Opioid Deaths Are Falling. Meth Didn't Get the Memo, and There Is Still No Pill for It

In a peer-led recovery center in downtown Pittsfield, Massachusetts, the people who run the front desk will tell you the opioid numbers are better and the room is not quieter. The center is called Living in Recovery. When reporters from WAMC visited in early October, the staff talked about what they are worried about now: meth, alcohol, and marijuana, with fentanyl still turning up inside the supply.

The good news is real. Massachusetts opioid overdose deaths fell below 1,000 in 2025 for the first time since 2013, to 978, down from almost 2,400 in 2022, according to the same WAMC report citing state and CDC figures. Free, visible naloxone in Pittsfield and Berkshire County gets some of the credit. Nobody at the center is pretending that finished the job.

Opioid deaths falling is not the same as people being okay, and meth is the proof.

The drug that fills the room after the headlines move on

Wolf Valentin, the center’s volunteer coordinator, put the shift in one line: meth is “the new crack, the new crack that’s cheaper,” he told WAMC, and it can be made from household ingredients. That second half is the part with a history. When Congress moved pseudoephedrine behind the pharmacy counter in 2005, the small home labs that cooked meth in kitchens and motel rooms dried up, and the market did not shrink with them. Production did not stop. It moved to larger operations and imported supply, and the lesson has been repeated in every drug panic since: squeeze one ingredient and the product finds another door. Meth is the drug that has been teaching that lesson longest, and the rest of us keep forgetting it between news cycles.

If you have used meth, you already know why it holds on. It does not just feel good. It makes the day feel possible, and then it takes that away and bills you for it in sleep, mood, and a flat gray stretch where nothing seems worth doing. Treating that as a willpower problem is how a lot of people got told they were failing at something that was never a test of character.

What a pill can do, and what the best new trial says it can’t

Here is the uncomfortable fact underneath all of it: there is still no FDA-approved medication for methamphetamine use disorder. A 2025 review in Current Addiction Reports says it plainly. Behavioral treatment, contingency management and cognitive behavioral therapy, remains the first-line option. Contingency management is the plain-spoken version of a hard idea: you earn small rewards for stretches of time without using, and it is the approach the review points to first. FDA has a guidance document for drug developers on how to design stimulant trials, which tells you the door is open and the building is still empty.

The most recent serious attempt came in April. In a randomized trial in JAMA Psychiatry, Rebecca McKetin, Steven Shoptaw and colleagues gave 344 adults with moderate or severe methamphetamine use disorder either 30 mg of mirtazapine, an antidepressant that also makes people sleepy, or a placebo, every day for 12 weeks at six outpatient clinics in Australia. People on mirtazapine cut their days of meth use by 7.0 in a 28-day stretch; people on placebo cut theirs by 4.8. The gap is 2.2 days, with a confidence range running from 4.2 days down to 0.2. That is a statistically real effect and a small one.

The detail to read slowly is the one the authors reported without spin. The share of oral-fluid samples that tested negative for meth was 13.2% on mirtazapine and 12.0% on placebo, no meaningful difference. Median adherence, how much of the medication people actually took, was only 52%. Drowsiness hit 47% of the mirtazapine group against 33% on placebo, weight gain 10% against 3%, and 23% stopped because of side effects against 15%. The authors themselves write that the results may have been diluted by a mixed group of people with long-entrenched use. Among people who were depressed at the start, insomnia improved more on the drug, but the authors flag that as exploratory.

Drowsiness hit 47% of the mirtazapine group against 33% on placebo, weight gain 10% against 3%, and 23% stopped because of side effects against 15%.

An earlier NIH-backed study of injectable naltrexone combined with oral bupropion was framed as promising, and it is the other name you will hear in this conversation. Neither one is a prescription you can get for this today.

Why the sleep detail is the human part

The one place the trial saw a clearer benefit beyond days of use was sleep, in the subgroup who were depressed when they started, and the authors are careful to call that exploratory. Still, anyone who has come off a run of meth knows the crash is not a metaphor: days of broken sleep, a mind that will not settle, and a mood that makes the old routine look like the only relief on offer. A medicine that takes the edge off the first weeks of stopping is not a cure. Whether it is the difference between staying in the room and leaving it is exactly what a trial with 52% adherence cannot tell us. That is a modest claim, and it is the honest one.

It also changes what a provider does this week. If someone on your caseload is stable on buprenorphine and quietly using meth, that is no longer a footnote in the chart; as opioid deaths fall, it is the main event. Ask the question directly and without a lecture. Ask your team whether you can offer contingency management, and check your state Medicaid rules before promising it, because coverage varies state by state and a federal green light does not mean a billing code in your county. Ask how sleep is going before you ask about use.

Brandon Marshall of Brown University, an epidemiologist quoted in a recent STAT report, said of the national overdose decline that “we’re nowhere near out of this crisis.” He was talking about opioids. The people in Pittsfield are describing the part of the crisis that the opioid numbers do not count.

What is still yours

Here is what has not been taken from you tonight. Naloxone is still available without a prescription, and it still works if what you are using turns out to have fentanyl in it, which is the reason Living in Recovery says the contamination worry has not gone away. Contingency management is still the first-line treatment, and a peer-run room like the one in Pittsfield still has a chair for you. None of that depends on a drug getting approved.

Julie MacDonald, the center’s program director, was talking about Massachusetts’ kratom ban when she told WAMC that people who go into withdrawal without immediate treatment may return to opioids. The point travels. A person does not need a better argument. A person needs somewhere to go on the day the drug stops working, and a hand on the door when they get there.