Meth and Cocaine Have One Proven Treatment. Most Medicaid Plans Still Won't Pay For It.

There is no FDA-approved medication for methamphetamine or cocaine use disorder — nothing that does for stimulants what buprenorphine does for opioids or naltrexone does for alcohol. The treatment with the strongest evidence base isn’t a pill at all. It’s contingency management: a patient submits a urine sample, tests negative, and walks out with a small reward — a gift card, often $5 to $10, escalating with consecutive clean tests. It sounds almost too simple to be real medicine. Deaths involving methamphetamine and cocaine nearly quadrupled between 2015 and 2022, and stimulants are now involved in more than half of all U.S. overdose deaths, which is what happens when the evidence-based treatment for a crisis this size stays a niche pilot program for two decades instead of standard care.

We have had a proven treatment for the fastest-growing overdose category in the country since the 1990s, and most insurance still won’t pay for it.

That’s finally starting to change. The federal government raised the maximum annual incentive cap tenfold, to $750 per patient, in January 2025, clearing the path for state Medicaid programs to build real contingency management benefits instead of token pilots. A cost-effectiveness analysis published this year found the math works even at that higher incentive level — the treatment pays for itself in avoided ER visits, hospitalizations, and overdose deaths. More states are adopting it as covered care in 2026, and both ASAM and SAMHSA now formally recognize it as evidence-based practice, which is the federal government’s way of saying: stop treating this like a fringe idea.

If you run a treatment program and haven’t checked whether your state Medicaid plan now reimburses contingency management, that’s a five-minute call this week, not a someday project — the billing pathway exists in more states than it did a year ago, and the patients who’d benefit are the ones you’re already seeing walk back in after a relapse with nothing else on offer. This isn’t a treatment waiting for more research. It’s a treatment waiting for someone to bill for it.