Overdose Deaths Fell Everywhere. Cocaine Didn't Get the Memo.

The national overdose death count fell by 24 percent in 2024, the largest single-year decline ever recorded. In the same period, stimulant-only overdose deaths — people who died from cocaine or methamphetamine, without any opioid in the mix — grew from 17.3 percent to 23.8 percent of all drug fatalities. In absolute numbers: 18,142 in 2023 to 18,907 in 2024. Up, not down.

The two trends are not coincidental. Fentanyl was the engine of the overdose crisis, and fentanyl drove the improvement. The new naloxone infrastructure, expanded buprenorphine prescribing, fentanyl test strip distribution — all of this is calibrated for opioids. For stimulants, the treatment toolkit is near-empty by comparison.

There is no FDA-approved medication for cocaine use disorder. There is no FDA-approved medication for methamphetamine use disorder. Contingency management — a behavioral intervention that provides small financial incentives for negative drug tests — is the most rigorously supported treatment approach for stimulant use disorders, with evidence going back decades. California’s Medicaid program won a federal waiver to cover it in 2021; Washington, Delaware, Montana, and West Virginia have submitted their own waiver requests. In states without Medicaid coverage, contingency management is often unavailable or unaffordable in a system designed around billing for clinical services, not behavior.

The racial dimension of this treatment gap cannot be separated from the epidemiology. Cocaine deaths disproportionately affect Black Americans, who face an overdose mortality rate already 1.5 times the national average. A CDC analysis of stimulant deaths from January 2018 through June 2024 found that 59 percent of all overdose deaths during that period involved stimulants. Among the stimulant deaths not co-involving opioids — the category that’s growing — cocaine is the dominant substance, and its demographic footprint maps directly onto communities where contingency management is least likely to be available and where Medicaid coverage has historically been thinnest.

Methamphetamine deaths tell a parallel story in a different population. American Indian and Alaska Native communities face an overdose rate of 50.8 per 100,000 — more than double the national average — driven substantially by methamphetamine. The geographic isolation of many tribal communities, limited behavioral health infrastructure, and specific barriers to treatment access that tribal health systems face (including federal underfunding) mean that the same contingency management approaches being piloted in California are reaching these communities at a much slower pace, if at all.

What the 2024 numbers say is that the overdose crisis is bifurcating. One branch — fentanyl-involved deaths — is responding to the tools built in the last decade. The other branch — stimulant deaths without opioids — is growing, is concentrated in communities of color, and has no pharmacological equivalent to buprenorphine waiting in the wings. The next decade of progress requires building the treatment infrastructure for this second branch the way the last decade built the opioid infrastructure: with clinical investment, insurance coverage, and a willingness to spend money on behavioral interventions that don’t come in a pill.

The headline number said 80,000 people died. The subtext said almost 19,000 of them died from cocaine or meth, in communities with the fewest resources to respond, and the count is going up.