Three Hundred and Seventy-One Trials Later, There Is Still No Approved Drug for Meth or Cocaine. The Best Treatment We Have Is a Gift Card.

Here is the number that should stop a room: in the best trial anyone has run of a drug for methamphetamine use disorder, 13.6% of people responded to the medicine and 2.5% responded to the placebo. That is ADAPT-2, naltrexone plus bupropion, and the authors of a new CNS Drugs umbrella review (Danovitch and colleagues, published August 21, covering 371 trials across 16 systematic reviews) say it still isn’t enough to approve. Their bottom line: no medication is approved anywhere in the review’s scope for cannabis, cocaine, methamphetamine or other stimulants.

Nobody who works in a clinic needs to be told this. The people who use meth and cocaine have been told it for decades, one way or another, by being handed pamphlets instead of prescriptions.

There is no pill for stimulants yet. What there is, and the only thing there is, works on behavior.

That one is contingency management, and it is as plain as it sounds: people who give a drug-free urine sample get a small reward, a gift card or a voucher, right then. Psychologists have a name for why it works. The simpler version is that craving is a bet on right now, and a reward you can touch today wins more bets than a promise about next year. The National Health Law Program lays out why it’s a promising fit for Medicaid beneficiaries with stimulant use disorder, and the review’s own numbers explain why programs are not waiting for a drug: where the pharmacology is empty, the one tool with trial evidence is the one that treats the person as someone who responds to being rewarded for doing well.

The review has limits you should hold alongside its headline. It pools trials that measured outcomes differently across substances, and it leaves out foundational studies from before 2016. It says nothing about how long the effect of a reward lasts once the gift cards stop, and the lesson from every behavioral treatment is that the support has to outlast the incentive.

If you run a program in Arizona or anywhere that sees people using meth or cocaine, this is the week to ask your Medicaid health plan, in writing, whether contingency management is a covered service and what the billing pathway is. If it isn’t covered, you now have a published review to attach to the question. If you are using and you have been told there is nothing that works, that is incomplete: the thing that works is a program that pays you, in small and immediate ways, for every day you show up clean-handed.

The people most in need of a pill are still waiting for one. They shouldn’t have to wait for a gift card too.