Category: Washington Post

When Susan Akin first started injecting a coveted weight-loss drug early this year, the chaos in her brain quieted. The relentless cravings subsided — only they’d never been for food.

The medication instead dulled her urges for the cocaine and alcohol that caused her to plow her car into a tree, spiral into psychosis, and wind up admitted to a high-end addiction treatment center in Delray Beach, Fla.

Doctors at Caron Treatment Centers tried a novel approach for the slender 41-year-old by prescribing her Zepbound, part of a blockbuster class of obesity and diabetes medications known as GLP-1s. Federal regulators have not approved the drugs for behavioral health, but doctors are already prescribing them off-label, encouraged by studies suggesting that they could reshape addiction treatment.

Scientists caution that the research remains nascent. Health insurers do not cover the pricey drugs for that purpose. Addiction specialists say the medications might not be a cure but may work as a tool to quell addictive behaviors.

For Akin, the weekly shot helps her endure a world full of triggers. She can visit a gas station without wanting to buy beer or see sugar without dialing a cocaine dealer. The cravings linger but are muted, she said.

“I know when I’m due for my shot because I get a little antsy or irritable, or just kind of off,” Akin said. “But it has changed my life.”

Emerging science

As GLP-1 drugs for weight loss generate billions for pharmaceutical companies, researchers are exploring their potential for other purposes. Clinical trials have already shown that semaglutide, the active ingredient in Ozempic and Wegovy, can reduce the risk of heart attacks and treat liver disease.

These drugs appear to reduce cravings for food because they mimic a natural hormone that boosts insulin production, curbs appetite, and slows stomach emptying to create a feeling of fullness. Tirzepatide, the active ingredient in Zepbound, imitates a related hormone that enhances insulin release and amplifies appetite suppression.

The mechanism of how GLP-1s could also curb alcohol and drug cravings is not entirely understood. The medication may block release of dopamine, the chemical associated with reinforcing pleasurable activities, said Kyle Simmons, a professor of pharmacology and physiology at Oklahoma State University. The medications appear to be “turning down the gain on the reward circuitry in the brain,” Simmons said, possibly explaining why they have a broad effect on behavior.

The potential has ushered in a wave of research that includes whether the drugs help veterans with moderate to severe drinking problems, diabetic patients who smoke, and people addicted to opioids, among others.

Federally backed studies of patient records released since early 2024 have shown GLP-1 use in some patients who are diabetic or obese is associated with lower risks of alcohol abuse, cannabis use disorder, and opioid overdoses.

Associations alone do not prove that the weight-loss drugs are causing those changes, but small early clinical trials have shown promise. In one study published in February in JAMA Psychiatry, researchers found that problem drinkers who received a weekly semaglutide injection drank less and had fewer cravings for alcohol and cigarettes compared with those given a placebo.

Researchers at the National Institute on Drug Abuse and Simmons are running separate but similar double-blind clinical trials to measure whether the drugs curb alcohol cravings in patients with drinking problems. Researchers are charting brain activity to see how participants respond when exposed to alcohol cues and using virtual-reality headsets to measure how they respond to images of food. In the NIDA study, scientists have built a mock bar to observe how patients react to being near alcohol.

A spokeswoman for Eli Lilly, which manufactures Zepbound, said the company is considering clinical trials to assess the drug as a treatment for substance use disorders, including for alcohol and tobacco. Novo Nordisk, the maker of Wegovy and Ozempic, declined to say whether it would study the drugs’ effectiveness for addiction.

Medical treatments lacking

The use of GLP-1s for unapproved purposes is surging, including micro-dosing to promote longevity and wellness, despite little evidence supporting these lower doses. Researchers also caution that long-term use of the drugs — which can cause unpleasant stomach side effects — remain understudied.

Still, if GLP-1s prove effective at curbing cravings of different substances — and include behavioral addictions such as gambling and shopping — it “really opens up a whole new sort of therapeutic avenue that’s not been available before,” said Joji Suzuki, an addiction researcher at Brigham and Women’s Hospital in Boston.

