The best evidenced treatment for stimulant addiction is one almost nobody is offered

There is no approved medication for methamphetamine or cocaine addiction. There is a behavioral treatment with better evidence than anything else in the field, it costs very little, and it is barely available. The reasons why are uncomfortable, and so is its biggest weakness.

For opioid addiction there are medications that work and are, in many places, reachable. For stimulants, methamphetamine and cocaine, there is no approved medication at all. Nothing to prescribe.

What does exist is a behavioral treatment with the strongest evidence of anything in the field, which is partly a statement about how little it is up against. It is called contingency management, and the odds are that nobody has ever offered it to you or anyone you know.

What it is

People are paid, in vouchers or small cash-equivalent prizes, for drug-free urine tests. The amounts are modest and they usually escalate with each consecutive negative result, resetting if one comes back positive.

That is the whole intervention. It reads like something that should not work, or worse, like paying people to behave. The numbers are still better than almost anything else on offer.

What the trials show

A review of reviews on stimulant use disorder found pooled odds ratios of about 2.29 for abstinence at twelve weeks and 2.22 at the end of treatment. Roughly double the odds, against comparison conditions.

A 2025 health technology assessment pooling cocaine trials found a moderate effect, a standardized mean difference of 0.65 with a confidence interval of 0.44 to 0.87.

A 2026 meta-analysis in people using both stimulants and opioids found the longest run of continuous abstinence from both extended by an average of 1.42 weeks, confidence interval 0.77 to 2.08. It held for people on buprenorphine and on methadone.

An extra week and a half of abstinence is not a cure and nobody should present it as one. In a condition with no medication and few options, it is a real effect produced cheaply.

The weakness

Here is the part usually left out of enthusiastic write-ups, and it is the most important thing on this page.

The effect has not been shown to survive the incentives stopping. The 2025 assessment looked at trials that followed people with urine testing at nine to twelve months, and none of them found a persistent effect on abstinence after the intervention ended.

Note which claim that is. No trial finding a lasting effect is not the same as trials establishing there is none, and these are the same low-certainty trials as everything else here. But there is no positive evidence that the abstinence outlasts the vouchers, and a treatment is better described by what has been shown than by what is hoped for.

So contingency management reliably produces abstinence while it is running, and the gains have not been shown to outlast it. That is a serious limitation and it shapes what the treatment is for: buying a stretch of stability inside which other things, housing, treatment for what sits underneath, repairing relationships, have room to happen. Not a fix on its own.

Consistent with that, the review of reviews found the highest abstinence and retention came from combining it with the community reinforcement approach, which works on the rest of someone's life. The incentives open a window. Something else has to be built inside it.

Two more honest notes on the evidence. The 2025 assessment rated certainty as generally low across most outcomes, mainly from high risk of bias in individual trials. And the 2026 review flagged the absence of fentanyl-specific data as an urgent gap, which matters because the drug supply people are actually using has changed faster than the trials have.

Why it is so rarely offered

Three reasons, and only one is about evidence.

The moral objection. Paying people not to take drugs offends something. It feels like rewarding what should be expected. This objection is not applied consistently: nobody argues that paying for a gym membership corrupts exercise, and no one calls a nicotine patch a bribe. Addiction is treated as a character matter in a way other conditions are not. That double standard runs through who gets care and who does not.

The legal and funding tangle. In some systems, paying patients runs into rules written to stop providers inducing people to use services they do not need. Caps have historically been set low enough to fall under the amounts the trials found effective, which produces the elegant result of a treatment delivered at a dose known not to work.

It is unglamorous. No molecule, no neuroscience, no story. A clipboard, a test, and a voucher.

What to do with this

If you are looking for help with stimulant use, it is worth asking directly whether contingency management is available near you, because it will rarely be offered unprompted. In some regions it is being funded specifically because there is no medication to prescribe.

And if the honest answer where you are is that it does not exist, that is worth knowing too, rather than assuming the absence means it does not work.

Mura does not provide addiction treatment and cannot prescribe or arrange anything. What it can do is be somewhere to talk at the hour when the decision is actually being made, which is usually not during clinic opening times. If you are in crisis, please contact your local emergency services or a crisis line now.

This article is for general information and is not a substitute for professional care. If you are in crisis or thinking about harming yourself, please contact your local emergency services or a crisis line. See crisis lines.