I'm William Brangham and this is "Horizons."

The popularity of GLP-1 drugs has exploded.

Once used almost exclusively for diabetes, these revolutionary drugs are now booming as a way to lose weight.

Aren't GLP-1s a helpful tool or a lifelong dependence?

And do they also work to curb addiction?

Coming up next.

♪ Narrator: Support for "Horizons" has been provided by Steve and Marilyn Kerman and the Gordon and Betty Moore Foundation.

Additional support is provided by Friends of the News Hour.

♪ This program was made possible by contributions to your PBS station from viewers like you.

Thank you.

From the David M. Rubenstein Studio at WETA in Washington, here is William Brangham.

Welcome to "Horizons" from PBS News.

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Once a relatively obscure class of drugs used for people with diabetes, GLP-1s have now shown an impressive ability to treat obesity, which affects over 100 million Americans.

People taking drugs like Wegovy and Ozempic have lost huge amounts of weight, some losing up to 20% of their body weight.

Many also saw a reduced risk of heart attacks and strokes, improvement in sleep apnea and joint and liver health.

The market for these drugs has exploded, growing by over 40-fold in a very short period.

Last year, one in eight Americans, about 12% of the population, said they were taking these costly prescription medicines.

As remarkable as they are, their immense popularity and high cost has meant that the drugs haven't always been available for those who need them the most.

Later in the show, we're going to look at how GLP-1s are also showing great promise treating drug and alcohol abuse.

But first, we want to hear from two doctors who prescribe these medications, about what they do for their patients, but also concerns over their rampant use.

Dr.

Jody Dushay is an assistant professor at Harvard Medical School and a physician at Beth Israel Deaconess Medical Center.

And Dr.

Rekha B. Kumar is an associate professor of clinical medicine at Weill Cornell Medical College and is senior medical advisor for FoundHealth.

Thank you both so much for being here.

Jody, a question to you first.

So much of the public attention on these drugs is focused on their cosmetic ability to get people to lose weight.

But it sometimes, I think, overshadows the people who really do need these drugs for medical purposes.

So tell us about the people who you prescribe the medications for and what they do for them.

Sure.

Thank you for having me.

In fact, it's true, they are so popular that you think that we may have lost sight of what they were actually designed... who they were designed for.

So, these medications really are designed for people who have a high body weight, a high body mass index, and metabolic comorbidities.

So they are meant to be used for people in whom a lot of excess body weight is having metabolic... is leading to metabolic complications or orthopedic complications.

But they really are meant for that, for people who also may have a very strong, I guess you can call it a brain drive to eat.

So where appetite regulation is problematic, appetite is dysregulated, people have a difficult time stopping eating even with a high body weight.

But that's really the category of people for whom these medications were designed.

And unfortunately, I think that we are losing sight of that as they become so widely used for much less weight loss.

Dr.

Kumar, what would you add to that?

This focus on "Let's remember who these medications "were principally designed for."

So I agree with everything that Dr.

Dushay said about who is supposed to take these medicines, patients with diabetes, patients with obesity, or overweight with medical comorbidities.

The more time that passes and the more real world evidence we have, and we start learning about potential other benefits, reducing the risk of heart disease, treating fatty liver, treating sleep apnea, I think we're increasingly seeing a group of patients that don't fit the original criteria are using it for their health and not necessarily vanity.

So I think there's also this in-between group of off-label use, not cosmetic use, but not the intended use.

I see.

Dr.

Dushay, can you help us...?

Dushay: Although I just... - Please, go right ahead.

Dushay: Sorry.

Yeah, sorry.

I would add that, in fact, some of them are on label use.

So secondary prevention of heart disease, fatty liver disease, treatment of sleep apnea, those are all on label use.

So we're having that.

And then there are emerging other diseases for which these medications may be beneficial.

Dr.

Dushay, staying with you for a moment, can you explain what is the mechanism?

Like, how do patients describe to you the effects that these drugs have on them and why they seem to work?

So many people describe what they call a switch.

They feel as though there's really been a switch in terms of what's going on in their brain, where intrusive, constant thoughts about food, about what they want to eat, what they are eating, what they're going to eat next, thinking about what they just ate, you know, really interfering with their daily life.

That is sort of a switch.

That gets all quieted down and people are able to eat and feel full and then feel, hopefully feel hunger again and have another meal.

Feel full on smaller portions.

Feel satisfied.

I mean, I have patients who have said to me, "I didn't know what it was like to feel full."

They would finish eating and want to have other food.

And also, it can affect just the behavioral... the behavioral habits of just constant snacking.

Even when you know you're not hungry, it's sometimes really hard to implement behavioral changes when your brain is sort of in maybe like an overdrive, dysregulated state causing you to seek food even though you just ate and you really don't have like sort of true metabolic hunger.