An estimated 48 million Americans had a substance use disorder last year, according to federal researchers. More than 80,000 died of drug overdoses last year while more than 47,000 died from alcohol complications, according to federal estimates.

There are no approved medications to reduce cravings for other substances including cannabis, cocaine, or methamphetamine. For opioid addiction, medications such as buprenorphine or methadone are considered effective at staving off withdrawal and cravings, but carry stigma.

While the FDA has approved three drugs to reduce alcohol consumption, only 2 to 4% with alcohol-use disorder get any medication treatment, said Lisa Clemans-Cope, a researcher at the Urban Institute, a nonpartisan economic and social policy research group.

An affordability problem

Early research and anecdotal evidence proved enough for Steven Klein, a physician who specializes in addiction at Caron, to begin prescribing GLP-1s to his patients.

For Klein, the project is more than a professional curiosity: He is a recovering alcoholic who has long struggled with his weight. Three years ago, while in recovery and working as a pediatrician, Klein was prescribed the anti-diabetes drug Mounjaro for weight loss. He found the drug calmed his mind. “The voice that was talking to me about food was very similar to the voice that used to talk to me on drugs and alcohol,” Klein said.

Moved by his experience, Klein switched to addiction care and joined Caron, a high-end rehab center with facilities near Reading and in Atlanta, Washington, and Delray Beach.

He spearheads a pilot program that has prescribed GLP-1s to more than 130 patients in Pennsylvania and South Florida, most diagnosed with alcohol-use disorder and some who took stimulants.

Klein has also partnered with Open Doors, a nonprofit in Rhode Island that helps formerly incarcerated women reenter society, to begin offering GLP-1s through its recovery program.

“We see how hard it is for people to maintain their recovery long-term after they leave the support of our housing,” Open Doors Co-Executive Director Nick Horton said. “But with this medicine, I’m hopeful.”

Regina Roberts, a 41-year-old alcoholic in recovery, is living at an Open Doors facility after stints in rehab and a family court program after she lost custody of her teenage son. She has been sober since 2023 with the help of 12-step programs, therapy, and life-skills classes. But she faced frequent reminders of her past: walking past a liquor store, smelling alcohol on someone’s breath, cigarette smoke wafting in the air. When Open Doors told her about the promise of GLP-1s several months ago, she agreed.

“I figured, why not try it?” Roberts said. “I’ll take anything to help me stay on my road to sobriety.”

With her cravings dialed back, Roberts hopes to reunite with her teenage son and move out of Open Doors in a few months. But she’s unsure whether she can keep taking the medication; she can’t afford to pay out of pocket and Medicaid might not cover it.

At Caron’s Wernersville location, staff reduce costs by receiving semaglutides from compounding pharmacies, which can legally produce cheaper versions of name-brand mediations.

In the Delray Beach facility, most patients receive Zepbound through their insurance by “piggybacking” under FDA-approved uses, or by paying out of pocket with manufacturer discounts, said medical director Mohammad Sarhan. Those costs add to the price of rehab programs that can cost up to $100,000.

Akin, the Caron patient who is approaching one year sober, said she relies on her inheritance to pay nearly $1,000 every month for prefilled Zepbound shots. Akin could receive a modest discount in the coming months now that Eli Lilly, along with Novo Nordisk, announced they could lower direct-to-consumer prices as part of a deal struck with the Trump administration.

She considers Zepbound an essential drug like insulin.

“It’s not a cure. We have to do the work,” Akin said. “But it helps. It slows things down enough to the point where you don’t feel like you have to jump off a bridge or put your head in a cocaine plant to survive.”

