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As methadone use increases, the potential for methadone-induced cardiotoxicity (MIC) may rise. We describe a case of acute right ventricular (RV) failure leading to cardiogenic shock after methadone overdose. This presentation was followed by full RV recovery. This previously undescribed presentation highlights the challenges involved with MIC, its diagnosis and its management.We present a case of a 75-year-old man who was admitted to an Australian tertiary emergency department with severe hypotension, wheeze, widespread urticarial rash