So people describe it as like a switch.

Dr.

Kumar, I see you nodding there.

I take it that's the kind of thing you're hearing.

I mean, I remember in the days before these drugs that people who were on diets were always describing this.

They have to fight that hunger, that desire, that urge that they're constantly feeling, separate from whether or not they're actually full or satisfied.

Are you hearing the same kind of thing from your patients?

Yeah, I'm absolutely hearing the same kind of thing.

And some people call it food noise.

In endocrinology, we call it metabolic adaptation.

When somebody loses weight, the body tries to fight back.

The brain will make somebody hungry.

The slowing of the metabolism will make weight loss more difficult.

And so, when people can take these medicines on a weight loss journey, they don't feel like they're constantly white-knuckling it through every day.

Brangham: It's really remarkable.

Jody, can you explain...?

These are costly drugs.

Do your patients...?

Is insurance covering them?

How are people able to afford these medications?

Well, another switch that happened as of January 1, 2026, unfortunately, was an off switch for insurance coverage.

So, Blue Cross Blue Shield, Tufts, Harvard Pilgrim, some of the local... a local Massachusetts insurance through a certain hospital system, as well as MassHealth, all of these changed.

Some of them completely stopped covering them, covering these medications, even if there were appropriate comorbidities, appropriate, you know, say, secondary prevention of heart disease or sleep apnea or fatty liver.

So they just stopped covering them.

So we are back to a point where there is tremendous inequity.

There's not... There aren't shortages.

So we're not agonizing over who should get it when there's not enough supply.

But in fact, the fact that insurance stopped covering it means that a lot of people who really need them and for whom they are definitely indicated can't get them.

They're just too expensive.

And meanwhile, you have this sort of surge of what you see in the media and the social media lay press about people using them through all other kinds of different... getting them through different outfits.

Right.

Dr.

Kumar, what about that?

There is this growing trend of people being able to go to telehealth organizations and get medications without necessarily the supervision of a doctor.

What do you make of that trend?

So I agree with everything Dr.

Dushay said about we're seeing a reduction in coverage.

And often these coverage decisions are made at the level of the employer.

So employers are deciding they don't want to cover these medicines because they're literally bankrupting small to medium-sized businesses.

And so people are going elsewhere for prescriptions.

They're going to telehealth companies.

Some of the companies will have you see a doctor in a very appropriate way, but then others are really there for this price, speed, convenience, GLP seeker that literally is just looking for a prescription.

And those exist too.

And I would be very cautious about a medicine like that.

I mean, Dr.

Kumar, staying with you, what is the concern?

If someone is taking this medication without seeing a doctor on a regular basis, what are the potential downstream consequences or risks there?

So the most obvious would be side effects.

Anytime somebody is taking a medication without medical supervision, we're worried about who's going to manage side effects.

And in this particular class of medicine, so much support is required in terms of how to adapt your life to this new appetite control.

You don't want people to not eat.

Some people not getting coaching on nutrition and lifestyle might think, "Wow, I'm never hungry.

"I'm just not going to eat the entire day."

And those people will develop nutritional deficiencies.

They feel weak, they get dehydrated.

And people that aren't receiving adequate support from a clinician, will run into these issues.

Dr.

Dushay, you've touched on this before.

And I wonder if you would just reflect on this concern that some people make the critique that with the ready availability of these drugs that can cause you to lose weight so quickly, that it is just adding to this cultural, I don't know, problem, phenomenon we're seeing of an obsessive skinniness culture.

And that that really falls heavily on all people, but young women in particular.

Right.

So there is, I mean, there is a prevalence of... there's a prevalent association between weight and health.

And people think that what you weigh is how healthy you are.

And so that's just... By extension, thinner would be healthier if that's the form of reasoning that you're using.

And people are forgetting that there are a range of body weights that are normal.

There should be a range of body weights across a population.

Yes, there are extreme... There's dysregulation on both ends, right?

So a very high body weight is a dysregulation of body weight maintenance, but also forcing weight too low, that is an illness, that is unhealthy.

And I think that because these medications in some people are very powerful, weights can get down to be too low, appetite can be suppressed too much and you can be in a state of very poor health, despite the fact that the scale is showing you a weight that you think is a big victory.

That is really a danger of these medications.

And especially just going off of what Dr.

Kumar said, that if you don't have someone who's there supporting you, you could get carried away.

I mean, you might not know how severe side effects are and you also might not know that you've reached a weight that is unhealthy, that you are now malnourished, or dehydrated, or have, you know, other aspects of your health have gotten worse.

Right.

This is such an important conversation.

I want to thank the two of you so much for being here.

Dr.

Jody Dushay, Dr.

Rekha Kumar, thank you so much.

Dushay: Thank you.

Kumar: Thank you for having us.

As we have been hearing, GLP-1s provide a striking array of health benefits.

