BACKGROUND:
Cocaine and crack cocaine use disorders disproportionately affect socially marginalized populations and are associated with high morbidity, mortality, and low engagement with existing treatment systems. While agonist-based models have profoundly reshaped opioid policy and care, stimulant use disorders are still predominantly addressed through abstinence-oriented, moralizing, or punitive frameworks, with limited public health impact. This situation raises fundamental questions regarding equity, inclusion, and the state’s responsibility toward populations excluded from standard care. The session This organized session uses a supervised cocaine substitution model as a conceptual and practical reference point to explore the political, ethical, and public health conditions required for such an approach. The session examines underlying assumptions about addiction, acceptable risk, and the legitimacy of prescribing controlled substances to mitigate population-level harm. The Swiss regulatory and policy context, which—drawing on long-standing harm reduction and agonist-treatment traditions—already allows, in principle, the medical use of controlled substances within a supervised framework without requiring legislative change. This setting offers a unique lens for discussing governance, institutional trust, and boundary-setting in public health innovation. Experiences from agonist-based and harm reduction programs suggest that such models can reduce exposure to illicit drug markets, improve continuity of care, and reach populations otherwise excluded from treatment. Framing these interventions as public health instruments, rather than exceptional or transgressive clinical measures, appears critical to their political and societal acceptability.

CONCLUSIONS:
Supervised cocaine substitution challenges dominant moral, clinical, and policy narratives surrounding stimulant use. This session invites participants to critically discuss the public health rationale, ethical limits, and political prerequisites of such interventions, using the Swiss context as an illustrative case where regulatory feasibility precedes political consensus. The goal is to foster an open, international dialogue on how far public health systems can—and should—go in addressing stimulant use disorders through equity-oriented, evidence-informed innovation.