Polysubstance Use and the Current Overdose Epidemic
By Tanisha Taneja
In recent years, polysubstance use, or the use of two or more drugs together, has become a defining feature of the overdose crisis in the United States. Although polysubstance use includes a variety of substance combinations, co-use of opioids and stimulants in particular has been a major driver of overdose deaths. Between 2021-2024, approximately 43% of all overdose deaths in the United States involved co-use of stimulants and opioids. Increases in polysubstance use have also occurred as new adulterants, such as xylazine and medetomidine, regularly enter the drug supply.
As polysubstance use continues to drive overdose deaths in the United States, it is important to consider how the country’s treatment infrastructure is equipped to deliver the type of comprehensive care that is responsive to today’s overdose crisis.
Polysubstance Use Related Gaps in the Current Treatment Infrastructure
Many treatment programs have historically operated using single-substance models of care, rather than addressing polysubstance use in an integrated manner. National practice guidelines note that polysubstance use should not disqualify patients from being offered medications for opioid use disorder (MOUD), such as methadone and buprenorphine, which are highly effective treatments for opioid use disorder. However, individuals with opioid use disorder and co-use of another substance can be less likely to initiate or continue medications for opioid use disorder. Some researchers have suggested this may be driven by gaps in clinician training on treating polysubstance use, clinician preferences for abstinence-based models of care, and stigma toward patients using multiple substances. Additionally, there are no FDA-approved medications for stimulant use disorder, leaving clinicians with limited pharmacological options for treating this common component of polysubstance use. Treating polysubstance use can also require unique considerations for clinicians as different substances can produce opposing effects that make patterns of use and withdrawal more difficult to identify, such as the sedation associated with opioids and the increased energy associated with stimulants.
While there is a lack of medication options for stimulant use disorder, contingency management has emerged as an evidence-based behavioral intervention. Contingency management uses incentives, such as gift cards, prizes, or other valued items, to reinforce behaviors that are aligned with treatment goals, such as abstaining from drug use. Contingency management for individuals with stimulant use disorder has been associated with abstinence from stimulants as well as improvements in treatment retention, adherence to medication for other co-occurring conditions, and secondary drug and alcohol abstinence. However, uptake of contingency management has been slow, in part due to federal funding limitations.
Opportunities to Enhance the Treatment Infrastructure to Address Polysubstance Use
Opportunity #1: Integrate contingency management within settings that treat opioid use disorder.
Research has demonstrated that contingency management is associated with improved treatment outcomes for individuals with co-occurring stimulant use and opioid use disorders receiving MOUD. Given the prevalence of stimulant and opioid co-use, scaling contingency management within settings that already treat opioid use disorder represents a promising strategy.
States can consider using the federal Substance Abuse and Mental Services Administration’s (SAMHSA) State Opioid Response (SOR) grant program as a funding source to implement contingency management services in these settings. For example, Rhode Island has used SOR funds to help opioid treatment programs offer contingency management to adults receiving MOUD with co-occurring stimulant use disorder. In 2025, SAMHSA raised the annual cap on contingency management incentives funded by its grants from a value of $75 to $750 per patient per year, creating more opportunities for states to provide these services through initiatives like SOR.
Additionally, five states received approval from Centers for Medicare & Medicaid Services (CMS) between 2021-2025 to cover contingency management services through Medicaid Section 1115 demonstration waivers. For example, California’s waiver covers a 24-week contingency management program for Medicaid beneficiaries, allowing eligible participants to earn up to $599 in incentives. However, the feasibility for additional states to obtain federal approval for Medicaid coverage of contingency management services is currently uncertain.1
States may also consider leveraging opioid settlement funds to support contingency management implementation. For example, Michigan has invested settlement dollars in a contingency management pilot. Michigan’s pilot encourages providers to offer MOUD for patients receiving contingency management with co-occurring opioid use disorder.
Opportunity #2: Ensure workforce training and development opportunities reflect the current overdose epidemic.
Despite the scale of the nationwide opioid crisis, many physicians outside of addiction medicine specialties do not receive adequate training on treating patients with substance use disorder, limiting access to care. Calls for graduate medical education programs to provide more training across the range of specialties that can treat substance use disorder (e.g., emergency medicine, internal medicine, family medicine, pediatrics, psychiatry, OBGYN) have grown in recent years. Subsequent efforts from graduate medical education programs to increase addiction-focused training opportunities should be informed by the nature of today’s overdose crisis, with curricula that cover approaches to polysubstance use screening, assessment and treatment.
For active clinicians, the Agency for Healthcare Research and Quality’s behavioral health & primary care integration webpage has several resources related to polysubstance use treatment that healthcare organizations can use to inform workforce development.
Opportunity #3: Expand the research base on approaches to polysubstance use treatment.
While polysubstance use has become a defining driver of overdose deaths, research on the best practices for treating polysubstance has remained limited. For example, clinicians lack guidelines on which specific MOUD should be favored for individuals with co-occurring opioid and stimulant use. As Howell et al. suggest, new studies comparing the effectiveness of different MOUD options among individuals co-using opioids and stimulants and looking at outcomes across key subgroups (e.g., by the primary drug individuals are using, use of methamphetamine vs. cocaine) can help fill this gap.
Additionally, as new models for integrated behavioral health care emerge, research on the extent to which they are meeting the needs of individuals with polysubstance use is needed. Certified Community Behavioral Health Centers (CCBHCs), one of the fastest growing models for integrated behavioral health care,2 could be a practical starting point for this research. CCBHCs are a federally designated model of care for clinics meeting criteria for integrated substance use, mental health and physical health services. There has been broader research on the services provided by CCBHCs, however, little of it has focused specifically on polysubstance use.
Footnotes
- The CMS approval process has stalled for two states with Medicaid 1115 waiver applications seeking to cover contingency management under the current federal administration. Rhode Island has since withdrawn its request to CMS for a contingency management pilot and Michigan’s negotiations with CMS on its Medicaid 1115 waiver application have been ongoing since April 2024. It is unclear whether contingency management or other application components have specifically delayed these negotiations.
- Over 500 CCBHCs currently operate across 46 states.
Tanisha Taneja is a senior at Johns Hopkins majoring in Public Health Studies. Her research interests include, substance use disorder policy, overdose prevention, and health equity, with a particular focus on working with marginalized communities. She is drawn to the intersection of clinical medicine and policy, leveraging evidence-based research to inform policies that create real, sustainable change.