(150) Consequences of GLP-1 Coverage Loss in Alcohol Use Disorder

Background & Introduction: Glucagon-like-peptide-1 (GLP-1) receptor agonists have become a topic of growing interest in the treatment of substance use disorder (SUD). These agents modulate food reward pathways within mesolimbic brain regions implicated in addiction (Skibicka). Although GLP-1 receptor agonists are not currently approved by the U.S. Food and Drug Administration (FDA) for the treatment of SUD, observational reports and emerging clinical trials suggest they may reduce cravings for alcohol and other substances (Shen et al). In a randomized controlled trial evaluating dulaglutide for nicotine dependence, participants demonstrated a 29% reduction in alcohol consumption over 12 weeks (Probst et al). Many patients currently receive GLP-1 receptor agonists for diabetes mellitus, cardiovascular disease, or obesity and may experience secondary benefits in the management of substance-related cravings. However, increasing restrictions on prescribing, particularly for obesity alone, may lead to abrupt discontinuation and place patients at increased risk of relapse or return to use. Here, we present the case of a patient with alcohol use disorder who experienced increased cravings and alcohol consumption after losing insurance coverage for her GLP-1 receptor agonist medication.

Case Description: The patient is a woman in her 60s with a past medical history of hypertension, hyperlipidemia, alcohol use disorder (AUD), major depressive disorder, and obesity (body mass index 30–39.9) who was initiated on semaglutide in March 2024. Prior to treatment, she reported drinking two or more glasses of wine nightly (approximately 3–4 bottles per week) and felt her alcohol consumption was no longer under her control, with a goal of reducing intake. She was started on extended-release naltrexone 380 mg intramuscularly every four weeks in December 2021, which led to some reduction in alcohol cravings; however, she continued drinking one to two glasses of wine nightly. By May 2022, she reported the effects of naltrexone were “waning” and she resumed drinking two to three glasses of wine per night. Semaglutide was prescribed for obesity (weight 170 lb in February 2024), with both her primary care provider and Bridge Clinic provider hopeful it may also improve her AUD. Over five months, she was titrated from 0.25 mg weekly to 2 mg weekly. Following titration, she reported drinking approximately one drink most evenings and sometimes not finishing it, noting a sense of accomplishment that she was consuming fewer bottles of wine per week. By November 2024, her weight had decreased to 140 lb. In early 2025, semaglutide was no longer covered by insurance. A prior authorization was denied due to lack of qualifying diagnoses (cardiac disease, sleep apnea, or diabetes mellitus), and it was hypothesized the coverage criteria may have previously been overlooked. After approximately two weeks off semaglutide in February 2025, she reported a marked increase in cravings for sugar, food, and alcohol and was no longer able to stop after one glass of wine, returning to two to three glasses nightly despite continuing naltrexone 380 mg intramuscularly every four weeks. Given the prior improvement in cravings, she obtained semaglutide at lower cost from a pharmacy in Great Britain. Concurrently, a sleep study revealed sleep apnea, allowing insurance coverage of tirzepatide. Although beneficial, the patient reported greater improvement in AUD symptoms with semaglutide compared with tirzepatide.

Conclusion & Discussion: The role of GLP-1 agonists in the treatment of substance use disorders continues to gain support in both literature and clinical practice. In this case, initiation of semaglutide was temporally associated with a clinically meaningful reduction in alcohol cravings and consumption in a patient with AUD who had a partial response to standard pharmacotherapy. In contrast, discontinuation of semaglutide due to loss of insurance coverage was followed by a rapid return of cravings and increased alcohol intake. This case highlights potential harms associated with abrupt discontinuation of GLP-1 receptor agonists, which may increasingly occur amid more restrictive insurance coverage policies. Medicare Part D represents one example of such restrictions, as coverage for GLP-1 medications is often limited to patients with qualifying medical conditions such as diabetes mellitus or cardiovascular disease (Wreschnig). However, similar utilization management strategies, including prior authorization requirements, indication-based coverage limitations, and formulary exclusions, are emerging across both public and private insurers. As coverage criteria evolve, patients with substance use disorders who experience secondary benefits from GLP-1 receptor agonists prescribed for co-occurring conditions (e.g., obesity) may be particularly vulnerable to relapse when access is restricted and medications are abruptly discontinued. Addiction medicine remains an area with relatively limited pharmacotherapeutic options. FDA approval and broader insurance coverage of GLP-1 receptor agonists may expand the treatment landscape for individuals with SUD and reduce the risk of destabilization associated with abrupt medication discontinuation.

References: Shen MR, Owusu-Boaitey K, Holsen LM, Suzuki J. The efficacy of GLP-1 agonists in treating substance use disorder in patients: a scoping review. J Addict Med. 2024;18(5):488-498. doi:10.1097/ADM.0000000000001347

Probst L, Monnerat S, Vogt DR, et al. Effects of dulaglutide on alcohol consumption during smoking cessation. JCI Insight. 2023;8(22):e170419. doi:10.1172/jci.insight.170419

Skibicka KP. The central GLP-1: implications for food and drug reward. Frontiers in Neuroscience. 2013;7:181. doi:10.3389/fnins.2013.00181

Wreschnig LA. Medicare Coverage of GLP-1 Drugs. Congressional Research Service; September 9, 2024. In Focus: IF12758.

Hwang JH, Laiteerapong N, Huang ES, Kim DD. Lifetime health effects and cost-effectiveness of tirzepatide and semaglutide in US adults. JAMA Health Forum. 2025;6(3):e245586. doi:10.1001/jamahealthforum.2024.5586