree of lean muscle mass, that they have a better chance of that weight staying off.
• 32:06
  SPEAKER_00: The truth is we don't know in the realm of cravings if there'll be some rebound effect.
• 32:11
  SPEAKER_00: What's interesting also, though, is you know, that for me doesn't mean we don't use them.
• 32:16
  SPEAKER_00: For example, the medications that we discussed last episode, buprenorphine, methadone, and naltrexone.
• 32:22
  SPEAKER_00: I know what happens when a patient comes off buprenorphine, their cravings do return.
• 32:26
  SPEAKER_00: They do have withdrawal symptoms.
• 32:28
  SPEAKER_00: So I don't think that disqualifies these medications from being used.
• 32:32
  SPEAKER_00: We have a little bit of hesitancy, I think, as a society to think about a medication that's being used for our lifetimes, but we also seem to be pretty selective.
• 32:40
  SPEAKER_00: Most statins are prescribed for a lifetime.
• 32:43
  SPEAKER_00: Most SSRIs are considered long-term medications.
• 32:47
  SPEAKER_00: So I think, you know, for me, again, it comes down to the risk-benefit analysis of these medications for right now.
• 32:54
  SPEAKER_00: I think that they're really helping the patients that they're being prescribed to.
• 32:58
  SPEAKER_01: So I know we talked about MOUD or medications for opioid use disorder in last week's episode.
• 33:04
  SPEAKER_01: When you say coming off of some of those could lead to cravings coming back.
• 33:08
  SPEAKER_01: And if GLP1s reduce cravings, do you see the two prescribed together?
• 33:13
  SPEAKER_00: Absolutely.
• 33:14
  SPEAKER_00: I think going back to something we discussed last episode, number needed to treat, the lower the number needed to treat, the more efficacious a medication is.
• 33:22
  SPEAKER_00: The number needed to treat for ozempic wagovies, that bound and mongiorno are also in the two to three range.
• 33:29
  SPEAKER_00: So when you start combining these things, like buprenorphine plus semaglutide, now trexone plus semaglutide, I think these things will be additive and they'll give patients the best shot, um, the best chance at recovery, the best chance at abstinence, and then getting to the deeper questions and being able to do some of the deeper work.
• 33:49
  SPEAKER_01: Because if you see television commercials or online commercials, it's always, you know, take this with your antidepressant, take this with your blank, and the two together can work differently and better.
• 34:00
  SPEAKER_00: Yeah, I think they'll definitely be additive, also kind of building from our last conversation.
• 34:05
  SPEAKER_00: One of the major barriers we have in addiction medicine is just accessibility to these medications.
• 34:09
  SPEAKER_00: So I certainly am encouraged by the new wave of addiction medicine treatments.
• 34:15
  SPEAKER_00: I also think they need to, we need to kind of keep our focus broad and that we should be increasing accessibility not only to GLP1s, but also buprenorphine and naltrexone and methadone.
• 34:26
  SPEAKER_00: Um, I think the more treatment options that are available, the better.
• 34:30
  SPEAKER_00: And I think the more that we can curtail our treatment planning to individual patients, their experience, their individual stigmas and societal stigmas, the better outcomes we'll have as a society.
• 34:42
  SPEAKER_01: Speaking of stigma, I would think that GLP1s have way lower stigma than a lot of other drugs because you're seeing people very proudly say, this is me on blank, and look how much better I look and feel.
• 34:55
  SPEAKER_00: Yeah, I actually love that these medications treat obesity.
• 34:59
  SPEAKER_00: Yeah.
• 34:59
  SPEAKER_00: I think it's opening up the dialogue in a way that we've never seen in a in a scale larger than we've seen before and breaking down the stigma of addiction.
• 35:08
  SPEAKER_00: If we compare obesity and addiction, the similarities are so striking.
• 35:14
  SPEAKER_00: There are things that throughout generations we've told people that it's something that you are doing.
• 35:19
  SPEAKER_00: You are lazy, you are not eating correctly.
• 35:21
  SPEAKER_00: No self-control.
