Guest Editorial – A Heartbreaking Face of the Stimulant Crisis: The Cardiac Toll of Stimulant Use

By Nicolas Garel, MD, MSc, FRCPC, and Paola Lavin, MD, MSc

Stimulants and methamphetamine-related emergencies are no longer confined to the pages of public health reports, they are unfolding daily in hospitals and emergency departments across North America. Clinicians increasingly encounter young adults experiencing chest pain, arrhythmias, or new cases of heart failure with no prior cardiac history but with a positive toxicology screen for (meth)amphetamine. This clinical pattern, once rare, has become alarmingly common.

A new national cohort analysis by Garel and colleagues quantifies what frontline physicians have long observed. Using high-dimensional propensity score matching on more than 137,000 patients with substance use disorders (SUD), the authors compared the cardiovascular impact of stimulant use disorder (StUD) with non-stimulant SUD. Their findings showed that individuals with StUD had a 37% higher risk of major adverse cardiac events (MACE), including myocardial infarction, stroke, heart failure, or death, as compared with patients with non-stimulant SUDs. Even after rigorous adjustment for demographic and clinical confounders, mortality remained 23% higher.¹ These results demonstrate that stimulant use carries distinct and substantial cardiovascular risk, even within an already vulnerable population.

An Evolving Drug Crisis

Methamphetamine itself has changed profoundly. The DEA National Drug Threat Assessment 2025 reports that approximately 98% of methamphetamine seized in the US is now produced using the phenyl-2-propanone, which yields higher purity and potency than ephedrine-based synthesis.² At the same time, methamphetamine is increasingly adulterated with fentanyl. The DEA laboratory analyses show that nearly four of every ten pills contain potentially lethal fentanyl doses.³ These shifts have expanded both the potency and lethality of the modern methamphetamine supply.

Epidemiologic data confirm the magnitude of this evolution. CDC statistics estimated that “[a]mong 309,274 overdose deaths during January 2021–June 2024 in 49 states and DC, 59.0% involved any stimulant, 31.2% involved methamphetamine, and 30.0% involved cocaine; 3.8% involved both methamphetamine and cocaine.”⁴ Meanwhile, the SAMHSA National Survey on Drug Use and Health (2023) documented sharp increases in methamphetamine use disorder among adults aged 26–49 and those over 50, even as adolescent use stabilizes.⁵ Taken together, these data depict a stimulant crisis that is expanding across age groups and geographic regions, with cardiovascular complications as one of its most devastating consequences.

The Biology Behind the Crisis

Our findings are reinforced by converging evidence from basic science, pathology, and clinical observation. Schwarzbach et al characterized methamphetamine-associated cardiovascular disease as a multifactorial and chronic toxic process driven by endothelial injury, mitochondrial dysfunction, oxidative stress, and inflammation, which are pathways that accelerate both structural heart damage and atherosclerosis.⁶ Kevil and colleagues further demonstrated that methamphetamine disrupts nitric oxide signaling, increases reactive oxygen species, and destabilizes vascular homeostasis, leading to vasospasm, thrombosis, and arrhythmias.⁷ These mechanisms explain why methamphetamine users often develop cardiac dysfunction at a young age, even in the absence of traditional risk factors.

Clinical data complement these mechanistic insights. Tobolski et al summarized that methamphetamine use is consistently linked with heart failure, ischemic stroke, and pulmonary hypertension, and emphasized that these conditions frequently emerge in otherwise healthy adults.⁸ The overlap between addiction, neurotoxicity, and cardiovascular injury places methamphetamine at the nexus of psychiatry, cardiology, and public health.

Clinical Implications

For psychiatrists and addiction medicine physicians, these findings demand a broader view of what StUD treatment entails. We routinely monitor liver enzymes in alcohol use disorder and respiratory function in opioid use disorder. Similarly, cardiovascular assessment must become standard practice for patients with StUD. At minimum, this includes a thorough cardiovascular and family history, focused physical examination, and electrocardiography, while selectively considering echocardiography or cardiac biomarkers. These evaluations should occur early and not be contingent on abstinence.

Equally essential is timely collaboration with cardiology. Stimulant-associated cardiomyopathy could stabilize or partially reverse with abstinence and appropriate therapy but only if detected before irreversible damage occurs. Delays lead to recurrent admissions and early mortality. Patient education is a crucial, often neglected, element. Many patients interpret palpitations or shortness of breath as transient effects rather than early cardiac warning signs. Integrating brief, visual, and accessible educational materials into treatment programs can bridge this gap and encourage timely care-seeking.

