Will 2023 be the year that the battle against addiction is finally won? The key, it seems, may be the new diabetes drug, Ozempic. While doctors and pharmaceutical companies hail it as a powerful new weight loss drug, early reports also suggest that GLP-1 analogue drugs like Ozempic, Wegovy and Mounjaro may suppress a variety of other appetites, from smoking and alcohol to shopping and nail-biting.
GLP-1 analogues were developed to control diabetes by triggering insulin secretion from the pancreas. Some evidence suggests these drugs also affect the brain’s dopamine pathways, which appear so significant in rewarding our behavior that some neuroscientists have labeled it the “wanting” system. The hope is that GLP-1 analogues might target this wanting system directly, eliminating or reducing cravings — including those associated with addiction. Are we around the corner from a major advance in the science of desire?
Not so fast. The history of many failed attempts to generate a reliable biological treatment for thorny problems like addiction should caution us against anticipating another magic bullet. Explaining desire through simple biology fails to grasp the variety of motivations for drug-taking, and previous medical fixations on extinguishing “cravings” alone typically did more harm than good.
The search for a scientific solution to cure addiction dates back over 150 years. In the mid-19th century, the fast-developing science of neurophysiology believed that the source of all human motivations could be traced back to the brain. “All [man’s] desires and motives are experienced in and act upon this important apparatus,” the pioneering brain physician Thomas Laycock declared in 1860. Only “perfect knowledge” of this neurological system, Laycock added, would allow man “to direct and control the internal or vital forces, just as he directs and controls the physical or external forces.”
Inspired by these developments, many doctors became convinced that disorders like “opium poisoning,” “inebriety” and “morphinism” were linked by a common “disease of the will” that required a physiological solution. By the turn of the 20th century, the language of “addiction” had developed as a catchall term to describe this group of afflictions that had previously been considered separate conditions.
But the medical history of addiction treatment since then is a litany of false hopes and wrong starts. For example, in the late 19th century, doctors hoped that cocaine would suppress desire for the likes of morphine and alcohol. Sigmund Freud first made a name for himself reporting on the coca plant’s “power to suppress the craving for morphine in habitual addicts” in 1884. He also concluded, based on his own experience, that it was safe: “a first dose or even repeated doses of coca produce no compulsive desire to use the stimulant further.” This turned out to be wrong on all counts. Within a year, Freud had left Vienna for Paris under a darkening storm of controversy, and by the turn of the century cocaine had entered into wide recreational use.
Yet the quest for a biological cure for desire did not cease. In the mid-20th century, a battery of techniques were announced as successful weapons against addictive cravings, particularly opiate withdrawal symptoms. A mild coma induced by injected insulin “extinguished all craving” in a morphine-addicted patient, one doctor happily reported in 1932. In the 1940s, experiments with electroconvulsive (“shock”) therapy were similarly championed.
Some even advocated lobotomies as a cure for addictive cravings. The prefrontal lobotomy procedure was invented in 1935. By 1936, its American pioneers, Walter Freeman and James Watts of George Washington University, completed the procedure on an alcoholic — who was only their 15th patient. The patient “dressed, put his hat over his bandages, and walked out of the hospital.” He was found shortly thereafter in a nearby bar, so inebriated he could barely walk back.
Yet, doctors were not deterred. Prefrontal lobotomy was used to treat addictive cravings for several decades, especially as a “cure” for patients treating chronic pain with morphine. In one lobotomy experiment performed on a 29-year old schizophrenic patient deliberately injected with morphine, doctors observed afterward that while “the patient’s affect was flattened” and “there still appeared to be some poverty of ideas,” fortunately “at no time during the study did the patient ever display any interest in, or craving for, drugs of any sort.” Such dramatic surgeries often left patients incapacitated for life, and eventually fell out of fashion.
Instead, beginning in the 1960s, such techniques largely gave way to the residential treatments, therapeutic communities, methadone maintenance programs and other addiction treatment models that we are familiar with today. While more humane, these treatments remain expensive, time-consuming and frequently prone to relapse. Addiction has stubbornly persisted as a public health crisis, and opiate-driven overdose deaths in particular have skyrocketed in the past decade.
As a result, since the 1990s, the search for a biological solution has made a dramatic comeback. Neuroscientists have sought to frame addiction as brain disease, and promised that effective drugs will follow. Within this neurological model, even surgical interventions for addiction have returned in the form of deep brain stimulation, in which implanted probes send electrical impulses into the center of the brain.
In this context, GLP-1 analogues like Ozempic have been championed as a novel breakthrough in the problem of addictive cravings. It is certainly conceivable that they have potential. But it is worth remembering that effective and general-use addiction drugs have repeatedly failed to materialize despite decades of research and investment. One explanation may be that desire is too complex a phenomenon to be reduced to the pathways of a single neurotransmitter like dopamine, which is also key to all kinds of nonaddictive activities like exercise.
What we call the “craving” for drugs might be generated for any number of reasons, from physiological withdrawal symptoms and pain alleviation to desires for relaxation, status or even fun. This gamut of motivations is simply not well captured by a single biological model. Ultimately, the quest for miracle desire drugs may continue to distract us from the collective problems — inequality, unemployment, inadequate access to health care and effective pain management — that cultivate addiction and impede recovery from it in the first place.