Q: I’ve been married for only two years, and I’m already wondering if I made a bad decision. When we were dating, my husband was incredibly charming and thoughtful, and in many ways, much more sensitive and dialed in than most of the men I had dated. And since my track record hasn’t been great, I dated him for at least a year before getting engaged so I had time to really get to know him. Or so I thought, because the warm and charming man he once was started going away almost as soon as our wedding was over. And far from being the considerate person who charmed me, he’s incredibly self-centered, moody and angry most of the time. When the topic is on him, it’s all good; but as soon as I want to talk about what’s going on in my life, he gets bored, annoyed, or downright mean. Did I marry a narcissist?

A: It’s not uncommon for people to wonder whether a partner’s self-centeredness, emotional volatility, or lack of empathy points to narcissism. The term gets thrown around so often that it can lose meaning — but for those who live with a truly narcissistic partner, the experience is anything but trivial.

Recent research shows that while full narcissistic personality disorder (NPD) is relatively rare, its impact on intimate relationships can be profound. People with NPD share a cluster of traits centered on grandiosity (believing they’re superior or above the rules), entitlement, and impaired empathy, expressed through an exaggerated need for admiration, a fragile and easily threatened sense of self, and a tendency to exploit or dismiss others’ needs. They often oscillate between inflated self-importance and deep insecurity, react poorly to criticism, and rely on defenses such as blame-shifting, minimization, or rage to protect a vulnerable self-image.

Studies of couples in which one partner has elevated narcissistic traits or NPD have found patterns of low empathy, high conflict, and poor responsiveness to a partner’s needs, often driven by the narcissistic partner’s fragile self-esteem and heightened sensitivity to criticism.

This means that the distress you feel is not imagined — NPD reliably predicts greater marital dissatisfaction, more emotional volatility, and higher rates of separation.

Researchers today also distinguish between grandiose and vulnerable narcissism. Grandiose narcissists tend to be dominant, entitled, and attention seeking. They’re also more likely to be difficult in romantic relationships, less empathic, and more prone to infidelity.

Vulnerable narcissists, on the other hand, tend more toward hypersensitivity and fears of being shamed. Like grandiose narcissists, vulnerable narcissists crave validation, but withdraw or attack when criticized. Both forms undermine romantic relationships, but in different ways: one through arrogance, the other through insecurity.

However, whether he is narcissistic doesn’t necessarily mean that you should leave him. Research suggests that narcissistic traits can soften over time, particularly when life experiences challenge the person’s grandiosity.

Therapy can also help partners by getting them to focus less on “fixing” the narcissist and more on clarifying boundaries, recognizing manipulation, and reclaiming one’s own sense of reality.

Psychotherapy can also help if he is motivated, but genuine change requires confronting shame, entitlement, and fear of dependency — tasks many with NPD tend to resist.

It may not be just narcissism

In addition to narcissism, there are other potential diagnoses and dynamics that could be operating. Perhaps your husband is depressed. Research shows that men often externalize depression through irritability, defensiveness, or emotional shutdown rather than sadness. This occurs in part because of cultural expectations that discourage vulnerability in men. What can look like indifference or hostility may, in some cases, be a form of masked distress — an effort to manage feelings that are too threatening to acknowledge directly.

On the other hand, he may have issues with drugs or alcohol, which can also lead to moodiness, self-centered behavior and, in the case of stimulants, grandiosity.

Perhaps he has intense fears of losing you and that causes him to defend against how weak or vulnerable it makes him feel. Instead, he diminishes your value so you’re not as important in his heart or mind.

None of these make him easy to live with, but they all suggest a different response from you or a different treatment strategy if he or you were to enter therapy.

The pull of the familiar

Since you said that your track record with choosing men isn’t great, it may be useful to do some reflection or therapy around why you’re drawn to certain types. Sometimes we have blind spots in who we’re attracted to because they have much in common with parental figures who made us feel unloved or unseen. Familiarity can be a serious attractor because of the kind of predictability it seems to offer.

In addition, someone who appears to “have it all” may promise to heal all the broken or wounded places inside us and blind us to the reality that they’re a little too good to be true.

