The Complex Link Between Drugs and Stroke
Stroke, a disease affecting the arteries leading to and within the brain, kills nearly 150,000 Americans annually [1.3.2]. While often associated with age and lifestyle factors, the use of certain drugs—both illicit and prescribed—is a major contributor, especially in younger populations [1.4.4]. A drug-induced stroke can occur through various mechanisms, including sudden increases in blood pressure, the formation of blood clots (ischemic stroke), or bleeding in the brain (hemorrhagic stroke) [1.6.3, 1.3.2]. The risk is not limited to illegal substances; many common medications carry a recognized risk of cerebrovascular events [1.5.2, 1.7.2].
Understanding which drugs pose the greatest threat requires differentiating between types of stroke and considering the specific substance. For hemorrhagic strokes in young adults, amphetamines are associated with an almost five-fold increased risk, a significantly higher risk than that posed by cocaine [1.3.5]. Conversely, cocaine use is strongly associated with both ischemic and hemorrhagic strokes [1.3.5, 1.4.5]. The American Heart Association notes that drug abusers aged 15 to 44 are 6.5 times more likely to have a stroke than non-users [1.4.4].
Illicit Drugs and Their Stroke Mechanisms
Illicit drugs, particularly stimulants, have the strongest and most immediate association with stroke [1.3.4]. Their powerful effects on the cardiovascular system can trigger life-threatening cerebrovascular events even in healthy, young individuals.
Amphetamines and Methamphetamine: Amphetamine use is strongly associated with hemorrhagic stroke, increasing the odds by nearly five times in young adults [1.3.5]. Methamphetamine, a potent amphetamine, is a putative cause of stroke in young people, with a preponderance of hemorrhagic events reported [1.10.1]. These drugs cause a sudden surge in blood pressure, which can lead to spontaneous bleeding in the brain [1.4.4]. Chronic use can also cause vasculitis (inflammation of blood vessels) and damage to vessel walls, further increasing risk [1.4.4, 1.10.1]. A third of individuals who suffer a methamphetamine-related hemorrhagic stroke die [1.10.1].
Cocaine: Cocaine is the illicit drug most commonly associated with stroke and has a strong link to both ischemic and hemorrhagic types [1.4.5, 1.3.4]. Acute use within 24 hours can increase the risk of ischemic stroke by more than six times [1.9.5]. Mechanisms include cerebral vasospasm (narrowing of blood vessels), enhanced platelet aggregation leading to clots, hypertensive surges, and cardioembolism [1.3.3, 1.9.3]. The risk of a hemorrhagic stroke from cocaine is more than doubled [1.4.2].
Heroin and Other Opioids: Stroke associated with heroin is most often ischemic and related to the complications of intravenous use [1.3.4]. Using non-sterile needles can lead to infective endocarditis, a bacterial infection where clumps of bacteria can travel from the heart to the brain, causing a septic embolic stroke [1.3.2, 1.3.4]. Foreign body embolization, where substances used to cut heroin (like talc or cornstarch) travel to the brain, is another risk [1.4.1].
Prescription Medications That Elevate Stroke Risk
While illicit drugs are a major concern, several classes of widely used prescription and over-the-counter (OTC) medications also carry an increased risk of stroke. This risk is often dose-dependent and can be higher in individuals with pre-existing cardiovascular conditions [1.7.2, 1.5.2].
Nonsteroidal Anti-Inflammatory Drugs (NSAIDs): The FDA has strengthened warnings that non-aspirin NSAIDs (like ibuprofen and naproxen) can increase the risk of heart attack and stroke [1.7.2]. The risk can occur within the first few weeks of use and appears greater at higher doses [1.7.2, 1.7.5]. These drugs can increase blood pressure and interfere with the protective effects of low-dose aspirin [1.7.2, 1.6.4]. Certain NSAIDs, like diclofenac, have been associated with a modestly elevated risk of hemorrhagic stroke [1.7.1].
Hormone Replacement Therapy (HRT) and Oral Contraceptives: Oral estrogen therapies, including combined oral contraceptives and HRT, are associated with an increased risk of ischemic stroke [1.2.3, 1.8.2]. A 2022 study in Stroke found that HRT use was associated with a higher risk of any stroke, especially during the first year of use [1.8.1]. The risk is linked to estrogen's role in blood clotting [1.8.2].
Anticoagulants (Blood Thinners): While prescribed to prevent ischemic strokes, anticoagulants like warfarin can increase the risk of hemorrhagic stroke if the blood becomes too thin [1.6.1, 1.6.2]. A brain hemorrhage in a patient taking warfarin can result in about twice as much initial bleeding compared to those not on the drug [1.6.1].
Antipsychotics: Certain antipsychotic medications have been associated with an increased risk of cerebrovascular events, particularly in elderly patients with dementia [1.5.2, 1.6.3].
Comparison of Drug-Related Stroke Risks
| Drug/Drug Class | Primary Stroke Type(s) | Key Mechanism(s) | Relative Risk Factor | Source(s) |
|---|---|---|---|---|
| Amphetamines | Hemorrhagic | Hypertensive surge, vasculitis, direct vascular toxicity | Adjusted odds ratio of 4.95 for hemorrhagic stroke in young adults. | [1.3.5, 1.4.4, 1.10.1] |
| Cocaine | Ischemic & Hemorrhagic | Vasospasm, hypertensive surge, platelet aggregation, cardioembolism | Adjusted odds ratio of 2.33 for hemorrhagic stroke and 2.03 for ischemic stroke. | [1.4.2, 1.9.3, 1.9.5] |
| NSAIDs (non-aspirin) | Ischemic & Hemorrhagic | Increased blood pressure, thrombosis, interference with aspirin | Risk can increase by 10% to 50% or more depending on the drug and dose. | [1.7.2, 1.7.4] |
| Hormone Therapy (Oral) | Ischemic, Subarachnoid Hemorrhage | Prothrombotic effects (promotes clotting) | Increased risk, especially during the first year of use. | [1.2.3, 1.8.1] |
| Anticoagulants | Hemorrhagic | Impaired coagulation (over-thinning of blood) | Can double the amount of bleeding in a brain hemorrhage. | [1.6.1, 1.6.2] |
Conclusion
No single drug can be definitively named the 'most likely' to cause a stroke, as the risk is highly dependent on the drug type, stroke classification, and individual user. However, studies show that stimulant drugs, particularly amphetamines and cocaine, have the strongest association, especially concerning severe strokes in young adults [1.3.4, 1.3.5]. Amphetamines pose a particularly high risk for hemorrhagic stroke, while cocaine is strongly linked to both ischemic and hemorrhagic events [1.3.5]. Among prescription drugs, NSAIDs, oral hormone therapies, and anticoagulants all carry documented risks that must be carefully managed with a healthcare provider [1.7.2, 1.8.1, 1.6.2]. Awareness of these risks is the first step toward prevention.
For more information, consult resources from the American Stroke Association: https://www.stroke.org [1.4.3]