One of those that has emerged is evidence that these drugs can also help curve people's cravings for alcohol and drugs, and might even be effective at preventing people from getting into trouble to start with.

So for more on that, we turn to psychiatrist Anna Lembke.

She's a professor and medical director of addiction medicine at Stanford University's Medical School, and the author, most recently, of "Dopamine Nation, "Finding Balance in the Age of Indulgence."

And Dr.

Ziyad Al-Aly is clinical epidemiologist at WashU Medicine in St.

Louis.

Thank you both so much for being here.

Anna Lembke... Dr.

Al-Aly first.

For years, we have been hearing these anecdotal stories, you see them all over social media, that people who are taking GLP-1s, perhaps for their weight control, for obesity, are also testifying that, "Wow, I just don't feel the need to have a drink anymore."

"I don't feel the need to smoke as many cigarettes as before."

You have looked into what that mechanism might be about.

Can you explain just briefly what you found in your study?

Sure.

Well, we've heard these anecdotes in clinics.

So when I go to clinic, I hear a lot of patients telling me that, "I started on a GLP-1, "and all of a sudden, I lost my taste for alcohol," or "I lost my taste for smoking," or "I don't crave smoking anymore."

So we decided to look at this in about 600,000 individuals, a little bit more than half a million people, who started a GLP-1 drug.

And we followed these patients for three years.

Well, we found that people on a GLP-1 drug have less risk of developing an addiction in the first place.

If they didn't have a problem with addiction, being on a GLP-1 drug prevented them from developing an addiction in the first place.

And second, we found that, if they're already struggling with an addiction, being on a GLP-1 drug reduced their risk of overdose, drug-related death, drug-related hospitalization, and suicidal attempts.

Dr.

Lembke, I mean, I know you work in this exact realm.

Given what we know about how GLP-1s affect people's cravings for food, does everything that Dr.

Al-Aly... does that resonate with you?

Does that make sense to you that that mechanism would work for patients?

Neuroscientists have known for a long time that all reinforcing substances and behaviors work on the same common brain reward pathway.

And although they work by different chemical cascades, at the end of the day, they all release dopamine in that reward pathway.

The more dopamine that's released and the faster that it's released, the more likely is a given substance or behavior going to be reinforcing and potentially addictive for a given individual.

What's so interesting about the GLP-1s is that they appear to work directly on that brain reward pathway by blunting or decreasing activation and dopamine release in response to that individual's drug of choice, whether it's food or opioids or nicotine or what have you.

So it's a very exciting potential intervention when it comes to the growing problem of addiction, especially in a world of overwhelming overabundance, where we don't have to work very hard to get these highly reinforcing substances and behaviors, especially when you think that this ancient brain reward mechanism really evolved for a world of scarcity, where we would have to do a lot of work to get a little bit of reward.

Dr.

Al-Aly, did these findings surprise you?

I mean, again, I know we have been struggling with how to tame addiction in this country for many, many years.

There's only a few pharmaceutical interventions that have shown even minimal promise for this.

Were you surprised by the size of the effect that you were documenting?

Yes, and what's even more surprising was the consistency of these GLP-1 drugs across several addictive substances.

And then to give viewers a perspective on this, there is nothing in our addiction toolbox at this moment that actually does the same thing.

For people who really want to quit smoking, they get a nicotine patch.

For people who want to quit drinking alcohol, they get naltrexone or other medications.

There's not a single medication now currently in our toolbox that actually works across addictive substances.

And here comes these GLP-1 drugs, which, as you said, these are started as diabetes drugs and now later discovered to actually work on obesity.

These GLP-1 drugs seem to be working across several addictive substances.

Naturally, the aha moment for us was a bit surprising.

And it's telling us a little bit more about addiction and neurobiology or the biology of addiction.

It's likely all driven by craving per se, that sort of upstream craving that drives people, that pulls people magnetically, almost magnetically, toward a substance and that craving seems to be quieted or suppressed.

That drug noise, if you will, seems to be quieted or suppressed by GLP-1 drugs.

Dr.

Lembke, are you now using this as a tool for people who are struggling with addiction?

So we are using GLP-1s in treatment refractory alcohol use disorder.

That's to say alcohol addiction.

In our patients where we've tried all the other existing interventions, including the on-label FDA-approved drugs for alcohol addiction, and patients still haven't been able to get into recovery.

And it's been interesting to see that we have some patients for whom the GLP-1s really are remarkably effective.

And that is very, very exciting because we haven't had a new tool in our toolbox for a long time.

On the other hand, I will say we have some patients in whom we try the GLP-1s and they just kind of don't work, which is also not unexpected.

When you're talking about the brain, which is incredibly complicated and we still only scratch the surface of what's happening in the brain, it's not really a surprise that our medications are only going to work for some of the people some of the time.