We don’t fall for people at random — we choose those who make us feel like ourselves. The trouble is, if our self-view isn’t great, we’re vulnerable to choosing partners, even friends, who bruise us in familiar ways. Psychologists call this self-verification: the drive to confirm what we already believe about ourselves, however irrational or negative that self-image.

Whatever the diagnosis, you’ll need additional support to navigate what you’re facing. A good couples therapist can be particularly helpful because they can assess what’s driving his behavior and identify whether referrals to other therapists or agencies are warranted.

Meanwhile, regardless of the diagnosis, your needs for empathy, care, and reflection are just as important as his. If he does carry the diagnosis of NPD, the following principles can help:

1. Stop arguing with reality. People with NPD often distort facts to preserve their self-image. Trying to prove your version of events can leave you frustrated and drained. Instead of debating every detail, focus on what’s true for you: your boundaries, feelings, and choices.

2. Set limits early and consistently. Boundaries aren’t punishments; they’re forms of self-respect. If he’s responding to you with hostility, try saying the following: “I won’t be talked to in that way. If you have something you’d like to tell me, I’m happy to listen, but I won’t tolerate being criticized or demeaned by you or anyone else.” If you find yourself close to the edge of divorce, tell him before it’s too late. His self-centeredness may blind him to the possibility of losing you. You can say, “If this doesn’t change, I’m not sure I can stay married to you.” Narcissistic partners may test limits repeatedly, so consistency matters more than explanation. Calm, brief, and predictable responses are more effective than emotional appeals.

3. Don’t take the bait. Narcissistic partners often escalate conflict to reassert dominance or control. When you stay centered and refuse to match their reactivity, you deprive the dynamic of its usual fuel. This isn’t submission — it’s strategy. Use the technique of “gray rocking.” If he begins provoking you with criticism or baiting you into an argument, try responding in a neutral, minimally reactive way, such as: “I understand that you’re upset.” No counteraccusations, defending, or emotional escalation. You keep your tone flat and your answers brief, and you avoid being pulled into the cycle. The goal isn’t to be cold; it’s to not reward the behavior with the intensity or engagement it’s designed to elicit, which often helps de-escalate the interaction.

4. Protect your self-esteem. Over time, living with a narcissistic partner can make you question your value. Remind yourself that their inability to empathize isn’t proof that you’re unworthy — it’s evidence of their disorder. Surround yourself with people who mirror your strengths and kindness, not your partner’s distortions.

5. Plan for safety — emotional and physical. If manipulation turns to threats, intimidation, or physical aggression, take it seriously. Reach out to trusted friends, a therapist, or a domestic violence hotline. Protecting yourself isn’t betrayal; it’s survival.

You didn’t cause your husband’s behavior, nor can you cure it — but you can respond with clarity and care. Whether the problem is narcissism, depression, or something else, healthy relationships require mutual accountability, empathy, and respect. If he’s willing to work on those qualities, change is possible. If not, your task isn’t to fix him — it’s to protect your own stability and make choices that restore safety and dignity. Sometimes the healthiest outcome is renewed and deepened understanding; other times, it’s learning to let go without bitterness. Either way, your safety and sanity are nonnegotiable.

Joshua Coleman, PhD, is a clinical psychologist in the Bay Area, keynote speaker and senior fellow with the Council on Contemporary Families. His newest book is “Rules of Estrangement: Why Adult Children Cut Ties and How to Heal the Conflict.” His Substack is Family Troubles.

For more than three decades, Marion Nestle has been telling people what to eat.

In the late 1980s, she edited the first Surgeon General’s Report on Nutrition and Health, then went on to cowrite the federal government’s Dietary Guidelines for Americans and cofound New York University’s influential food studies program.

Nestle, now an emerita professor at NYU, says her time in government opened her eyes to the multi-billion-dollar food industry’s enormous influence over Congress. By the early 2000s, she became a critic of the food industry and an advocate for major food reforms, which she made the case for in best-selling books.

