5HT #112: What if weight loss was the side effect?

Bold prediction: 10 years from now—maybe a lot sooner—we'll find it laughable that we ever called GLP-1s “weight loss drugs.” 👀

We think we invented a better Weight Watchers. I think we accidentally invented an anti-compulsion drug 🤯. The shrinking waistline was just the first thing it happened to quiet.

Because the main event isn't in your gut. It's upstairs. 🧠 And I know that because I’ve felt the difference in my own brain.

Most of you know I started microdosing GLP-1s in early 2025. I had always planned to get off of them eventually. But when I quit cold turkey last summer, the food noise came roaring back. 

I hadn’t realized how much of it I’d been living with—that low-grade, all-day negotiation with the fridge or pantry. What's next? Where's lunch? Do we have any good snacks? 😵‍💫 Nobody warns you that you don't really notice the noise until it's gone. And then you definitely notice it when it returns.

I didn't want it back. So I went back on, microdosing the smallest dose I could find that flips the food noise switch off. Not to lose weight. (I've maintained the same weight for six months.) Minimum effective intervention. And, like, just amazing that it does that?!

This is why my conversation with Geoff Cook, Noom's CEO, continues to stick with me. We talked a lot about food noise—how it lives in the brain's default network, the channel your mind runs when it’s idle, and how GLP-1s switch it off. Then he said it's not just food noise, but alcohol noise and others, too. Same channel, same off switch. 

Mechanistically, that tracks, right? GLP-1 receptors are scattered all over the brain's reward plumbing—the dopamine real estate where wanting gets built. Not just for food and booze, but drugs 💊, nicotine 🚬, gambling 🎰, and the whole compulsion buffet. They all run the same circuit. So a drug that turns the volume down on one craving probably turns it down on the rest. (It may even be why some believe GLP-1s affect things like sexual desire.)

And the clinical results are starting to back that up.

In April, The Lancet published the strongest evidence for GLP-1s and alcohol. The randomized controlled trial (RCT) had a little over 100 adults with moderate to severe alcohol use disorder (AUD) randomized to semaglutide or placebo for 26 weeks. Heavy drinking days dropped 41 points versus 26 on the placebo.

The number that made me sit up most? The number-needed-to-treat was 4.3… versus 7 or higher for the three meds the FDA already approves for alcohol. One of the co-authors was George F. Koob, who runs the National Institute on Alcohol Abuse and Alcoholism (NIAAA), and he called a more accessible option a potential "game-changer" for the treatment gap. Point is: This is not fringe. It’s not just booze, either.

A study in the Annals of Internal Medicine tied semaglutide to a lower risk for tobacco use disorder diagnosis (TUD). One in Molecular Psychiatry found it cut both the incidence and relapse of cannabis use disorder (CUD). And a research letter in JAMA Network Open linked it to a significantly lower risk of opioid overdose. Booze, smokes, opioids. One molecule. Pick your poison. (Or is it anti-venom?) 😮

Now, it’s important to say three of those four are observational. Confounding is the original sin of cohort data, okay? And every one of these studies, including the gold-standard Lancet RCT, was run in people who were already metabolically sick. Obese, diabetic, or both. (The Lancet trial was specifically AUD plus obesity, and everyone in it also got cognitive behavioral therapy on top of the drug—so it's "GLP-1 plus therapy," not GLP-1 solo.) 

Point is: we don't yet have clean evidence that a lean person with a pure drug problem gets the same gift. 🤷‍♂️

But I'll tell you why I'm not losing sleep over it. Lean people take these drugs and lose weight too (shocker, I know)—which means the appetite-and-reward circuitry is obviously firing in them, not just in someone with a broken metabolism. The mechanism lives upstairs, in the wanting, not down in the fat cells. So… the leap from "works in metabolically sick people" to "works in basically everyone" feels awfully short. 

Plus, I’m at least one living proof of it! Worth emphasizing: I'm not saying my experience was anything like curing addiction, but I am saying we might not be thinking about it in quite the right way.

An aside: Remember the 2023 panic that these drugs might cause suicidal thoughts? It didn't fade—it flipped. A study in Nature found semaglutide users had a lower rate of suicidal ideation. And, earlier this year, the FDA asked manufacturers to remove the suicidality warning from weight-loss labels entirely! A real mental health drug has to clear a bar like this—and it already has.

To me, the real concern seems to be durability. The drug seems to open a window, but a window isn't a cure. The noise can creep back, just as it did for me when I quit. The drug buys you quiet… but somebody still has to build the thing that makes recovery last.

So, I'm increasingly convinced GLP-1s will be used in a more precision-focused way and will be considered as a first-line intervention for addressing any type of addiction. This area of care has traditionally not been about your metabolic health, biology, fitness, and overall health. I think there's a massive opportunity there for GLP-1s to change that game.

That’s a major reason I became an advisor to Nosis Health, where founder Duffy Fallon and others are betting GLP-1s shouldn’t replace addiction care but effectively wrap it with the metabolic and health layer recovery’s never had. Think GLP-1s, biomarker testing, and behavior change habits for recovering addicts. More broadly, others are circling this, too… including the aforementioned Noom with their Proactive Health program.

Right now, we only have three FDA-approved meds for AUD, a gap that feels like it can easily be replaced. There are a few FDA-approved meds for OUD, and then there are your typical treatments like psychiatry and other therapies for things like gambling and sex. Plus, Birches Health just raised $20 million for treating gambling addiction and other compulsive addictions. It really feels the market’s moving in this direction—and there’s a big opportunity.

So, is this compulsive industrialized complex we live in about to falter?! 

I’d even bet (pun intended) that things like booze, vaping, UPFs, TikTok, all these addictive things, will increasingly get less successful at hooking people, because of GLP-1s becoming more commonplace and maybe even recommending GLP-1s explicitly for this. 

Whether it’s 10 years from now or 10 months from now, I think it’s all happening. 

Bottom line: We've traditionally called GLP-1s a diet drug, and it feels to me like the brain was always a much bigger prize. 

It was just hard to hear over all the food noise.

👋 Who are you again? I’m Derek Flanzraich—founder of two venture-backed startups in Greatist (👍) and Ness (👎). I’ve worked with brands like GoodRx, Parsley, Midi, Ro, NOCD, and Peloton. I now run Healthyish Content, a premium health content & SEO agency (among other things).

Every Thursday (and now Sunday!), I share healthyish things I feel strongly about. (Disclaimer: I’m more your friend with health benefits. None of this is medical advice.) Also some links are affiliate links, but they influence my decisions zero.

Oh, you also feel strongly about some health things? Hit reply—I’d love to hear it.