• 35:22
  SPEAKER_00: No self-control.
• 35:23
  SPEAKER_00: Yeah.
• 35:24
  SPEAKER_00: Drugs, Nancy Reagan, just say no.
• 35:26
  SPEAKER_00: It's your moral fiber.
• 35:28
  SPEAKER_00: These are things that are wrong with you.
• 35:30
  SPEAKER_00: For the first time with an effective medication, we've been able to say, actually, this isn't just about you.
• 35:37
  SPEAKER_00: This isn't just that you are doing something wrong.
• 35:40
  SPEAKER_00: It's the system.
• 35:42
  SPEAKER_00: It's actually really, really hard to maintain a BMI of 45 if you can't walk into a restaurant and order 5,000 calories in one plate of food.
• 35:51
  SPEAKER_00: It's also really, really hard to be a drug addict and an alcoholic if you're not in a society where dopamine has basically been sold to the highest bidder for the past three generations.
• 36:01
  SPEAKER_00: So I think we're at a point now where we can, as a society, start clawing back some of that agency from the highest bidder to now giving it back to the people.
• 36:11
  SPEAKER_00: And that's where I think that this conversation is amazing.
• 36:14
  SPEAKER_00: Seeing Serena Williams on a row commercial, I love.
• 36:17
  SPEAKER_00: Seeing Oprah on the cover of People magazine, incredible.
• 36:22
  SPEAKER_00: Oprah has enough money to truly have someone exercise each one of her fingers independently.
• 36:28
  SPEAKER_00: If she cannot maintain her weight without a GLP one, what chance does anyone have?
• 36:34
  SPEAKER_01: So if somebody is listening or watching this discussion and thinks, I should maybe consider this.
• 36:41
  SPEAKER_01: GLP one's to help me if it could help with my addiction or that of a loved one.
• 36:46
  SPEAKER_01: What do you suggest they do next?
• 36:49
  SPEAKER_00: So first, I always like to start with honoring the amount of work that goes into that journey.
• 36:53
  SPEAKER_00: So looking, I think, retrospectively and and introspectively at yourself and saying there's something in my life that I don't like, I think is heroic and courageous.
• 37:02
  SPEAKER_00: So first just saying, you know, wow, I've gotten to this place.
• 37:05
  SPEAKER_00: Now what's the next step that I take?
• 37:07
  SPEAKER_00: I think finding a doctor that you can align with, whether, again, I think there's we like to say there's no wrong door to recovery.
• 37:15
  SPEAKER_00: There's no wrong door to getting agency back.
• 37:17
  SPEAKER_00: And that you can enter the system from the level of your PCP, your pediatrician, your endocrinologist, your gynecologist, whatever the conversation starter.
• 37:26
  SPEAKER_00: I think then utilizing the resources that are available to you, we have amazing addiction medicine providers throughout the country.
• 37:33
  SPEAKER_00: Not everyone is prescribing a GLP1 right now, but starting that conversation and seeing if they're open to it.
• 37:40
  SPEAKER_00: I think there are providers we're growing in numbers as these become more pervasively prescribed.
• 37:45
  SPEAKER_00: But just starting the conversation, this is something that I've heard about.
• 37:49
  SPEAKER_00: Is this potentially helpful to me?
• 37:51
  SPEAKER_00: And maybe they'll recommend something else first, but eventually getting there.
• 37:55
  SPEAKER_01: How long is the road between sort of anecdotal proof that something is effective and getting enough research so that the FDA approves it?
• 38:05
  SPEAKER_01: How far away do you think we might be from having GLP ones uh available and covered by insurance?
• 38:11
  SPEAKER_00: I think optimistically, my hope is for the next 12 months.
• 38:14
  SPEAKER_00: There are some big studies coming through the pipeline.
• 38:17
  SPEAKER_00: There are some companies that have brought new versions of GLP ones that are currently being tested that are going to be just for alcohol use or opioid use disorder.
• 38:26
  SPEAKER_00: So there's a lot of movement.