In 2002, Nestle published Food Politics, an exposé that argued that the food industry is at the root of many of the country’s nutritional problems. The industry rakes in ever-growing profits by churning out highly processed foods laden with additives, Nestle wrote, and then aggressively markets those foods to children and adults while lobbying against regulations and trying to co-opt nutrition experts.

Over the years, Nestle’s blunt nutrition advice, sharp criticism of food companies, and frequent media appearances made her one of the most recognizable names in nutrition. In 2006, she published one of her most popular books, What to Eat, which showed consumers how to navigate supermarkets and improve their health by deciphering food labels.

At age 89, Nestle, who lives in New York City and Ithaca, is still going strong. In November, she published her latest book: What to Eat Now: The Indispensable Guide to Good Food, How to Find It, and Why It Matters.

We wanted to know how Nestle’s knowledge of nutrition and the food industry affects her daily food decisions. So we caught up with her to find out what she eats in a typical day, which foods she loves and avoids, which “junk foods” she can’t resist, and whether she takes supplements or has advice on how to navigate grocery stores. This interview has been edited for length and clarity.

Q: What’s your general approach to food?

A: I follow Michael Pollan’s famous mantra: Eat food, not too much, mostly plants. And I define food as being unprocessed or as minimally processed as possible. Not ultra-processed. I really think that takes care of it. That doesn’t mean I’m perfect. I’m an omnivore. I eat everything. I just don’t eat very much in part because metabolism drops with age, and I don’t have much metabolism left.

I eat pretty healthy, but I don’t obsess about it. If I have a bad day of eating, I don’t worry about it. By this time, it’s pretty clear I’m not going to die prematurely. Obviously, what I’m eating is working for me because I’m 89 and I’m still here.

Q: What do you eat for breakfast?

A: I start with coffee between 8 and 9 a.m. I’ll have a couple cups of weak coffee with milk, no sugar. And then I’m at work. That’s when I do my writing. I don’t get hungry until about 10:30 or 11 a.m. That’s when I’ll usually have oatmeal or unsweetened Post Shredded Wheat cereal. It basically has one ingredient: wheat. I like the texture of Shredded Wheat and the way that it tastes. I add a little brown sugar, not much. I use a lot less sugar than what’s in presweetened cereals. And then I’ll add blueberries or whatever fruit is in season. That combination to me is really appealing.

I’ve never believed any of the research on breakfast being the most important meal of the day. Most of that was sponsored by cereal companies.

Q: What about lunch?

A: My lunches are totally irregular. Sometimes I’ll have a salad for lunch. Or if I’m having lunch with someone then I’ll eat whatever is in the restaurant. If I’m at home in New York City, I’ll harvest whatever is growing on my terrace. The peaches, cherries, raspberries, and blueberries that I was growing are long gone. But I’ve still got some lettuce and tomatoes, so I’m going to go out and pick those. I might cut up some cheese or have it with peanuts. And I might have some bread with that.

Q: What about dinner?

A: It depends. I just don’t eat that much. But I do really like salads. I can have salads twice a day. If I’m at home, I might have an egg. I might have crackers and cheese with that. I kind of like making meals based on what I have available. So, it depends on what I bought, what’s in the house, or what’s on the terrace. That’s my favorite way of cooking. We have a garden in Ithaca, there’s a garden on my terrace, and there’s a farmers market not very far from here.

I also go to a lot of neighborhood restaurants. I’m going to Mark Bittman’s restaurant this week — the kitchen that he started in the East Village where people pay according to their income. I’ll eat whatever they’re serving. One restaurant that I like a lot is il Buco Alimentari & Vineria. I love going there. They have a particular salad that I adore. It’s always so crisp, and they have wonderful pasta dishes.

Q: What are some foods that you love?

A: Fortunately, I like a lot of very simple foods. I like vegetables. I like eggs. I like cheese. I do eat some ultra-processed foods. But not a lot of them. I don’t like ultra-processed foods that have a long list of ingredients. Most of those don’t taste good to me. I do really like vegetables. I like the crunch, the flavors, and the colors. That makes it easy to eat healthy.

