Meth and Cocaine Still Have No Approved Medication — and the One Treatment That Works Is Starving for Funding

If you’re in treatment for opioid use, someone can hand you a prescription. Buprenorphine, methadone, naltrexone — three medications, decades of research, insurance codes that already exist. If you’re in treatment for alcohol use, same story: naltrexone, acamprosate, disulfiram. If you’re trying to stop using methamphetamine or cocaine, there is no pill. Not one. Not because nobody’s looked — pharmaceutical companies have spent thirty years and hundreds of failed trials trying — but because the neuroscience of stimulant addiction hasn’t handed researchers a clean drug target the way opioid receptors did.

Stimulant users are dying in record numbers while getting the least medical treatment of anyone in the overdose crisis.

Methamphetamine was implicated in 31.2% of overdose deaths and cocaine in 30.0% nationally between January 2021 and June 2024, and stimulants of any kind now show up in 59.0% of all U.S. overdose deaths — a majority, according to the CDC’s Morbidity and Mortality Weekly Report published in August 2025. Zoom into Arizona and it’s worse: methamphetamine alone was implicated in 67% of Maricopa County’s fatal overdoses in 2024. This isn’t a fentanyl story with stimulants as a footnote anymore. It’s its own crisis, running in parallel, with none of the medication infrastructure that opioid treatment spent two decades building.

The death rate climbed for years, and it’s still not what it looks like

Between 2018 and 2023, the cocaine overdose death rate nearly doubled, from 4.5 to 8.6 per 100,000 people, and the rate for drugs that speed up rather than sedate the nervous system — methamphetamine and its close relatives, a group the CDC labels psychostimulants — climbed from 3.9 to 10.4 per 100,000 over the same stretch. The MMWR analysis found something else, too, and it’s not comfortable: American Indian and Alaska Native people saw the sharpest increases in psychostimulant deaths, while Black and African American people saw the sharpest increases in cocaine deaths specifically. This isn’t one crisis distributed evenly. It’s two overlapping ones, breaking along lines that map onto who has access to treatment and who doesn’t.

There’s a real piece of better news buried in the newest numbers. A 2026 CDC data brief found the cocaine death rate fell 26.7%, from 8.6 to 6.3 per 100,000, between 2023 and 2024, part of the broader national decline in overdose deaths. But that’s a one-year dip after a climb that took cocaine deaths from 4,681 in 2011 to 29,449 in 2023 — a six-fold increase in twelve years. One good year doesn’t undo a decade, and it doesn’t change the fact that whatever’s driving the decline, it isn’t a new medication. Nothing changed on that front. Nothing has changed on that front in decades.

The only thing that actually works looks like gift cards, not pills

Here’s what does have strong evidence behind it: a structured program where someone gets a small reward, often a gift card worth $10 to $75, every time they provide a drug test that comes back negative — contingency management, or CM for short, in the research literature. That’s the entire mechanism. No prescription, no receptor, no chemistry. Just a verified test and an immediate, tangible reward, repeated on a schedule, building a new set of consequences around not using. It sounds almost too simple to be real medicine. It’s also, according to the California Health Care Foundation, the only treatment with strong evidence behind it for a pattern of meth or cocaine use someone can’t control even when it’s costing them things they care about — what clinicians call stimulant use disorder.

Picture what that actually looks like day to day, because it’s easy to reduce to a policy line. Someone eight days off meth walks into a clinic three mornings a week. Cup, test strip, five minutes. Negative. A gift card gets loaded with $12. Same routine Wednesday. Same Friday. Nobody’s pretending twelve dollars erases the pull of the drug — it’s not a bribe big enough to compete with meth’s chemistry, and nobody involved in CM research claims it is. What it does is give a nervous system that’s stopped producing its own reward signals a concrete, immediate, external one to hold onto while it heals. Critics have a one-line dismissal ready: paying people not to use drugs. It undersells what’s happening in that clinic room three mornings a week, and it’s the reason CM has spent years fighting for funding that opioid medications never had to fight for.

