Wegovy is the New Methadone

The overlap between losing weight and recovering from addiction

Having overcome a vicious addiction to prescription painkillers, and having dieted for most of my adult life, I know that there is a profound overlap between addiction and obesity. They share root causes, can be similar in how we experience them, and are overlapping in how we treat them. Many of the same brain regions and pathways are involved. Several of the new weight loss drugs help stem cravings and reduce the use of drugs and alcohol.

In many ways, semaglutide (Wegovy/Ozempic/Trulicity) is the new methadone, and tirzepatide (Zepbound/Mounjaro) is the new Suboxone.

Huge issue

According to the CDC there are tens of millions of people who are obese in the United States. Some estimates put the number at 100 million – 40% of the adult population. There are tens of millions of people in the U.S. alone that are addicted to alcohol and millions more are addicted to opioids. We suffer about one hundred thousand deaths annually from drug overdoses in the United States. Alcohol, alone, is implicated in 178,000 deaths, including from liver disease, cancer, and cardiovascular disease. Of note, obesity contributes to these same diseases. Millions of Americans die each year from obesity-related causes. Both addiction and obesity are associated with traumatic childhood experiences, poverty and homelessness.

One wonders if these are entirely separate epidemics, or if they have the same root causes.

Overlap

It is well documented that the important drivers of addiction are trauma, undertreated anxiety, depression, and poor distress tolerance. People self-treat and self-soothe, looking for temporary relief from their intolerable symptoms. Eventually, as our brains adapt to the substances, the addiction takes on a life of its own. One rapidly sinks to a dark and miserable place. We enter a binge/withdraw cycle, and we become entirely controlled by the drugs. Our behavior is relegated to a treadmill of drug seeking, drug use, and withdrawal. I document this particular type of misery in my memoir, “Free Refills”.

The brain circuits which underly how this happens are well-characterized. They center around our “amygdala” which is part of our “limbic system” which control emotions, reward, and memory. This is all mediated by everyone’s favorite neurotransmitter: dopamine.

The amygdala in our brain – a tiny region that controls an enormous amount of our behavior.

Obesity has many of the same etiologies as does addiction. There is a significant association between people experiencing childhood trauma and the development of obesity as adults. Anxiety and depression are also linked to obesity. People eat emotionally and can use food to soothe the same bad feelings that other people soothe with drugs. People binge with food to fill an emptiness inside and to temporarily quell their anxiety. Eventually, the reflex to overeat can supplement or supplant our ability to “self-soothe”, just as happens with addiction. My addiction textbook describes, “binge eating disorder” and states,

• data suggest that both substance use and eating behaviors may be modulated by the same motivational neurocircuitry, leading to the conceptualization of “foods as drugs.”

A paper, from the Canadian Medical Journal, discusses food as an addiction,

• The concept of food addiction…can be described in much the same way as other addictive behaviors. Both food and drugs induce tolerance over time, whereby increasing amounts are needed to reach and maintain intoxication or satiety. In addition, withdrawal symptoms, such as distress and dysphoria, often occur upon discontinuation of the drug or during dieting. There is also a high incidence of relapse with both types of behavior.

How exactly is this process mediated? Ghrelin is the hormone which signals that we are hungry and need to consume more calories. It is the “hunger hormone.” It also helps maintain energy balance. According one paper, “the ghrelin receptor is found in…the amygdala, a brain region that regulates negative emotional states such as fear.” The same part of the brain, the amygdala, which mediates our emotions and rewards, is integral to the progression of both addiction and overeating. Another hormone called “leptin” tells us when we are full, and this, too, has been implicated in reward-seeking behaviors, including substance use disorders.

Same obstacles and cravings

With both addiction and obesity, there exists persisting stigma. People with either condition can feel criticized, judged, and shunned by society. Studies have shown that these groups aren’t treated as well as their cohorts who don’t suffer from addiction or obesity. This makes it more difficult to feel good about yourself, to correct course, and to seek help. It is easy to just give up, and to start eating, drinking, snorting or injecting.

When addicted, we suffer from cravings for our drug or drugs of choice. These can be profoundly intense and disturbing. They often lead one to relapse – just to get some transient relief. During my addiction I had vivid, unsettling dreams about using prescription opioids. Part of recovery was learning how to “surf the cravings” and how to not give in despite overwhelming urges.

With obesity and dieting, the analogy is hunger. When trying to lose weight, you are constantly hungry, uncomfortably starving. Cravings for food can be similar in quality and intensity as cravings for a drug. They lead people to relapse on their diets, to gorge, to binge, and, just as with addiction, to restart the clock again on their program.

People relapse with both drugs and food consciously, deliberately or impulsively, against their own will, knowing they are sabotaging themselves - due to overwhelming desires and an inability to mount a successful resistance.

In both conditions, our bodies fight back in a way that is profoundly unhelpful. With addiction, you get withdrawal symptoms. Typically, these present as the opposite of what the drug does in the first place. With withdrawal from alcohol, which is a sedative, one can experience excitation, irritability, restlessness, and can even have a seizure. When withdrawing from cannabis, people become anxious, grumpy, and have trouble sleeping and eating. Withdrawal symptoms can rapidly lead to relapse. Consuming the drug offers immediate and profound relief – if only for a few hours.

