An illegal opioid drug, heroin is considered to be highly addictive and has no accepted medicinal use in the United States. In 2014, heroin was abused by 435,000 people over the age of 12 in America, the National Survey on Drug Use and Health (NSDUH) reported.
Heroin use has increased across all demographics in recent years, potentially in response to tighter regulation of prescription opioid painkillers. The Centers for Disease Control and Prevention (CDC) publishes that overdose deaths related to heroin abuse practically quadrupled between 2002 and 2013. In 2014, USA Today reported that there were over 10,000 heroin overdose fatalities in the United States, a number that has continued to rise in the past several years. The New York Times published that 78 Americans die every day in this country from an opioid overdose (the number includes both prescription opioids and heroin).
How Dependence Forms
Heroin is commonly injected, snorted, or smoked. The American Society of Addiction Medicine (ASAM) estimates that almost a quarter of people who abuse heroin develop an opioid abuse disorder, or an addiction to opioids.
One of the side effects of addiction is drug dependence, which in the case of heroin, can be caused by the brain becoming accustomed to the changes in the reward, motivation, and emotional regulation pathways. When heroin enters the bloodstream, it causes a flood of dopamine (one of the brain’s naturally occurring neurotransmitters, or messengers) that signals a person to feel happy. This produces the intense “high” that characterizes heroin intoxication. Users feel happy, relaxed, and less anxious. Decision-making abilities are impaired by heroin abuse as are motor skills and cognition in general.
Repeated heroin abuse causes the disruption in the circuitry of the brain to become more fixed, and sets up a kind of shortcut to happiness that can then only be perpetuated by the drug. Individuals who are dependent on heroin may not be able to feel happy without the drug, and intense withdrawal symptoms may occur when it is removed or leaves the body. Heroin withdrawal is not life-threatening; however, it does come with both physical and psychological symptoms that can be powerful and significant.
Duration of Heroin Withdrawal
There are two main facets to heroin withdrawal: the physical symptoms and the emotional, or psychological, ones. Heroin is considered a fast-acting opioid with a relatively short half-life, meaning that the drug takes effect quickly and also leaves the bloodstream rapidly.
Drug withdrawal generally starts when a drug stops being effective. The National Highway Traffic Safety Administration (NHTSA) reports that heroin withdrawal can start within 6-12 hours of the last dose. Symptoms typically peak in severity within 2-3 days, and the majority of symptoms dissipate in 5-10 days. Withdrawal from heroin may be broken down into early and late withdrawal, with the early symptoms beginning in the first 12 hours and late symptoms beginning a few days after the last dose.
Early physical withdrawal symptoms of heroin include:
- Runny nose
- Muscle aches
- Tearing up
- Elevated heart rate and blood pressure
Late physical heroin withdrawal symptoms are:
- Stomach pain or cramps
- Loss of appetite
- Bone pain
- Muscle spasms
Physical withdrawal from heroin is not that dissimilar from a bad case of the flu. It is often the emotional symptoms of heroin withdrawal that are considered to be more significant.
Psychological heroin withdrawal symptoms include:
- Dysphoria (difficulty feeling pleasure)
- Drug cravings
Withdrawal is highly individual, and everyone may experience it somewhat differently. Some of the factors that influence the intensity of withdrawal are related to the severity of dependence on the drug. For example, individuals who use large quantities of heroin, and have done so for an extended amount of time, may be more dependent on the drug than occasional users, or those who use less of the drug each time.
Biological and genetic factors can impact heroin dependency, as the journal Clinical Pharmacology & Therapeutics points out that opioid addiction is highly heritable. This means that family history can influence why one person develops a stronger dependence on heroin than another person. Stress, family support (or lack thereof), and environmental aspects also play a role in drug dependence and its severity.
Medical Detox and Pharmaceutical Management of Heroin Withdrawal
When an individual is addicted to, or dependent on, medical detox is the safest and smoothest way to remove the drug from the body. In order to manage withdrawal symptoms and drug cravings, and prevent a return to heroin use after detox, it is not recommended to suddenly stop taking it without professional help.
Medical detox often includes pharmaceutical help and around-the-clock professional care and supervision in a specialized facility. Heroin detox typically lasts between 5-10 days, depending on the person and the level of dependency. In some instances, medications may be used for weeks or months, in a tapered detox approach. Detox should always be followed with a comprehensive treatment program that includes therapy.
The FDA has approved three medications for the treatment of opioid dependence: naltrexone, buprenorphine, and methadone, as published by the Office of National Drug Control Policy (ONDCP). Several other medications may be useful during medical detox to target specific withdrawal symptoms. Medications that may be regularly used during heroin detox and withdrawal include:
- Naltrexone: An opioid antagonist, naltrexone works by blocking opioid receptors from receiving more of the drug of abuse. It is typically used in later stages of opioid dependence treatment as a method of preventing relapse. It includes the brand name drugs Vivitrol, ReVia, and Depade.
- Buprenorphine: An opioid agonist that only partially fills opioid receptors, buprenorphine keeps these receptors activated at lower levels than full agonists do, thereby lessening withdrawal symptoms. Products like Subutex also have a plateau effect, keeping the drug from causing the “high” that other opioids do when abused. This plateau effect is meant to work as an abuse deterrent, as opioid effects do not increase with higher doses.
- Combination buprenorphine and naloxone products: Suboxone, Zubsolv, and Bunavail are combinations of both opioid agonists and antagonist products. The partial agonist helps to manage withdrawal symptoms. The antagonist mechanism remains dormant unless the drug is abused; if abused, it takes effect and precipitates withdrawal.
- Methadone: Another opioid agonist with a longer half-life, methadone is used to replace heroin and prevent, or lessen, withdrawal symptoms. It can be taken once a day and stay in the body for up to 30 hours. Methadone is only dispensed in federally regulated clinics as it has a high potential for abuse and diversion.
- Antidepressants: Depression is a common side effect of heroin withdrawal. Antidepressants can help to balance moods during detox and beyond.
- Benzodiazepines: Useful for both their anxiolytic and sedative effects, these drugs may be helpful for decreasing anxiety and insomnia symptoms during heroin withdrawal. They also carry a high risk of dependence and abuse, however; as a result, they should be used carefully and only on a short-term basis.
- Antipsychotics: These medications can decrease agitation and help individuals sleep during heroin detox.
- Anti-nausea medications or antispasmodics: These medications target the nausea, abdominal cramps, and vomiting that can accompany heroin withdrawal.
Other medications may be used as adjunct medications during detox, such as the high-blood pressure medications clonidine or lofexidine, which act on the noradrenaline system and help to manage opioid withdrawal symptoms, per the NICE Clinical Guidelines. Medical or mental health professionals may also prescribe supplements during detox as drug addiction can deplete the body of essential vitamins or minerals.
It is essential to make sure that all treatment providers are aware of any drugs that may be in the body when detox begins in order to avoid any potential negative interactions between medications. Heroin withdrawal can be managed with the help of medical detox and with pharmaceutical tools that are administered by trained substance abuse, medical, and/or mental health professionals.
Withdrawal is an individual process, so there is single timeline that everyone can expect to follow. Specifics vary from person to person; however, treating professionals can give individual clients a better idea of what to expect after an initial treatment consult.