Heroin is an illegal opioid drug that may be smoked, snorted, or injected. Roughly 23% of the people who abuse heroin will ultimately develop an opioid addiction, and the 2017 National Survey on Drug Use and Health estimates that about 652,000 Americans age 12 and older suffer from heroin addiction.1,2
Tapering off heroin is not usually recommended for people who want to quit. The doses and purity of street heroin vary and are impossible to fully control, making an effective tapering schedule difficult to carry out.
On the other hand, FDA-approved opioid replacement medications such as buprenorphine or methadone can be given in regular, specific doses and can be adjusted up or tapered down as needed. These drugs help people complete withdrawal safely and with minimal discomfort, which can lower the risk of relapse.
How Does Heroin Dependence Develop?
When a person takes heroin, it binds to and activates receptors in the brain called mu-opioid receptors. This action sets in motion the same biochemical process that rewards people with pleasurable feelings when they participate in activities such as eating and sex. These feelings can lead to the person to want to use the drug again and again.3
At first, continued heroin use is reinforced by the activation of the brain’s reward system. But over time, people may become more compelled to keep using heroin because of physiological dependence and withdrawal avoidance.3
As people regularly use heroin, the effect of the drug elicited by opioid receptor activation diminishes; essentially, the brain become less responsive to the drug as tolerance develops. The person therefore needs to take higher and higher doses to feel the effect they previously felt. Additionally, at some point after consistent exposure to the drug, the user’s brain begins to function normally only when heroin is in their system (dependence).3
Withdrawal symptoms usually begin 6-12 hours after the last dose.
Someone who is dependent on heroin will experience withdrawal symptoms when they cut back or reduce their use. Often, these symptoms are so unpleasant that the person continues to use to avoid them.3
When people are dependent on heroin, quitting suddenly, or going “cold turkey,” can result in the onset of a very unpleasant withdrawal syndrome. Withdrawal symptoms usually begin 6-12 hours after the last dose and can include:4
- Muscle pains, including aches in the back and legs.
- Runny nose.
- Teary eyes.
These symptoms can last up to a week. But some people can show signs of withdrawal for weeks or months, such as anxiety, depressed mood, lack of pleasure, and insomnia.4
During the withdrawal period, the person is at risk of relapse or other medical complications from withdrawal.
Heroin’s reinforcing effects are strong and may persist beyond the acute withdrawal phase and well into recovery. For example, a recovering individual may continue to be triggered by certain people they used with or places where they used, and these cues can lead to cravings and contribute to relapse.3
How Medication-Assisted Treatment Works
Tapering off heroin is rarely done with the drug itself, at least not as part of professional treatment. As an illicit substance with no pharmacologic quality control, it would be nearly impossible to gauge the proper dose of the drug needed to gradually wean the person off. Heroin is also relatively short-acting, which means a person would require multiple doses a day and be more likely to cycle through rapid highs and lows.
The more common method of helping people detox and quit heroin is to use an opioid substitute medication. This process is known as medication-assisted treatment or MAT. The person takes the medication under the guidance of a doctor—usually once a day or every other day. Some people may only take the medication for detox, while others may be on the medication for months, years, or even the rest of their life. MAT is usually combined with some form of counseling.5
Research shows that MAT can:5
- Improve survival rates of patients.
- Increase retention in treatment.
- Reduce use of illegal opioids and criminal activity.
- Make it easier for patients to find and maintain a job.
- Improve birth outcomes among pregnant women who use.
- Lower the risk of contracting HIV or hepatitis.