Analogously, the body has several physiological mechanisms to defeat you when you are dieting. In a sense we withdraw from the amount of food that the primitive part of our brains think we need. These aspects of our physiology go back to our evolutionary history when we were hunter gatherers – for millions of years. Back then, if we lost weight we would usually die from malnutrition. Consequently, our bodies are wired to prevent weight loss at all costs. We are biologically conditioned to eat as much as possible when succulent food is available. This is partly why, in our plentiful society, so many people find themselves to be overweight.

When we start to lose weight, for example as the result of a diet, our bodies react in a way that is not helpful. We become hungrier, our food cravings and hunger increase, and our metabolism slows down. We burn fewer calories. Our body tries to maintain and protect our current weight at a “defended set point” which makes it extremely difficult to continue losing weight. This was advantageous for much of our evolutionary history but isn’t at all useful to the tens of millions of people who are trying to stop being overweight.

Analogous treatments

Both obesity and addiction can become catastrophic if left untreated. With addiction, there are too many medical harms to review here, including, infection, overdose and death. With obesity, people die early from heart disease, diabetes, and cancer, and tend to suffer from excruciating arthritis and disability. Joints, hips, and backs wear out. A surgeon often won’t even replace your worn out joint if you are obese because it is too dangerous. Patients end up on opioids.

Social support is a huge component of recovery from both addiction and obesity. For people suffering from addiction, there are a wide variety of popular programs. These range from the more cult-like AA (Alcoholics Anonymous) and NA (Narcotics Anonymous) to less religiously inspired programs such as Smart Recovery. With obesity, there is OA (Overeaters Anonymous) which is based on AA, as well as Weight Watchers, and various other groups including on-line support communities.

There are profoundly effective medications for both conditions. For addiction, we have, to name a few, methadone and Suboxone for opioid use disorder, as well as naltrexone and acamprosate for alcohol use disorder. These medications help control cravings and perceived reward and, in the case of methadone and Suboxone, can help control withdrawal symptoms. For weight we have the entire GLP-1 class of drugs, including Wegovy, Trulicity, Ozempic, Mounjaro, and Zepbound. These help with cravings, hunger, and sense of satiety. They also seem to inactivate our “defended set point” to facilitate weight loss. There are other drugs for obesity (e.g., metformin, phentermine, topiramate) but they aren’t as effective. Topiramate is also used for both alcohol and stimulant addiction as well – another overlap.

GLP-1 weight loss drugs may lessen the amounts of dopamine released by the brain when we consume junk food, drink a beer, or smoke a cigarette. These bursts of dopamine yield feelings of satisfaction, which can reinforce unhealthy behaviors, including both overeating and drinking/drugging. There is emerging evidence that GLP-1 drugs can lessen cravings for, and consumption of drugs and alcohol. Some examples of this are summarized in a recent Boston Globe article,

• Early findings from a small recent clinical trial run by the University of North Carolina showed that low weekly doses of semaglutide, the active ingredient in Ozempic and Wegovy…reduced alcohol consumption over two months in volunteers with alcohol use disorder.

• A Swedish study published in JAMA Psychiatry found that people with alcoholism and Type 2 diabetes were “substantially” less likely to be hospitalized for alcohol-related issues when taking GLP-1 drugs.

• Researchers from the Penn State College of Medicine reported that the active ingredient in another GLP-1, Saxenda, significantly reduced opioid cravings in a study of 20 patients with opioid use disorder. Patients who received the drug experienced a 40 percent decline in their desire for opioids compared with those who got a placebo.

This article further posits that the GLP-1 drugs can help alleviate other “behavioral addictions” such as compulsive gambling, shopping, eating, and internet use. All of these are mediated by the same dopamine pathways in the amygdala.

Conclusions

Ideally, we’d live in a society where we treat people with stigmatized conditions, such as addiction and obesity, without judgment, scorn, criticism, and shame. It would be more productive, and humane, to approach these issues with scientific skill, empathy, and modern medical remedies. Effective treatments exist but can be extremely difficult to access. At bottom, this has to do with our society’s failing social safety nets. Addicted people struggle with homelessness, poor access to medical care, and limited employment opportunities. There aren’t nearly enough providers prescribing methadone and Suboxone – doctors can reflect the same stigma towards these patients that other people do.

Obese patients struggle with greedy health insurance companies to get coverage for these GLP-1 medications, as well as the other weight-loss medications, and other necessary treatments, such as nutritional counseling. All patients find it difficult to receive basic primary care, not to mention treatment for mental and psychological disorders.

Substance use disorders and behavioral addictions, such as slowly eating yourself to death, can overlap across the board. The causes, symptoms, challenges, and treatments are interlinked. They are life-degrading and life-threatening conditions. When they don’t kill us outright, they can profoundly impact our quality of life. People are suffering, often alone, feeling bad about themselves, in the shadows. We can do better in addressing these related conditions. We must overcome the many obstacles and prejudices, in order to put our vast knowledge on how to treat these conditions into practice.

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