Q&A: Pharmacists Could Play Key Role in Managing GLP-1 Use for SUD

With emerging evidence in the space, pharmacists may play an essential role in ensuring patient safety when managing the use of glucagon-like peptide-1 (GLP-1) medications for individuals with substance use disorders (SUDs).

“A physician might prescribe a GLP-1 for a metabolic issue, while making it a conscious part of the patient's addiction treatment plan, hoping that it simultaneously helps them to stop their drug or alcohol use. That’s not really a new concept in medicine, using this sort of dual-benefit prescribing,” Sylvie Stacy, MD, MPH, chief medical officer at Rehab.com, told Drug Topics. “Thinking about what the pharmacist’s role may be in this, I do think that pharmacists can play a major role in monitoring and patient safety.”

In part 2 of our interview with Stacy, through the lens of both pharmacists and physicians, she explores a “gray area” of modern medicine within this dual-benefit prescribing. She highlights the evolving clinical landscape where medications approved for diabetes or obesity are being intentionally utilized to help quiet cravings for addictive substances.

This intersection of metabolic health and addiction medicine creates a compelling narrative for health care professionals, as it requires a high level of vigilance regarding mental health, mood changes, and careful dose titration in a vulnerable patient population. Amid these suspected concerns, should more data on GLP-1s for SUD arise, pharmacists will be primed to address patient concerns.

READ MORE: GLP-1s May Treat SUD by Muffling Dopamine Reward Spikes

Drug Topics: Currently, GLP-1s are not FDA-approved for addiction. You’ve mentioned a strategy of prescribing for metabolic indications while hoping for secondary benefits in cravings. What advice do you have for pharmacists regarding the navigation of managing these medications in an addiction context?

Sylvie Stacy: Since we don't have that FDA-approved indication for addictions yet, we are in this gray area where we're often prescribing them for a metabolic issue, either obesity or diabetes. At least in the field of addiction medicine, we're keeping a very close eye on control of any comorbid addictions. A physician might prescribe a GLP-1 for a metabolic issue, while making it a conscious part of the patient's addiction treatment plan, hoping that it simultaneously helps them to stop their drug or alcohol use. That’s not really a new concept in medicine, using this sort of dual-benefit prescribing. For example, thinking about clonidine, I might prescribe it for a patient's opioid withdrawal symptoms, but then also notice that it helps their hypertension. Then, it becomes intentional that I'm treating both. Propranolol: I might prescribe it for someone's heart rate control but intentionally pick that specific medication because I know it might help with their anxiety at the same time. We're doing the same thing with GLPs right now.

Thinking about what the pharmacist’s role may be in this, I do think that pharmacists can play a major role in monitoring and patient safety. We know that the most common side effects are gastrointestinal-related; they're nausea, vomiting, diarrhea. When we're thinking about patients who are in early recovery for opioid use or alcohol use, those are the same symptoms that they're going to have during a period of withdrawal. That can get confusing. If a patient says they're nauseous, pharmacists can be thinking about, is this the GLP, or is this patient slipping into withdrawal, and help distinguish those.

On the mental health side, data has not shown any clear link between GLPs and suicidal ideation, but the patient population of those with addictions is really a vulnerable group. Addiction and depression co-occur so frequently that I would say, as a pharmacist, if you're at the counter and you see a change in a patient's mood or they have a very flat affect that you hadn't noticed before, advise them to talk to their doctor. We really want to monitor those depressive symptoms very closely. Along those same lines, I would advocate for slow titration of GLPs. We shouldn't be rushing the dose, especially in someone who's dealing with physical instability of early recovery from an addiction. Starting low in the dose, titrating slowly, and educating the patient about why we're doing that, that can also just help them to quiet those drug cravings while also minimizing those gastrointestinal effects.

A pharmacist might suggest that a patient stay at their current dose for an extra couple weeks, or even back down one level. With addictions, we really need to keep them on treatment long enough that they can establish new lifestyle behaviors and routines that they can stick with in the long run.

Drug Topics: What has been done, and what is still needed to occur, to further expand the use of GLP-1s in the arena of treating addiction? And where may pharmacists fall in line within these ongoing processes?

Sylvie Stacy: I talked a little bit about the exciting anecdotes we have from the field of addiction medicine, in terms of how GLP-1s seem to be making a difference for our patients. Some of the smaller studies show positive results, but we really need to move from all of that toward gathering the required evidence that will actually help get official FDA indications for addictions. I don't want to downplay how much has already been done in the research, but to get those FDA indications, we really need those large-scale phase 3 trials.

In addition to results from those studies in general, as we move forward, we also need to have a better understanding of dosing. I don't necessarily think that [dosing] will be the same for the indications that GLP-1s are already approved for. In addiction medicine, I suspect that we might find less is more. I wonder if lower doses than what we use for obesity might be enough to help manage someone's addiction without causing side effects that make them want to quit. We also don't know yet if patients will develop potentially a tolerance to the anti-craving effect that GLP-1s appear to have, or if they might experience a rebound in their substance use if they stop the GLP, similar to the rebound weight gain that we see for people taking it for obesity. I think that's what we need in terms of scientific evidence.

Even if the science is there, I do think we'll have a big hurdle in terms of insurance coverage. Right now, without an FDA indication, getting these covered specifically for addictions is nearly impossible. As your listeners know, insurance companies want to see hard outcomes and actual FDA-approval before they're going to cover an indication. But we've seen this struggle before in addiction medicine. Buprenorphine, for example, when it was first approved for opioid use disorder, it was initially covered by some payers only in patients who had failed other treatment approaches. We've graduated away from that.

It might take even longer after we have the science to really see system-wide support. With the price point so high for these medications, there may be some pushback from insurance companies. But I think for pharmacists, you're often the experts in these access barriers, and will likely be the ones to help us identify patients who have the best chance of coverage with their insurance. I perceive prescribers and pharmacists really being partners here and helping to manage polypharmacy—as we combine GLP-1s with standard treatments—helping to monitor patients, as I mentioned before, for adverse side effects or those rebound signs if they have to stop the medications due to cost or supply issues. I'm really optimistic that this class of medications can become a standard and accessible part of how we treat addictions of various types.

READ MORE: Substance Use Disorder Resource Center

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