What it does is give a nervous system that’s stopped producing its own reward signals a concrete, immediate, external one to hold onto while it heals.

Some states are finally listening. California, Montana, West Virginia, and Washington now cover contingency management through Medicaid, and the federal Substance Abuse and Mental Health Services Administration, or SAMHSA, raised the allowable incentive cap to $750 per patient per year in January 2025 — real movement, real money. But it’s fragile money. California’s Medicaid director has to demonstrate the program’s value by the end of this year to justify continued federal funding, which means the treatment with the best evidence in stimulant recovery is currently on trial, one budget cycle from being cut, in a way naltrexone never has to be.

Why the craving comes back harder in week five, not week one

If you’re a few weeks off methamphetamine and the craving is hitting harder now than it did the day you quit, that’s not you losing ground. For many people, the urge to use meth doesn’t fade steadily after stopping — it can build for weeks before it starts to ease, peaking well after the physical withdrawal is over, a documented pattern researchers call incubation of craving. New neuroscience helps explain why. A 2026 study in Neuron looked at brain cells in the prefrontal cortex — the region behind your forehead that handles impulse control and decision-making — and found that small local regulator cells there, called interneurons because they manage nearby neurons instead of sending signals long-distance, behave differently depending on how far out from your last use you are. Two types, named for the proteins they contain (somatostatin and parvalbumin), seem to drive craving through separate mechanisms in early withdrawal versus weeks later. The practical translation: the brain isn’t running one craving process that slowly winds down. It’s running at least two, on different timelines, and the second one can hit after you’ve already told everyone the hard part is over.

That matters because it reframes the moment people are most likely to walk away from treatment. If week five feels worse than week one and nobody warned you that’s expected, it reads as proof the work isn’t working. It’s the opposite — it’s your prefrontal cortex doing something specific, mapped, and temporary, not a verdict on your willpower.

A sentencing law wrote the first draft of this treatment gap

The absence of a stimulant medication isn’t just a scientific accident — it has a policy history. The 1986 Anti-Drug Abuse Act set a 100-to-1 sentencing disparity between crack cocaine, associated with Black communities, and powder cocaine, associated with white communities: five grams of crack triggered the same mandatory minimum as five hundred grams of powder. Congress didn’t touch that ratio for twenty-four years, finally cutting it to 18-to-1 under the Fair Sentencing Act of 2010 — better, never zero, never retroactive for everyone already sentenced under it. For a full generation, the nation’s answer to cocaine wasn’t medicine. It was prison. Opioid deaths later drove billions into medication-assisted treatment and insurance mandates; cocaine and methamphetamine stayed inside that older, punishment-first framework, which is a real reason the pharmaceutical pipeline built for opioids never got built for stimulants.

The outreach gap nobody’s filling

Harm reduction has a structural blind spot here too. Programs built around opioids have a natural front door: someone comes in for naloxone or a fentanyl test strip, and that contact becomes a relationship, sometimes eventually a bridge to buprenorphine. Stimulant users don’t have that front door, according to Filter Magazine’s reporting — there’s no methadone-equivalent to organize outreach around, no daily dosing visit that doubles as a check-in, even as stimulant-involved deaths now rival or exceed opioid-involved deaths in a growing number of states. The result is a population that shows up constantly in overdose data and barely shows up in program design.

None of this means nothing is working. Contingency management works. The 2024 dip in cocaine deaths is real. Naloxone still reverses stimulant-involved overdoses when fentanyl is mixed in, and it’s still free and federally funded in every state that wants it. What’s missing isn’t hope — it’s the decades of pharmaceutical investment that opioids and alcohol got and stimulants didn’t, and a willingness to fund gift cards like they’re medicine, because right now, they’re the closest thing anyone has.

Naloxone still reverses stimulant-involved overdoses when fentanyl is mixed in, and it’s still free and federally funded in every state that wants it.