Heroin is classified as a Schedule I controlled substance by the United States Drug Enforcement Administration (DEA). This means that heroin is a drug that has no recognized medicinal uses and an extremely high potential for abuse and the development physical dependence.
Heroin is a member of the opiate class; these drugs are derived from substances in the poppy plant. Heroin has a well-deserved reputation of being a significant drug of abuse. It is considered by many to be one of the drugs with the greatest potential for the development of physical dependence (displaying both tolerance and withdrawal syndromes) in individuals who use it.
The major mode of administration for heroin is via injection, although the drug can also be taken in any number of ways. Individuals who have developed physical dependence on heroin are often caught in a downward spiral of continued use to avoid experiencing the symptoms of withdrawal. This cycle of using heroin, experiencing short periods of abstinence that trigger withdrawal symptoms followed by drug-seeking behavior to eliminate the onset of withdrawal symptoms leads to the development of a severe opiate use disorder in many individuals.
The syndrome of withdrawal from heroin can be affected by the length of time someone has abused the drug, the amount of the drug they typically abused, how they took the drug, whether or not they used the drug in combination with other drugs of abuse, and individual variables, such as differences in metabolism, weight, and psychological makeup.
Length of the Heroin Withdrawal Syndrome
According to the two-volume book set Opioids, a general outline of withdrawal from heroin includes some consistencies even though specifics vary from person to person. In heavy users, initial symptoms may begin to appear within 12-24 hours after they discontinue the drug. Some individuals may experience withdrawal symptoms even sooner.
Typical symptoms that appear in the early stages of withdrawal are headaches, nausea, fatigue, jitteriness, nervousness, mild agitation, and cravings. Other symptoms can include muscle aches, vomiting, spasms, runny nose, and watery eyes. Individuals are often depressed, irritable, and anxious.
After the individual experiences the onset of the symptoms, they will typically peak within 1-2 days. Users will often relapse during the initial onset of symptoms or when they reach their peak. Within 3-5 days of discontinuation, the symptoms will begin to become less severe in most cases. There will still be general malaise, aches, pains, irritability, anxiety, cravings, etc., but the symptoms will not be as severe as those experienced in the earlier phases.
Most individuals will experience a significant decline in their distress after seven days. Individuals may still have ongoing issues with depression, apathy, anxiety, loss of appetite, and cravings.
Some individuals will continue to experience issues with mood, motivation, cravings, sensitivity to stress, etc., for some time after they have discontinued heroin. Post-acute withdrawal syndrome, or protracted withdrawal, is a condition that can extend for months and even years. Some sources have identified it as an actual aspect of withdrawal; however, it is most likely related to other psychological issues, and it is not part of the formal withdrawal syndrome. Research studies have never been able to reliably identify such a syndrome as part of the official withdrawal process.
The withdrawal syndrome associated from some drugs, such as alcohol or benzodiazepines, is considered to have potential fatal consequences in individuals who do not seek treatment. The actual withdrawal syndrome associated with discontinuing heroin is not considered to be potentially physically dangerous in most cases.
Why Withdrawing Cold Turkey Is Not Recommended
Even though the actual symptoms that occur as a result of heroin withdrawal are not considered to be potentially physically dangerous, there are a number of other interacting factors that should dissuade anyone with an opiate use disorder from attempting withdrawal without medical supervision.
- Relapse potential during the withdrawal process is extremely high. The quickest way for most individuals to alleviate their distress during the withdrawal process is to take heroin. If an individual is attempting to discontinue heroin and deal with their substance abuse issue, cold-turkey detox is not a method that supports this goal. Numerous failed attempts at recovery can lead to a defeatist attitude, which can only make an individual’s substance use disorder worse.
- The potential to overdose is extremely high during withdrawal. Individuals going through detox from heroin often become extremely emotionally distraught. When an emotionally distraught individual attempts to use a dangerous drug like heroin, there is an increased possibility that the individual will not exercise sound judgment and could overdose as a result of using too much of the drug. While the withdrawal symptoms from heroin are not considered to be potentially fatal in most cases, a heroin overdose has a serious potential of producing a fatality.
- The potential for making other bad choices or having accidents is extremely high. During the withdrawal process, many individuals become confused, anxious, depressed, cannot concentrate, and have serious issues with judgment. Individuals in these situations are at an extreme risk for making other bad choices that can include potential self-harm (e.g., sharing needles during a relapse, getting heroin from untrustworthy sources, etc.) or becoming suicidal. They also are at significant risk for being involved in accidents.
- Some of the secondary issues associated with withdrawal symptoms can be dangerous. A number of complications can occur in individuals who are withdrawing from heroin as a result of the symptoms they experience. For instance, individuals undergoing heroin detox often have issues with appetite loss, nausea, vomiting, diarrhea, etc., that can result in severe dehydration. This can be a serious medical issue. Individuals who experience vomiting and are in severe distress may also run the risk of choking.
- Individuals who attempt to go cold turkey often do not change their environmental conditions. Attempting to detox from heroin while still associating with people who use heroin, living in a neighborhood where there is overt drug abuse, and dealing with the types of stressors that fostered substance abuse is a sure way to guarantee failure in recovery.
- Discomfort is not a necessary part of withdrawal.Advances in the management of withdrawal symptoms for a number of drugs have become so sophisticated and efficient that there is no need for individuals to undergo severe withdrawal syndromes when they are trying to deal with their substance abuse issues. Instead, people can begin to work on their recovery when they are undergoing the withdrawal process as opposed to simply trying to “tough it out.”
