The Only Treatment That Works for Cocaine Just Got a 10x Raise. Almost Nobody Can Cash It In.

Thomas Freese runs the addiction-medicine program at UCLA and leads California’s Recovery Incentives Program, which has enrolled nearly 10,000 people across 111 sites statewide. Twice a week, participants walk into a clinic, hand over a urine sample, and if it comes back negative for cocaine or methamphetamine, they walk out that same day with a gift card, or a shot at a bigger prize from a bin. That’s the whole intervention: pay someone a small, immediate reward for testing negative. Doctors call it contingency management, and per the American Psychological Association’s own reporting, Freese put the case for it bluntly: “We don’t have any FDA-approved medications for the treatment of stimulant use disorder, but what we do have is almost 40 years of evidence on the efficacy of contingency management.”

Sit with that. There is still no pill for cocaine use disorder — not one, not off-label, not in trials close to approval. The best answer medicine has, forty years running, is a gift card handed over on the spot.

A tenfold raise in what a program can legally pay someone to stay negative only matters if the money reaches them, and right now it mostly doesn’t.

In early 2025, SAMHSA raised its federal cap on contingency management incentives from $75 to $750 per person per year — a ceiling that, per the agency’s own advisory, had never been backed by evidence to begin with. University of Florida psychologist Jesse Dallery told the APA the shift means “the momentum in the field has shifted from developing interventions to implementing them in real-world settings. We know CM works. Now, it’s a matter of reaching as many people as possible.” That’s the optimistic read. Here’s the gap underneath it: as of this March, health policy writer Tommy Volkman reported that only five states — California, Delaware, Hawaii, Montana, and Washington — have won federal permission to pay for contingency management through Medicaid, with two more still waiting on approval. Everyone else on Medicaid, and everyone on a commercial plan, is stuck. The field’s own funding clearinghouse, CMinfo.org, still frames private insurance coverage as something it hopes will happen, not something that has.

There’s a second, quieter fight worth naming: what counts as this working. A meta-analysis of 12 randomized trials in JAMA Psychiatry found that stimulant pharmacotherapy trials graded only on total abstinence may be burying real progress. Cabergoline, a dopamine-boosting drug tested off-label for cocaine use disorder, produced reduced cocaine use in 44% of participants versus 28% on placebo — a real gap that abstinence-only scoring would erase. Going from using cocaine daily to using it once a week is not nothing. Counting it as nothing is a big part of why researchers keep concluding nothing works for cocaine use disorder.

None of this erases the win. A tenfold cap increase and a research shift toward counting reduction as progress are genuine, overdue moves for a diagnosis pharma has never bothered chasing a drug for. But a raised cap sitting in a SAMHSA advisory does nothing for someone in Ohio whose clinic has never applied for a waiver and whose insurance card won’t cover the testing. The gift card works. Somebody still has to be funded to hand it over.