And that in our experience so far is true for GLP-1s as well.

Right.

Dr.

Al-Aly, you both have been describing this, the phenomenon of the quieting of the voice.

I remember talking with one woman a year ago who was trying to cut down on her drinking and she found some success and she described it as getting this monkey off of her back.

And it seems that, especially with addiction, that has got to be an incredibly powerful tool to have because we know that cravings are such a principal driver of people relapsing.

To have a medication that seems to quiet that just seems so critical.

Dr.

Yeah, that's actually a very important concept.

This is what I tell my patients, that GLP-1, these GLP-1 drugs are actually acting on the brain, on GLP-1 receptors, specifically in an area called the mesolimbic system.

That area is actually responsible for reward signaling and then quieting that drug noise, that magnetic pull that actually pulls people toward, "Oh, I'm craving a cigarette," or "I want a drink," or really that magnetic pull that pulls people toward a drink or toward substances they know is harmful to them, but yet they continue to use it, to use these substances.

So what we're seeing with GLP-1 drugs is that they suppress that drug noise, if you will, in a very similar fashion to what people who are struggling with obesity would tell you.

All of that... All of a sudden, that food noise, that constant thinking about food, overeating, what to eat, when to cook, all of these constant intrusive thoughts about food that really, really preoccupy people who are struggling with obesity, all goes away with GLP-1 drugs.

We're seeing something very similar happening with people with addiction, that drug noise really almost vanishes in a lot of people.

Brangham: Dr.

Lembke, you wanted to add something to that?

Lembke: Yeah, thank you.

Yeah.

Yeah, I... I... You know, for people who have never struggled with a serious addiction, it's really hard to imagine the cognitive load that is cravings.

It takes so much energy to resist cravings.

Sometimes I tell people, imagine that you got a really bad case of poison oak or poison Ivy, and you tried really hard not to scratch it and you went all day and you didn't scratch it.

And in the middle of the night, you woke yourself up because you were scratching it involuntarily.

That is how people with severe addiction experience craving.

It takes all of their energy and creativity.

So when we... if we have a medication that can alleviate that craving, it really frees up that person's mind to think about other things, to invest creatively in other endeavors.

And I think that that's why there's so much excitement about the GLP-1s, because when they do work, people just... there's like this lifting of a cognitive load.

And a lot of people are also endorsing improved mood.

And I'm very curious to see whether or not GLP-1s may be effective as an antidepressant in the modern world, because on some level, like we're all struggling with the cognitive load of resisting temptation.

So much of our experience has been made more abundant, more reinforcing, more potently pleasurable.

So, and there are some preliminary placebo controlled trials, I believe.

I'm looking at GLP-1s simply for depression, even in people who are not struggling with addiction or obesity or diabetes per se.

So it's a really exciting medication with this centralized neurological mechanism that I think is, you know, we need more research, but it's a very exciting area.

Dr.

Al-Aly, just in the last minute or so we have, do you share the concern that, if people are taking this medication and it is suppressing those urges and cravings that you both have described, that, if someone stops taking it suddenly, and we know that there is a lot of freelance GLP-1 use out there in our culture right now, that in this era of fentanyl with very, very potent drugs, that, if someone thinks, "I've got my addiction under control, "I don't need this anymore," that they might then relapse and get themselves into some serious trouble?

That's exactly right, William.

I worry about this a lot because what GLP-1s are doing are really suppressing that craving.

And, if you think about it, I tell my patients, like you're putting the lid on that craving.

And I... sort of... it seems to have gone away, but really you're putting the lid on and you kind of building a pressure cooker.

And if, you know, you stop GLP-1 all of a sudden, I worry that that might invite a surge in that craving again, that magnetic pole that actually drives people to use, and in that, in those situations, I worry that people might overuse or overdose and end up in an ER or an emergency room or a hospital, or even worse.

That would be a fatal overdose.

So, while I'm enthusiastic about those results, the results that were presented, I'm also cautious that we don't know what we don't know and we don't really know what happens when people top GLP-1, you know, if they're using it for craving or addiction, if they stop cold turkey, what would happen to that craving.

Again, and I worry that it might resurge and... with problems.

Dr.

Ziyad Ad-Aly and Dr.

Anna Lembke, thank you both so much for being here.

Really wonderful conversation.

Lembke: Yeah, you're welcome.

Al-Aly: Well, thank you for having us.

And that is it for this episode of "Horizons."

You can find us on YouTube and wherever you get your podcasts.

Thank you so much for watching.

We'll see you next week.

Narrator: Support for "Horizons" has been provided by Steve and Marilyn Kerman and the Gordon and Betty Moore Foundation.

Additional support is provided by Friends of the News Hour.

♪ This program was made possible by contributions to your PBS station from viewers like you.

Thank you.

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