• 38:28
  SPEAKER_00: For example, Eli Lilly is the company that makes Mangiorno and Zetbound.
• 38:33
  SPEAKER_00: They just hired one of the most prominent addiction medicine researchers from the NIH into their company.
• 38:39
  SPEAKER_00: So I think there's real attention here.
• 38:41
  SPEAKER_00: I think there's a real, really a loud signal.
• 38:44
  SPEAKER_00: I'm a member of ASAM, the American Society of Addiction Medicine.
• 38:48
  SPEAKER_00: This was a whole topic at our annual meeting last year.
• 38:51
  SPEAKER_00: It's a buzz.
• 38:52
  SPEAKER_00: It's something that people are talking about.
• 38:54
  SPEAKER_00: I think we're getting closer and closer.
• 38:56
  SPEAKER_00: We still need those big randomized control trials, which are the real gold standard of demonstrating medical efficacy.
• 39:04
  SPEAKER_01: Tell me what it means that some GLP ones in the future could specifically target, if that's the right verb, um alcohol use or another substance use versus food, if it's all sort of connected.
• 39:19
  SPEAKER_00: Yeah, the truth is they won't.
• 39:20
  SPEAKER_00: They'll all be like cross-effective.
• 39:22
  SPEAKER_00: What I mean by that statement is so when we talk about these medications, we're really talking about a molecule.
• 39:28
  SPEAKER_00: So think about a ball of spaghetti with a couple of meatballs attached to it.
• 39:33
  SPEAKER_00: Like those are peptides.
• 39:34
  SPEAKER_00: Now, companies make peptides, so semaglutide, the active ingredient in Ozempic and Wigovi, is a peptide that really Nova Nordisk controls.
• 39:45
  SPEAKER_00: Zeppound, Bongiorno is a much bigger peptide, more spaghetti, a couple more meatballs.
• 39:50
  SPEAKER_00: And they're that's controlled by Eli Lilly.
• 39:53
  SPEAKER_00: Those are blockbusters for weight loss, for example.
• 39:58
  SPEAKER_00: The valuation of Nova Nordisk, a Danish company, just exceeded the GDP of the country of Denmark.
• 40:06
  SPEAKER_00: These are big money makers.
• 40:07
  SPEAKER_00: Wow.
• 40:08
  SPEAKER_00: So they are very protective of these peptides.
• 40:11
  SPEAKER_00: They're very protective of what they're used for, what they're not.
• 40:13
  SPEAKER_00: When I say another company is going to bring a peptide, they're just going to make a different combination of spaghetti and meatballs.
• 40:18
  SPEAKER_00: And their indication, what they're trying to treat, is alcohol use disorder.
• 40:22
  SPEAKER_00: Okay.
• 40:23
  SPEAKER_00: So they're potentially the same mechanisms.
• 40:26
  SPEAKER_00: They may have a little bit of difference.
• 40:27
  SPEAKER_00: They may be a little bit different in size or where they bind or their ability to get into the brain or different regions of the brain.
• 40:33
  SPEAKER_00: But the fact that companies are focusing just on that really highlights that there's an unmet need.
• 40:39
  SPEAKER_01: When you look at all the research, including your personal lived experience using GLP ones and the world of addiction which you are in, do you think that this that GLP ones hold promise or that they are it should become a gold standard?
• 40:56
  SPEAKER_01: Where do you, where are you on the spectrum?
• 40:59
  SPEAKER_00: Right now, my my personal practice and my practice at care and treatment centers is that we are we are at that moment.
• 41:07
  SPEAKER_00: We are in the present of GLP1s.
• 41:09
  SPEAKER_00: I think there is a wave coming.
• 41:11
  SPEAKER_00: We're kind of in the tidal wave of that title, we're in the title pool of that title wave, if you will.
• 41:17
  SPEAKER_00: Uh, but for me, I start from the place that addiction is a high morbidity, high mortality condition.
• 41:24
  SPEAKER_00: So when I'm weighing the potential risks and benefits, the side effects, all of that, especially in the realm of treating things like cocaine use disorder, methamphetamine use disorder, which have no FDA-approved indications or FDA-approved medications, I think for me, the calculus becomes a little bit easier.