But I recognize that I’m privileged. I weigh basically what I weighed when I was in high school. I don’t have a weight problem. And I have an enormous amount of sympathy for people who do. I consider myself extremely fortunate. Is it genetics? I have no idea. My father died of a heart attack at the age of 47. He was an obese three-pack-a-day smoker. It’s hard to know where genetics fits into this.

Q: Do you have any favorite treats or desserts?

A: Ice cream. When I’m at home in New York City, I try to find ginger ice cream, which I like very much. It’s hard to find. But when I find it, I buy it. And then my partner and I make homemade vanilla ice cream in Ithaca. It’s only three or four ingredients. It’s ruined other ice creams for me because a lot of commercial ice creams have all these emulsifiers in them that keep the ice cream sticking together. Real ice cream completely falls apart if it’s left at room temperature and not eaten right away. It separates and liquefies. But I like that. I think it tastes better and has a better texture than the commercial ice creams that have emulsifiers. I like ice cream without the emulsifiers.

Q: What about snacks?

A: I like corn chips. Not too salty. Some corn chips are ultra-processed, although most are not. The ones I like are Wegmans. They only have a few ingredients — just corn, oil, and salt basically. I also like candy, particularly See’s Candies. The one See’s candy store in New York is just a couple blocks away from me. I normally get the peanut brittle. Sometimes the lollipops. I can have these things in the house and not feel like I have to eat all of them all at once. Not everyone can do that.

Q: Can you tell us about your new book?

A: It’s called What to Eat Now. It’s the updated edition of What to Eat, which was published 20 years ago. It’s a completely rewritten book. I thought it was going to be a six-month project, and it ended up taking me four years because so much has changed in grocery stores. There’s been a huge turnover in products. For example, “functional waters” that contain vitamins, minerals, cannabis, supplements, and other things have replaced Coca-Cola and plain water. Plant milks are new. The only plant milk that existed 20 years ago was soy milk. Now there are tons of others. Plant-based meats did not exist 20 years ago — at least not in the way that they do now.

Q: What is one takeaway from the book?

A: It’s not a book about personal diets. It’s a book about how to think about food issues. I think what to eat now boils down to eat food, not too much, mostly plants.

Q: Do you take any supplements?

A: I don’t take supplements because I eat a healthy diet. I don’t think I need them. But two out of three Americans take supplements. They make people feel better — and it’s hard to argue with that. Life is tough. If all it takes is a supplement to make you feel better, then I’m not going to argue with that. I used to be much more upset about supplements. But now it’s clear to me that they make people feel better. Whether that’s because they’re doing something or because they’re a placebo, it’s hard to know.

But I don’t trust what’s in them. There’s so much evidence that what the label says isn’t what’s actually in them. Many studies have found that a remarkable percentage of supplements do not actually contain what’s listed on their labels. I don’t want to put something in my body if I don’t know what’s in it. And there are things in supplements that are not supposed to be there — that’s what so many studies have found. It’s not true of all supplements. But it’s very hard to know which ones are OK and which ones are not. So I don’t take any of them.

Q: Do you have any advice for our readers?

A: Eating healthfully in today’s society is very difficult because you’re fighting an entire food industry on your own— and that industry is trying to sell you the most profitable, least healthy foods available. But one thing you can do is read food labels. There’s a lot of information on them. If you’re looking at a packaged food and you can’t recognize the ingredients, or if you can’t purchase the ingredients at a supermarket, then it’s ultra-processed. There are certain ingredients that are indicators of ultra-processed foods. That would be color additives, flavor additives, and emulsifiers such as mono and diglycerides, polysorbates and carrageenan, and texturizers such as agar. I always read food labels. If something has a lot of artificial additives and ingredients that I don’t recognize, then I’m not going to eat it.