Policy and Systems Response

The White House Methamphetamine Implementation Report (2024) prioritizes prevention and treatment access but offers little discussion of cardiovascular outcomes. Our data underscore the urgency of closing that gap.¹ Treatment guidelines should incorporate routine cardiac screening into stimulant care protocols. Dedicated research funding is also needed to track long-term cardiovascular outcomes among individuals with StUD and evaluate integrated cardiology and addiction care models.

At the systems level, housing instability remains a powerful determinant of cardiac risk. Expecting a patient living on the street to monitor blood pressure or adhere to beta-blocker therapy is unrealistic. Housing-first programs, case management, and co-located cardiology and addiction clinics can improve continuity and survival.

Moving Forward

The parallels to the opioid epidemic are striking. Just as the rise of fentanyl transformed the overdose landscape, the emergence of high-purity, synthetic methamphetamine has transformed cardiovascular morbidity. Addiction medicine must evolve again by integrating cardiovascular care into the core of stimulant treatment.

Our study provides a quantifiable warning: within the SUD population, stimulant use is associated with a markedly higher risk of major cardiac events and mortality.¹ The challenge now is translating that evidence into clinical and policy action. As methamphetamine continues to evolve chemically, our treatment systems must evolve biologically and organizationally. The next frontier in addiction medicine is not only reducing or stopping stimulant use, it is preserving life, one heartbeat at a time.

Dr. Nicolas Garel is a psychiatrist and clinician-scientist at the Centre Hospitalier de l’Université de Montréal (CHUM). He is an assistant professor in the Department of Psychiatry at the Université de Montréal and adjunct professor in the Department of Psychiatry and Behavioral Sciences at Stanford University. Dr. Garel completed his medical degree at the Université de Montréal, followed by his psychiatry residency and clinician-scientist fellowship at McGill University, and later pursued advanced training in research and addiction medicine at Stanford University. His research program focuses on innovative interventions for treatment-resistant mood disorders and substance use disorders.

Dr. Paola Lavin is an associate researcher at the neuroscience and psychiatry axis at the Centre de Recherche du Centre Hospitalier de l’Université de Montréal (CR-CHUM). Her current work centers on developing and evaluating integrated treatments for individuals with co-occurring mood disorders and substance use disorders.

References

1. Garel N, Greenway KT, Lavin P, et al. Increased risks of major cardiac adverse events in stimulant use disorder as compared with other substance use disorders: a propensity-score matching cohort study. J Addict Med. 2025;19(5):599-604. doi:10.1097/ADM.0000000000001461.

2. Drug Enforcement Administration. 2025 National Drug Threat Assessment. https://www.dea.gov/documents/2025/2025-05/2025-05-13/national-drug-threat-assessment. Published May 2025. Accessed January 12, 2026.

3. Drug Enforcement Administration. One Pill Can Kill. https://www.dea.gov/onepill. Updated December 1, 2025. Accessed January 12, 2026.

4. Tanz LJ, Miller KD, Dinwiddie AT, et al. Drug overdose deaths involving stimulants—United States, January 2018–June 2024. MMWR Morb Mortal Wkly Rep. 2025;74(32):491–499. doi: 10.15585/mmwr.mm7432a1.

5. Substance Abuse and Mental Health Services Administration. Key substance use and mental health indicators in the United States: results from the 2023 National Survey on Drug Use and Health. https://www.samhsa.gov/data/sites/default/files/reports/rpt47095/National%20Report/National%20Report/2023-nsduh-annual-national.pdf. HHS Publication No. PEP24-07-021. NSDUH Series H-59. Published 2024. Accessed January 12, 2026.

6. Schwarzbach V, Lenk K, Laufs U. Methamphetamine-related cardiovascular diseases. ESC Heart Fail. 2020;7(2):407–414. doi:10.1002/ehf2.12572.

7. Kevil CG, Goeders NE, Woolard MD, et al. Methamphetamine use and cardiovascular disease. Arterioscler Thromb Vasc Biol. 2019;39(9):1739–1746. doi:10.1161/ATVBAHA.119.312461.

8. Tobolski J, Sawyer DB, Song SJ, Afari ME. Cardiovascular disease associated with methamphetamine use: a review. Heart Fail Rev. 2022;27(6):2059–2065. doi:10.1007/s10741-022-10261-7.