• 41:43
  SPEAKER_00: Again, 10 to 12% of Americans trying these medications, the safety data for me kind of speaks for itself.
• 41:50
  SPEAKER_00: I then take the next step and to say, so where we are right now, if someone's agency has been taken away enough that they are sitting in front of me in residential treatment, facing grave consequences, why shouldn't I make something else available to them?
• 42:05
  SPEAKER_00: Especially because the accessibility of these medications, as being evidenced by people like Serena Williams and Oprah, are available to people who can afford them.
• 42:15
  SPEAKER_00: So for me, part of my mission, part of my life's work at Care and Treatment Centers is making the medications available to people who want to try them as part of their recovery, and then helping them through the decision-making process, the continuation, and also more importantly, learning a different song.
• 42:34
  SPEAKER_01: So the more research there is, the more likely or the closer it moves toward hopeful FDA approval, which will mean insurance coverage, which will mean availability.
• 42:43
  SPEAKER_01: Absolutely.
• 42:44
  SPEAKER_01: What about people who do not need to or do not want to lose weight, and yet they have an addiction to something else that GLP1s might help with?
• 42:52
  SPEAKER_00: Thank you so much for asking that question.
• 42:54
  SPEAKER_00: It's it's one that I answer almost every day.
• 42:56
  SPEAKER_00: Um, and it's really important to for me, I break down that GLP ones have really three dosing windows.
• 43:03
  SPEAKER_00: Luckily, the first and the lowest is with cravings.
• 43:06
  SPEAKER_00: The middle is for type 2 diabetes, and then the extreme is for the treatment of obesity, where you have to be really up in the higher doses to lose those 10, 15, 20% of your body weight.
• 43:16
  SPEAKER_00: So I think for someone who doesn't have weight to lose or weight loss is not part of their goals and not part of what they see for themselves, we stay at the lower end of the dose.
• 43:25
  SPEAKER_00: Luckily, some of the studies that I mentioned earlier were at that lower end for example for example.
• 43:31
  SPEAKER_00: Semaglutide has a few commercially available doses, 0.25 milligrams, then 0.5 milligrams.
• 43:38
  SPEAKER_00: The study in JAMA psychiatry only went to 0.5 milligrams.
• 43:42
  SPEAKER_00: We've found in our experience of prescribing these medications at that dose, people are not pathologically losing weight.
• 43:48
  SPEAKER_00: It's something that is, again, a conversation and sometimes involves at care and treatment centers, our dietitian, our exercise team, making sure the calories are protected, that we're focusing on lean mass preservation with protein intake and things like that.
• 44:03
  SPEAKER_00: But it's certainly not, you start this medication, you instantaneously start losing weight.
• 44:07
  SPEAKER_00: But it is something that is a back and forth.
• 44:10
  SPEAKER_00: So if I do have a patient that's gone up in dose and say their cravings are much less, but their weight has started to come down, that needs to be a shared decision-making model of how can we either make a lifestyle change or come down in dose.
• 44:23
  SPEAKER_01: Okay.
• 44:23
  SPEAKER_01: That is the perfect place to end our conversation.
• 44:26
  SPEAKER_01: And I think that you've raised so many important questions and s and given us so much information with which to hopefully proceed in a way that will help us to be healthier and to treat the addictions that we or our loved ones have.
• 44:40
  SPEAKER_00: Thank you so much for continuing the conversation.
• 44:43
  SPEAKER_00: And to anyone out there who is struggling with any type of addiction or process disorder or things that are just not aligning with their agency, I want them to know there's hope.
• 44:53
  SPEAKER_01: The hope is so important, and the fact that you can come here and offer it is beautiful.
• 44:57
  SPEAKER_01: Thank you so much for having me.
• 44:58
  SPEAKER_01: Thank you.
• 44:59
  SPEAKER_01: And join us next week.
• 45:01
  SPEAKER_01: We will be back with another discussion on another behavioral health topic.