Cocaine Killed 29,449 People in 2023. There's Still No Medication For It.

In 2011, 4,681 Americans died from cocaine-involved overdoses. In 2023, 29,449 did. In the same twelve years, deaths involving methamphetamine and other psychostimulants rose from 2,266 to 34,855. Stimulant-involved deaths now account for more than half of all U.S. drug overdose mortality.

There is no FDA-approved medication for cocaine use disorder. There is no FDA-approved medication for methamphetamine use disorder. This is not a regulatory oversight waiting to be corrected — it reflects both the genuine difficulty of stimulant pharmacotherapy and, more honestly, how much less research funding has historically gone to stimulant SUD compared to opioid use disorder. The NIDA pipeline has candidates — topiramate, naltrexone combinations, and others in earlier stages — but nothing that’s cleared Phase 3 trials for stimulant disorders specifically.

Understanding why requires a quick detour into neuroscience. Methamphetamine and cocaine both act primarily on the dopamine system: cocaine blocks reuptake, meth floods release. Both produce a surge of dopamine in the nucleus accumbens — the brain’s reward center — that is orders of magnitude larger than anything a natural reward produces. With repeated use, the brain compensates by downregulating its dopamine receptors, reducing the number of receptors and their sensitivity. This is the neurobiological basis of tolerance, and it is also why recovery from stimulant use disorder involves a prolonged period of anhedonia — the inability to experience pleasure from normal activities — while the dopamine system slowly recovers its baseline. That period is when relapse rates are highest, and it’s the period for which we have the least pharmacological support.

The treatment that does work is contingency management — a behavioral intervention that rewards abstinence with monetary prizes or vouchers. The evidence base for CM in stimulant use disorder is among the strongest in behavioral health. Multiple randomized controlled trials confirm it. Real-world implementations at VA facilities, in state Medicaid programs that have piloted it, and in the APA Monitor’s April 2026 summary of the evidence all point the same direction: CM reduces stimulant use, reduces overdose risk, and is cost-effective compared to the alternative of no treatment.

And yet contingency management remains blocked from standard Medicaid reimbursement in most states, primarily because of a philosophical objection to “paying people not to use drugs.” That objection has now cost somewhere in the range of tens of thousands of lives. The stimulant death data is the receipts.

The CDC’s MMWR analysis of stimulant-involved deaths through mid-2024 shows rates still rising as of its data cutoff — cocaine deaths at 8.6 per 100,000 population, up from 4.5 in 2018; methamphetamine deaths at 10.4, up from 3.9. The polysubstance pattern complicates interpretation: the majority of stimulant-involved overdose deaths also involve fentanyl, meaning that expanding fentanyl testing and naloxone access saves some stimulant users too. But the long-term solution to stimulant use disorder deaths is a stimulant use disorder treatment, and the field still doesn’t have one it can prescribe.

That gap has a human cost. The data makes it legible. The question now is whether legibility produces action faster than the death toll grows.