The potent opioid fentanyl might be getting the lion's share of notoriety in recent years, but Santa Clara County — and California — have a much bigger drug-related killer: methamphetamine.

Methamphetamine-related deaths account for more than 50% of all drug-related fatalities in the county, far surpassing deaths from opioids, according to Santa Clara County Medical Examiner-Coroner data.

The dangers of methamphetamines, a cheap, powerful stimulant commonly known as meth, aren't just related to overdose; the drug is responsible for a voluminous increase in heart-failure deaths among younger, middle-aged people due to years of abuse, researchers said.

Between Jan. 1, 2018, and July 17, 2022, the county saw 1,339 drug-related deaths. Of those, 582, or 43.47%, were caused by methamphetamine alone. An additional 204 deaths or 15.24% were caused by a combination of methamphetamine and opioids, mainly fentanyl.

By contrast, opioids alone caused 23.3% of fatalities during the same time period. All other drug-related deaths accounted for 18%, according to the coroner's data.

Meth has consistently dominated, in large part because it is inexpensive and ubiquitous, according to the Executive Office of the President's Office of National Drug Control Policy High Intensity Drug Trafficking Areas Program 2021 Report to Congress.

Mira Parwiz, division director in the County of Santa Clara Behavioral Health Services Department, said meth has been a problem for a number of years in the county.

"Among all the drug-substance use issues in Santa Clara County, meth seems to be the number one issue. And the problem with meth is that it's growing and that it is very, very addictive. And secondly, it's readily available. Third, it's that we don't have any specific treatment for it," she said.

Although news stories in recent years have implicated methamphetamine use among tech workers to cope with long hours, Parwiz said there's no single demographic being affected by methamphetamine. People of all ages, genders and economic backgrounds are dying due to methamphetamine. Even fetuses.

In 2021 the county recorded three deaths of fetuses in the womb who succumbed to methamphetamine toxicity as a result of their mothers' usage.

Among racial and ethnic groups, deaths related to methamphetamine occurred among people who are white, Black, Polynesian or Hispanic at rates in greater proportion to their population in the county. Whites accounted for 46.52% of methamphetamine-related deaths — 1.6 times their percentage in the county's population, according to the 2021 U.S. Census estimates. Blacks accounted for 7.39% of the deaths, or 2.5 times their proportionate census population. Polynesians accounted for 1.73% of deaths — nearly 3.5 times their proportionate census population.

Hispanics accounted for 34.34% of deaths, representing nearly 1.4 times their proportionate population. Only Asians and Native Americans had death rates below their proportionate populations: at 0.2 times and 0.3 times deaths, respectively, according to the coroner and census 2021 data.

Meth also kills more men: more than three quarters of the county's methamphetamine-related deaths, the coroner's data shows.

The largest age group dying from meth were the middle-aged: 31.30% of those who died were 51 to 60 years old; 23.04% were ages 41 to 50; and 16.96% were 61 years and older, according to the corner's data.

Persons ages 31-40 accounted for 17.83% of the deaths; those aged 21-30 accounted for 9.13%, and young people ages 11 to 20 represented the smallest group of fatalities at 0.43%. Some of those deaths were caused by a mix of methamphetamine and fentanyl or other opioids, which are sometimes accidentally ingested when meth has been cut with fentanyl, according to the Office of National Drug Control Policy report.

More than overdoses

While an overdose from methamphetamine may be commonly assumed to be killing people, chronic meth use actually leads to more insidious causes of death: gastric hemorrhage, cardiac disease, aneurysm, ruptured aorta, congestive heart failure, brain hemorrhage and heart attack, according to the coroner's data.

Methamphetamine causes cardiac issues by triggering blood vessel spasms and life-threatening spikes in blood pressure, the study noted. It can increase plaque in the arteries and rewire the heart's electrical system.

Prolonged methamphetamine use is also associated with a severe form of dilated cardiomyopathy, in which the weakened heart muscle becomes enlarged and can't pump adequate blood, according to a July 2021 study led by Dr. Susan X. Zhao, a cardiologist at Santa Clara Valley Medical Center, which researched the socioeconomic burden of methamphetamine-related heart failure hospitalizations in California over a decade through 2018.

Heart failure usually occurs in adults over the age of 60. Yet, methamphetamine is the leading cause of heart failure in people who are younger than 65 years old, the research, which was published in the American Heart Association journal "Circulation: Cardiovascular Quality and Outcomes," found.

Methamphetamine-related heart failure hospitalizations rose a staggering 585% between 2008 and 2018 in California, compared with a 6% decline of heart-failure hospitalizations unrelated to methamphetamine use, the study noted.

Of the methamphetamine-related heart-failure patients, 94% were under age 65, with more than half being between ages 35 and 54. That's not likely to change as younger meth users age. The average age of new methamphetamines users is 23, according to the 2017 U.S. National Survey on Drug Use and Health.

Methamphetamine-related heart conditions are taking a huge economic toll. Hospital stays are several days longer for meth patients, who also require more medical procedures, the researchers said.

The costs for methamphetamine-related heart failure in California ballooned from $41.5 million in 2008 to $390.2 million in 2018 — an 840% increase — the researchers found, compared to an 82% increase in costs for all heart failure-related hospitalizations.

Will a new treatment program be the answer?

Solving the meth problem is difficult. While there are many interventions for people who are addicted to opioids, there are no Food and Drug Administration-approved medications for stimulant-use disorders such as methamphetamine addiction, the researchers noted.

Parwiz, who runs a county substance-abuse-treatment program that treats about 600 to 700 patients annually, said there are no stand-alone treatment facilities for meth users. Many of the people who are in the opioid treatment programs report they also have methamphetamine addictions, she said.

"If you have a heroin addiction, we do have drugs like methadone for that treatment available, (and) suboxone, etc. But none of those are really effective on meth if you're just using meth by itself," Parwiz said.

There is hope for medication-related treatment.

"They're hoping in the next two, three years there might be some medication available," she said.

There are also promising non-medication interventions, which some researchers say can help control stimulant addiction. "Contingency management" has been proven to reduce substance-abuse, according to research.

Contingency management rewards people with incentives such as prizes or vouchers, which are exchangeable for goods and services each time the client achieves a desired behavior, such as a negative drug test. If the behavior is not achieved, the client starts at the beginning of the incentive program, according to a May 2022 brief by the California Health Care Foundation.

A 2021 study published in the Journal of the American Medical Association found that in 18 of 22 studies, contingency management significantly reduced stimulant use. Of the programs' participants, 75.8% had a better outcome than the mean outcome in the control group, the California Health Care Foundation report noted.

A separate April 2018 study of contingency management among veterans at the Department of Veterans Affairs found the average abstinence rate, based on negative test results, exceeded 90%.

Now California is poised to become the first state in the nation to pilot a contingency management program. In December, California received authorization through a Medicaid waiver from the federal Centers for Medicare and Medicaid Services to include contingency management as a service.

The pilot program, which begins this fall, will be covered by Medi-Cal under the California Advancing and Innovating MediCal (CalAIM) initiative.

The California legislature also sought to make contingency management a permanent part of Medi-Cal payments. In June 2021, legislators approved Senate Bill 110, The Recovery Incentive Act, which would have assured that contingency management programs don't violate anti-kickback laws and would have required Medi-Cal to cover the cost of contingency management programs.

Gov. Gavin Newsom vetoed the bill on Oct. 8, 2021, however, saying the 2021-22 state budget includes funding to support the Medi-Cal benefit contingency management pilot program through March 2024. The program should be evaluated before permanently extending the Medi-Cal benefit, Newsom said, explaining his veto.