The Overdose Numbers Are Falling. Cocaine Is the Exception Nobody's Toasting.

The overdose crisis is, by the only measure most headlines use, getting better. The CDC’s latest data brief counted 79,384 U.S. overdose deaths in 2024, down 26 percent from 105,007 the year before, the largest one-year drop on record, driven mostly by fewer fentanyl deaths. Cocaine’s own death rate fell right along with it, down 27 percent to 6.3 per 100,000.

That falling number is hiding a rising one underneath it, and nobody built a press release for the part that’s getting worse.

A study published in Addictive Behaviors Reports this August found that once you strip fentanyl and other opioids out of the count, cocaine-only overdose deaths still rose 1.7 percent from 2023 to 2024, 166 more deaths, and methamphetamine-only deaths rose 2.4 percent. The topline cocaine number is falling because roughly 79 percent of cocaine deaths involve fentanyl, and fentanyl deaths are cratering nationwide. Pull that overlap out and cocaine, on its own, killed more people in 2024 than it did the year before. The authors, based at the University of Minnesota, Brown, and UCLA, wrote that “prevention must expand beyond opioids” — a blunter line than most epidemiology papers allow themselves.

There is no pill for this. Unlike opioid use disorder, cocaine use disorder has no FDA-approved medication — nothing to prescribe the way methadone or buprenorphine treat heroin, no overdose-reversal drug like naloxone. The treatment with the strongest evidence instead is behavioral: paying people small amounts, often gift cards starting around $10 to $12, for drug tests that come back negative, with the reward growing the longer the streak holds and resetting if it breaks. It’s called contingency management, and the American Society of Addiction Medicine calls it the standard of care for stimulant use disorder.

Medicaid, which covers most people with a diagnosed stimulant use disorder, has approved paying for it in exactly five states: California, Delaware, Hawaii, Montana, and Washington, each cleared through a federal waiver process that took years. By KFF’s count, roughly one in five Medicaid enrollees with a stimulant use disorder lives somewhere that will pay for the one treatment shown to work.

Connecticut isn’t waiting on that queue. Its “CM in CT” pilot uses opioid settlement money instead of Medicaid to fund contingency management at five clinics statewide — a state deciding the federal waiver line is too slow to wait behind.

A treatment that works and a system that mostly won’t pay for it isn’t a research gap. It’s a choice, renewed every budget cycle, about whose overdose numbers are worth chasing. Right now, that choice is fentanyl’s.