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What Are Some Tips for Tapering Off Heroin

Heroin is an illegal opioid drug that may be smoked, sniffed, snorted, or injected. Of the people that use heroin, an estimated 23% develop an addiction to opioids, and, based on the 2017 National Survey on Drug Use and Health, it was estimated that around 652,000 Americans age 12 and older suffered from a heroin use disorder in the past year.1,2,3

Medication-assisted treatment (MAT) involves combining counseling/behavioral therapy with medications, and it can be beneficial for those with opioid use disorder. Naltrexone, buprenorphine, and methadone have the approval of the U.S. Food & Drug Administration (FDA) for treating opioid dependence.4

How Does Heroin Dependence Develop?

When a person uses heroin, it can affect the mu, delta, and kappa opioid receptors. Binding to the mu receptors may result in euphoria.5 Additionally, activation of mu receptors in the brain’s reward center can encourage the person to use the drug again and again.6,7

As people regularly use heroin, they can develop tolerance, where the person has to use larger and larger doses to feel the effect they previously felt. This is due to the cells with opioid receptors reacting less to opioids.7

Additionally, an individual may develop dependence and keep using heroin to avoid withdrawal.7 Dependence is when the cells become used to the drug being present and properly function only when heroin is there.8

Heroin Withdrawal

Heroin is considered a short-acting opioid. For this type of opioid, withdrawal symptoms usually begin in dependent individuals 6-12 hours after they use their last dose.

Someone who is dependent on heroin will experience withdrawal symptoms when they stop or reduce their use. These symptoms can prompt the person to continue to use to avoid them.8

Heroin is considered a short-acting opioid. For this type of opioid, withdrawal symptoms usually begin in dependent individuals 6-12 hours after they use their last dose.9 Symptoms of heroin withdrawal can include:2

  • Bone and muscle pains.
  • Vomiting.
  • Diarrhea.
  • Restlessness.
  • Trouble sleeping.
  • Goosebumps.

Short-acting opioid withdrawal symptoms typically are their worst one to three days after use. They then usually lessen over the course of five days to a week. However, people can have some symptoms of withdrawal for weeks or months, such as anxiety, depressed mood, lack of pleasure, and insomnia.9

Cravings can occur during withdrawal and may lead to relapse.2,10 The risk of overdose is heightened in individuals who have gone through opioid withdrawal because their tolerance to opioids is decreased.10 Overdosing on heroin can be deadly.11

Avoiding triggers can help avert relapse. Triggers are activities, people, or locations which lead to the return of cravings.12

Medication-Assisted Treatment

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Heroin may be mixed with other substances.13 Because different samples may have different amounts of heroin, it is unwise to try to taper off heroin itself.

Medication-assisted treatment (MAT) for addiction to opioids involves the use of an FDA-approved medication for opioid maintenance treatment and/or detoxification.14 A person may be on the medication for months, years, or the rest of their life. MAT should also include some form of counseling/behavioral therapy.15

The Substance Abuse and Mental Health Services Administration states that MAT can:15

  • Improve treatment retention.
  • Raise survival rates.
  • Better enable patients to find and keep a job.
  • Reduce use of illegal opioids and other illegal behaviors in those who have substance use disorders (SUDs).
  • Help decrease the likelihood of getting hepatitis C or HIV (through lowering the relapse risk).
  • Foster better birth outcomes for pregnant women with SUDs.

Naltrexone, buprenorphine, and methadone have FDA-approval for treating opioid dependence.4 MAT is not replacing one addiction with another; rather, it assists a person in handling their addiction.12

  • Methadone – an opioid receptor agonist that can decrease withdrawal, cravings, and the effects of other opioids such as heroin16
  • Buprenorphine –a partial agonist for opioid receptors that can lessen cravings, withdrawal symptoms, and the effects of other opioids16
  • Naltrexone – an opioid receptor antagonist that does not produce any opioid effects but can prevent or reduce effects of other opioids (should only be used after withdrawal and sufficient time abstinent from opioids) and reduce cravings16

Methadone for addiction treatment can only be dispensed at certified opioid treatment programs (OTPs). Buprenorphine may also be available through OTPs but can also be prescribed by a medical provider who has a waiver to prescribe it. Any medical provider who is able to prescribe medicines can prescribe naltrexone.12,16,17 MAT may be done in an outpatient or residential/inpatient setting.14

First, the medical provider will assess the patient. They should then work together with the patient to develop a treatment plan. This may include plans for medication, counseling, and follow-up visits. If the medication isn’t working or is causing side effects, the provider may change the dose or switch the patient to a different medicine.12,18

Medication should not be stopped without talking to a medical provider. Some medications used in MAT have to be slowly stopped to avoid withdrawal.12 Each of these medications can have side effects.

Methadone may cause side effects such as:16

  • Sleepiness.
  • Nausea.
  • Constipation.
  • Increased weight.
  • Sweating.
  • Swelling.

Buprenorphine may cause side effects such as:16

  • Vomiting.
  • Constipation.
  • Trouble sleeping.
  • Sweating.
  • Trouble paying attention.
  • Blurry vision.
  • Tongue pain.
  • Opioid withdrawal.

Naltrexone may cause side effects such as:17

  • Vomiting.
  • Diarrhea.
  • Stomach upset.
  • Anxiety.
  • Trouble sleeping.
  • Fatigue.
  • Headache.
  • Muscle and/or joint pain.

Patients should let their medical provider know if they are having any side effects. Seek emergency help if any symptoms are severe.

Overdoses may be deadly. Using methadone or buprenorphine along with a benzodiazepine (such as Xanax or Valium) can increase the risk of deadly overdose.12 Call 911 if you think you or someone else may have overdosed.

