Stimulants are involved in a rising share of overdose deaths, but stimulant use disorder has no FDA-approved medication, leaving a treatment system built around drugs with none to offer.
Key Takeaways
- Stimulants are now central to the overdose crisis: Methamphetamine and cocaine were each involved in roughly a third and a quarter of 2023 overdose deaths, and stimulants figured in a majority of deaths overall. The crisis long framed as an opioid story is increasingly a stimulant one.
- There is no medication to prescribe: Unlike opioids and alcohol, stimulant use disorder has no FDA-approved medication, so a treatment system organized around prescribing has nothing pharmacological to offer. The central tool of modern addiction care does not exist here.
- The supply makes it deadlier: A large share of stimulant deaths also involve fentanyl, often unknowingly, so a stimulant user faces an opioid overdose risk they never chose. Naloxone addresses the opioid but not the stimulant.
- The infrastructure gap is the opportunity: Behavioral interventions work but are underbuilt and hard to fund, and the FDA has urged development of stimulant medications. The providers who build stimulant-specific capacity now are meeting a large, underserved need.
America’s overdose crisis has always been narrated as an opioid story, and for good reason: opioids drove the death counts to their staggering peaks, and the arc from prescription pills to heroin to fentanyl is the through-line of a quarter-century of American public health failure.
But the story has quietly acquired a second main character, and the treatment system has been slow to write it in. Stimulants, methamphetamine and cocaine, are now involved in a large and rising share of overdose deaths, and unlike the opioid crisis, which the field eventually met with a set of effective medications, the stimulant crisis arrives at a system that has, quite literally, nothing to prescribe.
That absence is the defining fact. Modern addiction medicine is built around medication: methadone and buprenorphine for opioids, naltrexone and acamprosate for alcohol, a clinical model that assumes a drug to reach for. For stimulant use disorder, no such medication exists, because none has been approved despite decades of trials, and a treatment system organized around prescribing finds itself facing a growing population of patients for whom the central tool of the field is simply unavailable. What opens up is a gap between how large the crisis has grown and the capacity to treat it, one the field is only beginning to confront.
How Central Stimulants Have Become
By the numbers, the crisis has moved well beyond opioids alone. According to the Centers for Disease Control and Prevention, nearly 35,000 overdose deaths in 2023 involved psychostimulants like methamphetamine, about a third of all overdose deaths that year, and nearly 30,000 involved cocaine, about 28 percent. Researchers analyzing surveillance data from 2021 through mid-2024 found that stimulants were involved in close to 60 percent of overdose deaths, a share that would have been unthinkable at the start of the fentanyl era. Whatever the crisis is called, stimulants are now central to it.
That trajectory is as striking as the totals. A 2025 study in the journal Substance Use and Misuse tracking methamphetamine and cocaine overdose deaths from 1999 through 2023 documented the sustained climb that turned stimulants from a secondary concern into a primary driver of mortality. There is a note of qualified hope in the most recent figures, since provisional data shows stimulant-involved deaths finally easing alongside the broader decline in overdoses. But they are easing from a very high plateau and remain deeply embedded in the overall picture, which means the demand for treatment is not going away even as the death counts edge down.
Why the Supply Makes Stimulants Deadlier
Part of what has made the stimulant crisis so lethal is not the stimulants themselves but what increasingly travels with them. A large share of stimulant-involved overdose deaths also involve opioids, most often illicitly manufactured fentanyl, and among the states reporting detailed data, close to half of 2023 overdose deaths involved both an opioid and a stimulant together. Some users deliberately combine the drugs, but many do not know the fentanyl is there at all, because a contaminated supply has folded the deadliest opioid into products sold as pure cocaine or methamphetamine.
This creates a clinical trap the field has learned to recognize. A person who uses only stimulants, and who has never knowingly taken an opioid, can suffer an opioid overdose from a tainted dose, and the standard response does not fully fit: naloxone reverses the fentanyl but does nothing for the stimulant, the same partial-rescue problem the field has confronted with sedative adulterants like xylazine woven into the drug supply. The adulterated-supply dynamic means that treating stimulant use disorder is now inseparable from managing an opioid overdose risk the patient may not even know they carry, and it complicates every part of the clinical response, from screening to overdose education to what a clean drug test actually means.
The Missing Medication
For a treatment system, the hardest part of the stimulant crisis is the empty formulary. For opioid use disorder, a clinician can prescribe a medication that reduces cravings, blocks the drug’s effect, or both, and build a treatment plan around it. For stimulant use disorder, there is no equivalent. Dozens of compounds have been tested, and while some have shown modest effects in trials, none has met the bar for FDA approval, and treatment response rates in the studies are generally low and complicated by high dropout. The clinician facing a methamphetamine or cocaine patient has counseling and behavioral tools, but nothing to write on a prescription pad.
The clinical picture differs from opioids in ways that compound the gap. A stimulant overdose is a cardiovascular emergency, not the slowed breathing of an opioid overdose, so it presents differently and naloxone does not touch it. Heavy methamphetamine use can produce a persistent, sometimes lasting psychosis that lands patients in psychiatric crisis rather than a detox bed, and there is no medically managed withdrawal protocol comparable to the ones that ease opioid or alcohol detoxification. A treatment system whose acute infrastructure, from its detox units to its crisis response, was designed around the pharmacology of opioids and alcohol finds that stimulants do not fit the template, which leaves both the acute and the ongoing sides of care improvising.
Its most effective behavioral tool, and the one with the strongest evidence, is contingency management, the approach that provides tangible incentives for verified abstinence, which Acuity has examined as both a proven intervention and a persistently difficult one to fund and operate. Its effectiveness for stimulants is well established, yet it remains underused, constrained by funding structures, regulatory caution around paying patients, and the simple fact that the field built its infrastructure, its billing codes, and its clinical habits around medication. Washington has acknowledged the gap directly: in October 2023 the FDA issued its first draft guidance to help drugmakers develop treatments for stimulant use disorder, an unusual step that signaled how wide the therapeutic hole has become. Until that changes, the treatment for the stimulant crisis is behavioral, and the system’s readiness to deliver it at scale is limited.
What the Stimulant Gap Means for Providers
For treatment organizations, the stimulant crisis presents an uncomfortable but genuine opportunity, a large and growing population of need that the medication-centric system is poorly organized to serve. The providers who build real stimulant-specific capacity, which means investing in contingency management and the behavioral therapies that work, training staff to manage a population with different clinical needs than opioid patients, and screening rigorously for the fentanyl exposure that shadows stimulant use, are addressing a demand that most of the field has been slow to meet. The need is documented, the tools exist even where the medication does not, and the competition to serve this population is thinner than its size would suggest.
One strategic caution is that the economics are genuinely hard, harder in some ways than opioid treatment, precisely because there is no billable medication to anchor a treatment episode and because the one intervention that works best sits in an awkward relationship with how addiction care is funded. A stimulant treatment program has to make the behavioral model pay in a system built to reimburse medication, which is a real obstacle and the reason the gap persists. But the population is not shrinking to fit the system’s convenience, and the eventual arrival of a stimulant medication, which the FDA is actively encouraging, would land first and most profitably in the hands of operators who had already built the treatment relationships. The stimulant crisis is the part of the overdose story the field has been slowest to build for, and that lag is precisely where the opportunity sits.
