Is a History of Substance Use Disorder a Disqualifier for Heart Transplantation?

Patients with heart failure who need a heart transplant undergo extensive assessment, including psychosocial evaluation, to determine whether the survival and recovery potential weighs in their favor. While active substance use disorder has been cited as a temporary contraindication or, at the very least, a reason for caution in listing a patient as a heart transplant candidate [López-Azor JC. Eur Heart J Qual Care Clin Outcomes 2026; 12:134-135], transplant considerations are not simple yes or no questions. 

“A referral for heart transplant becomes an eventual reality for a lot of patients [with heart failure],” said Angela Velleca, RN, BSN, clinical operations manager for the Heart and Lung Transplant Programs at the Cedars-Sinai Smidt Heart Institute in Los Angeles, who discussed transplant considerations during a presentation at the 2026 Annual Meeting of the American Association of Heart Failure Nurses. “Once advanced heart disease therapies reach an end point and a referral for heart transplant evaluation is considered, understanding the risks of transplant versus the benefits is usually the [first step].”  

Patients who are referred for heart transplantation are often older individuals with various comorbidities. While the transplant team must carefully consider a multitude of factors, including age, preexisting conditions, and how immunosuppression will affect the management of comorbidities, advances in transplant science and technology have significantly expanded the donor and recipient pools. Chronologic age alone is no longer a disqualifier for heart transplantation, as carefully screened patients who are older than 70 years can have survival and morbidity outcomes comparable to younger recipients [Peled Y. J Heart Lung Transplant 2024; 43:1529-1628.e54]. Obesity, glycemic control, renal or liver dysfunction, and frailty are also relative contraindications that must be considered along with other factors. Ultimately, eligibility for transplantation relies on an individual's unique health status, including their mental health profile.

“The psychosocial assessment can be one of the more challenging parts of the transplant evaluation,” Velleca noted. “These comprehensive evaluations focus on social support, adherence to care regimens, and potential mental health concerns. In our program, we have a dedicated social worker and psychiatry [specialists] to evaluate our patients. Many programs utilize validated tools, such as The Stanford Integrated Psychosocial Assessment for Transplant (SIPAT) score. The goal is not to deny the transplant but to understand the potential barriers that patients may have, so that we can strategize about what support to provide to patients and families.” 

When it comes to substance use disorder, the evaluation process can become even more complicated, due to the fluidity of substance abuse. The guidelines recommend screening patients for substance use disorder and identifying the criteria for transplant candidacy, which include abstinence from all substances for at least 6 months or enrollment in addiction services, where available. “Often the toxicology screen performed at the time of the evaluation may be the first indication to the team that there is a problem with substance use,” Velleca said. “The guidelines recommend a minimum of 6 months of abstinence prior to transplant listing. Patients with a history of substance use disorder often require abstinence surveillance.”

Medicinal marijuana use, which is legal in several states, represents a gray area, Velleca noted. Discontinuing marijuana is challenging when patients use it as an alternative to opioids to treat chronic pain. However, because marijuana has direct effects on the heart, similar to alcohol and smoking, providers should discuss these implications with patients. Moreover, insurance plans may require a period of abstinence before moving forward with the transplant listing. “We educate patients to consider discontinuing [marijuana],” Velleca added. “We also ensure that they are not smoking marijuana. But some patients prefer to use it for sleep or anxiety, and if the psychosocial evaluation does not indicate substance use disorder, then we do not monitor the drug further after the initial evaluation. All other transplant programs at our center had adopted this protocol and the heart team was the last to move forward with it. I think it is important that we approach this as a comprehensive transplant center protocol rather than everyone in our center doing something different.” 

Although the gray area of substance use in transplant candidates poses clinical and ethical dilemmas, a history of substance use disorder may not necessarily predict an unfavorable outcome in patients undergoing heart transplantation. In a study conducted at Cedars-Sinai, Velleca and colleagues reviewed the outcomes of heart transplantation from 2010 to 2024 in 67 transplant recipients with substance use disorder and compared them to a matched control cohort of 134 recipients with no history of substance use. The study showed that recipients with substance use disorder experienced more missed appointments, had higher rates of non-adherence to medication, and had increased rates of antibody-mediated rejection compared to the control cohort (Chang D et al. J Heart Lung Transplant 2026; 45:613). Importantly, Velleca remarked, patients with 1 year of abstinence or less at the time of listing were at a significantly higher risk of drug use recidivism (46.7%) compared with those who had longer periods of abstinence (7.7%), indicating that recent substance use, rather than a remote history, was the strongest predictor of substance use relapse. 

In terms of survival outcomes, the study showed that a history of substance use did not predict lower 1-year survival rates, suggesting that enhanced monitoring may be a better strategy than exclusion. Velleca mentioned that the team is planning to reexamine the outcomes over a longer period of time to get a clearer picture of the survival trends in this population. 

In evaluating candidacy, the transplant team should “align medical suitability with psychosocial readiness, support infrastructure, and patient goals, to guide the best path forward,” Velleca concluded. “No single factor should determine candidacy.” Given the complexity of the transplant evaluation process, shared decision-making and a multidisciplinary approach are critical tools for improving patient-centered care.