Whether opioid maintenance treatment or detoxification is appropriate for a MAT patient is impacted by whether the treatment is indicated, the patient’s choice, and practicality.11 The remainder of this article will focus on detoxification.


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Benefits of Medical Detox

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Opioid withdrawal is not usually life-threatening. But it can be intense, and people can be affected differently. There are complications that could develop that should be treated quickly by professionals.11 Thus, if a patient is going to detox, it is a good idea to do so under medical supervision.

Whether detox should be done in an inpatient or outpatient setting is influenced by factors including other drug use, social support, physical health, and mental health.19

Suddenly stopping an opioid can cause powerful cravings, which can lead to relapse.20 People in withdrawal from opioids can become dehydrated or develop an electrolyte imbalance from vomiting or diarrhea, although this is uncommon. Heart conditions may be aggravated by some of the possible elements of the opioid withdrawal syndrome, such as increased blood pressure and heart rate. Withdrawal may also make underlying anxiety disorders and/or pain worse. Supervision during detoxification may avert complications.11

Health professionals may provide supportive care and prescribe medications, such as methadone, buprenorphine, or another medicine to ease symptoms.19

Of heroin users, over 90% had other drug use as well, according to the Centers for Disease Control and Prevention.21 Dependence on another drug type in addition to opioids can increase the complexity of detox. Other drug types may cause different withdrawal symptoms and/or may worsen symptoms if they are detoxed at the same time.22 Thus, it’s important for patients to disclose all drugs of use when entering a detox program, and detox programs should perform a urine drug screening. The patient typically should be detoxed from the substances they are dependent on consecutively, starting with the type that has the worst potential withdrawal syndrome.11

Additionally, people going through heroin detox should be screened for medical concerns associated with opioid dependence, such as hepatitis B and C and HIV.11 Rehab centers should provide or arrange for appropriate treatment for any identified medical issues.

After Detox

Individuals with addiction who complete detox should continue addiction treatment, as just detox is generally not enough to assist them to stay in recovery long term.23 Therapies such as contingency management or cognitive-behavioral therapy may be beneficial.2 Naltrexone may reduce cravings for opioids and can avert or reduce effects of other opioids if the patient relapses.16,17

Opioid addiction is a manageable condition. Medication-assisted treatment, which should combine medication use with counseling and other forms of support, can assist a person with addiction to manage the disease.12 If you’re interested in MAT, talk to a medical provider or reach out to a rehabilitation facility that offers MAT for opioid use disorders.

Sources
  1. American Society of Addiction Medicine. (2016). Opioid Addiction 2016 Facts & Figures.
  2. National Institute on Drug Abuse. (2018). Heroin.
  3. Substance Abuse and Mental Health Services Administration. (2018). Key Substance Use and Mental Health Indicators in the United States: Results from the 2017 National Survey on Drug Use and Health.
  4. U.S. Food and Drug Administration. (2019). Information about Medication-Assisted Treatment (MAT).
  5. Huecker, M. R., & Marraffa, J. (2019). Heroin. In StatPearls [Internet]. StatPearls Publishing.
  6. National Institute on Drug Abuse. (2018). What effects does heroin have on the body?
  7. Kosten, T. and George, T.P. (2002). The Neurobiology of Opioid Dependence: Implications for TreatmentAddiction Science & Clinical Practice, 1(1), 13-20.
  8. National Institute on Drug Abuse. (2007). 8: Definition of dependence.
  9. American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.
  10. World Health Organization. (2009). Withdrawal Management. In Clinical guidelines for withdrawal management and treatment of drug dependence in closed settings.
  11. Center for Substance Abuse Treatment. (2006). Detoxification and Substance Abuse Treatment: A Treatment Improvement Protocol TIP 45.
  12. Substance Abuse and Mental Health Services Administration. (2011). Medication-Assisted Treatment for Opioid Addiction: Facts for Families and Friends.
  13. Drug Enforcement Administration. (2019). Heroin.
  14. Center for Substance Abuse Treatment. (2005). Medication-Assisted Treatment For Opioid Addiction in Opioid Treatment Programs: A Treatment Improvement Protocol TIP 43.
  15. Substance Abuse and Mental Health Services Administration. (2015). Medication and Counseling Treatment.
  16. Substance Abuse and Mental Health Services Administration. (2018). Part 3: Pharmacotherapy for Opioid Use Disorder: For Healthcare Professionals. In Medications for Opioid Use Disorder: For Healthcare and Addiction Professionals, Policymakers, Patients, and Families: Treatment Improvement Protocol TIP 63.
  17. Substance Abuse and Mental Health Services Administration. (2019). Naltrexone.
  18. American Society of Addiction Medicine. (2016). Opioid Addiction Treatment: A Guide for Patients, Families and Friends.
  19. Miller, S. C., Fiellin, D. A., Rosenthal, R. N., & Saitz, R. (2019). The ASAM Principles of Addiction Medicine. Philadelphia, PA: Wolters Kluwer.
  20. American Society of Addiction Medicine. (2015). The ASAM National Practice Guideline For the Use of Medications in the Treatment of Addiction Involving Opioid Use.
  21. Centers for Disease Control and Prevention. (2015). Today’s Heroin Epidemic.
  22. Kristensen, Ø., Lølandsmo, T., Isaksen, Å., Vederhus, J. K., & Clausen, T. (2006). Treatment of polydrug-using opiate dependents during withdrawal: towards a standardisation of treatmentBMC psychiatry6, 54.
  23. National Institute on Drug Abuse; National Institutes of Health; U.S. Department of Health and Human Services. (2018). Principles of Drug Addiction Treatment: A Research-Based Guide (Third Edition).

 


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