Withdrawal Management for Heroin
Withdrawal management refers to a physician-assisted approach to negotiating withdrawal symptoms. Some treatment facilities also refer to the process as medical detox. The overall approach to withdrawal management attempts to establish safe conditions for the individual, to give them support during the withdrawal process, to establish ongoing treatment for any co-occurring conditions, and to reduce the risk of any serious issues with relapse as the individual attempts to deal with their substance use disorder. The establishment of safe conditions often results in these individuals being placed in residential programs during detox or in intensive outpatient treatment programs where they can receive the attention they need and be isolated from toxic environmental conditions.
The withdrawal management approach for heroin typically uses opioid replacement medications to control major withdrawal symptoms. The two most predominantly used opioid replacement medications are methadone and buprenorphine.
Methadone is a partial opioid agonist, meaning that it occupies the same neurons in the brain that heroin does, but it does not produce the same effects as heroin; its effects are similar but not as intense. In addition, it stays in an individual’s system longer than heroin, so if an individual takes methadone, they will not get any effect from taking heroin. This reduces cravings, withdrawal symptoms, and the need to use heroin.
Buprenorphine is also a partial opioid agonist that is used in the withdrawal process from opioid drugs. One of the most common formulations of buprenorphine comes in the drug Suboxone, which contains both buprenorphine and naloxone. Naloxone is an opiate antagonist that is often used in individuals who have overdosed on opiate drugs like heroin; it acts as a safeguard against individuals who attempt to abuse buprenorphine. If an individual tries to grind up and snort or inject Suboxone, the naloxone component is activated, and it immediately occupies the neurons in the brain that are specialized for opiates. As a result, other drugs can’t occupy them. If an opiate drug is already occupying those neurons, naloxone removes that drug and occupies the neurons instead; hence, the individual will experience withdrawal symptoms.
The use of an opiate replacement medication allows the physician to slowly wean the individual off the opiate drug while at the same time controlling any withdrawal symptoms that the person would have otherwise experienced. Typically, the physician starts at an initial dose that results in the individual not experiencing any withdrawal symptoms and then slowly tapers down the dose at specific intervals to wean the person off the drug. For many individuals who have had numerous relapses, the use of methadone management may continue for lengthy periods of time and can even be indefinite in an attempt to keep these individuals from engaging in risky behaviors and crime.
Other medications that might be administered for individuals withdrawing from heroin include:
- Naltrexone: Naltrexone (trade names ReVia and Vivitrol) is also an opiate antagonist. It does not specifically address the withdrawal symptoms for opiate drugs, but it can be used to reduce cravings in individuals who continue to have them despite other treatments.
- Robaxin (methocarbamol): Robaxin is a muscle relaxant. It is not formally approved for the treatment of heroin withdrawal but may be useful in treating muscle aches, pain, tension, and anxiety.
- Clonidine: Clonidine (trade names Catapres, Kapvay, or Duraclon) is a medication that is designed to treat hypertension. It can also reduce symptoms of stress, anxiety, irritability, insomnia, and jitteriness in individuals undergoing opiate withdrawal. While it is not approved specifically for this purpose, it is often prescribed for individuals undergoing withdrawal.
- Other medications: Physicians can prescribe any number of medications to address specific symptoms that occur during the withdrawal process.
Cold Turkey vs. Medical Detox
While some people are able to detox from heroin via a cold-turkey approach, cases of success are few and far between. Some people don’t like the idea of taking a new substance while they are trying to detox from another substance; they think it logically makes more sense to stop all substances altogether. However, the case for choosing medical detox over cold-turkey detox is strengthened by the fact that physician-assisted withdrawal management programs have far greater overall success rates in empirical studies than the alternative choices do.
In addition, while there may be a number of anecdotal reports on the Internet of those who have successfully undergone withdrawal without help, in the real world, many people relapse during detox and develop serious physical problems. These complications are not often posted online. The majority of people who fail at recovery do not sit down and write about their experiences, as they are back in the throes of addiction.
The bottom line is that choosing to become involved in an assisted withdrawal management program will significantly increase one’s chances of getting a good start in recovery, help in avoiding relapse, and prepare individuals for the long road of recovery far better than attempting to approach these issues without help.
Positive Steps to Take
Even though it is preferable to become involved in a physician-assisted withdrawal management program, an individual should not be passive regarding their recovery. Individuals should take action to ensure that their recovery will be successful, particularly in the early stages of recovery when cravings, possible withdrawal symptoms, and overall uncertainty are present.
- Eating a balanced diet and avoiding junk food can help to balance stress levels and promote general health.
- Getting plenty of rest and remaining hydrated are essential to overall physical health.
- Regular exercise will help to negotiate any potential withdrawal symptoms. It can also provide a source of distraction, invigorate the person, and reduce stress. Of course, any individual who has not exercised for some time should consult with a physician before attempting to initiate any exercise program.
- Stress is one of the enemies of individuals in recovery. Learning to cope with stress is an extremely positive endeavor that can contribute to an overall positive recovery experience. One can learn stress management techniques in therapy, practice meditation, engage in exercise, identify triggers and avoid them, and stay busy. In addition, maintaining and developing positive social contacts will reduce stress and add to one’s potential to become successful during recovery.
- An important source of social support is participation in recovery support groups, such as 12-Step groups, community health groups, specialty groups, and group therapy.
It certainly is possible to stop using heroin via a cold-turkey approach; however, this approach is not preferable. Becoming involved in a formal withdrawal management program increases the probability that one will be successful in the early stages of recovery. With medical detox, a person can undergo withdrawal without experiencing any significant distress and avoid any potential complications that can be physically or mentally damaging.
The goal of the withdrawal management program is to provide a safe and secure environment for the individual, get them through the withdrawal process without any significant complications, and prepare them for the real challenges that will inevitably occur after heroin use has stopped.