The 2 drugs most often used in MAT are methadone and buprenorphine. Naltrexone is also sometimes used. These drugs help to balance brain chemistry, stabilize certain physical responses, block the effects of other opioids such as heroin, and relieve withdrawal symptoms and cravings.5
- Methadone – a long-acting opioid receptor agonist that reduces cravings and withdrawal and, with consistent use and significant building of cross-tolerance, blocks the effects of other opioids such as heroin
- Buprenorphine – a long-acting opioid receptor partial agonist that reduces withdrawal symptoms and cravings and dampens the effects of other opioids
- Naltrexone – an opioid receptor antagonist that does not produce any opioid effects but blocks the effects of other opioids (mainly used after withdrawal to prevent relapse)6
Methadone can only be dispensed at certified, accredited opioid treatment programs (OTPs). Buprenorphine may also be available through OTPs but can also be prescribed and dispensed by specially qualified physicians. Naltrexone can be prescribed by a doctor or at a treatment center.7
Health care providers will check in with someone a few hours after the first dose and then continue to evaluate regularly for the first week or two to make sure the medication is working and that the person is taking the drug as prescribed. If the medication isn’t working, they will adjust the dose or prescribe a different medication.7
When the person and their doctor agree that the person should stop taking a medication, the doctor will gradually lower the dose to prevent withdrawal.7
These medications can have side effects that users should be aware of, such as drowsiness, upset stomach, and sleep problems. It is also possible to overdose on them if someone takes too much.7
MAT may be used as a part of a drug abuse treatment program and applied in either an outpatient or residential setting, depending on patient preference, recovery needs, and other specific circumstances. For people with a long-standing heroin addiction and severe physical dependence, inpatient medical detox may be the most appropriate setting for them to complete withdrawal.
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Benefits of Medical Detox
Heroin withdrawal is not usually life-threatening. But it can be intense, and it affects each person differently. There are a number of risks that people face when they attempt to just stop using heroin without professional help.
Beyond the risk of relapse, people in withdrawal can become dehydrated or develop an electrolyte imbalance from vomiting or diarrhea. Cardiac conditions can be aggravated by the increased blood pressure and heart rates that often occur during withdrawal. Withdrawal can also make underlying anxiety disorders worse.8
Monitoring by a health professional in a medical detox setting can ensure that people experience a minimal amount of suffering during detox. Health professionals can prescribe medications to ease symptoms and make the process more comfortable.
Heroin is used with other drugs as often as 90% of the time, according to the Centers for Disease Control and Prevention.9 This polydrug abuse can complicate the detox process. Other drugs may have additional withdrawal symptoms, so it’s important to disclose all drugs of abuse when entering a detox program. A medically supervised program can treat these symptoms as well as the symptoms of heroin withdrawal.
Additionally, people who have used heroin should be screened for infectious diseases such as hepatitis C and HIV. Rehab centers can screen for these conditions as part of the detox program and arrange for appropriate treatment for them when needed.
Managing Withdrawal Symptoms
There are several things that can help during detox, or while undergoing medication-assisted treatment, to help manage your withdrawal symptoms including:
- Keeping the mind busy by engaging in activities.
- Exercising regularly to increase natural endorphin levels and to promote aspects of physical wellbeing.
- Eating balanced and nutritious meals that are high in protein and complex carbohydrates and low in refined sugars or processed ingredients.
- Being sure to get enough sleep, as being well rested helps to keep the mind clear and makes functioning easier.
- Taking care of any other medical and/or mental health concerns promptly.
Other tips to help sustain your recovery include:
- Joining a support group to help maintain forward progress and to build a healthy peer support network.
- Taking up a creative habit, like painting, sculpting, writing, or drawing.
- Considering mindfulness techniques such as meditation or yoga, as they may enhance the connection between mind, body, and spirit and promote an overall sense of peace.
- Attending counseling and/or therapy sessions to identify possible triggers and learn how to better cope with stress.
- Understanding that relapse is common, recovery is not linear, and addiction is a highly personal disease that no two people will experience in exactly the same manner.
- Asking for help when needed, and reach out to family, friends, and loved ones on a regular basis to stay connected.
- Setting real and attainable goals, and plan small rewards along the way as goals are reached.
Heroin addiction is a manageable condition. Medication-assisted treatment, when combined with counseling and other forms of support, can be an empowering step in the journey to overcoming that addiction and rebuilding your life. If you’re interested in MAT, talk to your doctor or investigate rehabilitation facilities that offer medical detox, medical withdrawal management, and/or longer-term medication therapy for opioid use disorders.
. American Society of Addiction Medicine. (2016). Opioid Addiction 2016 Facts & Figures.
. 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.
. Kosten, T. and George, T.P. (2002). The Neurobiology of Opioid Dependence: Implications for Treatment. Addiction Science & Clinical Practice, 1(1), 13-20.
. American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.
. Substance Abuse and Mental Health Services Administration. (2015). Medication and Counseling Treatment.
. Substance Abuse and Mental Health Services Administration. (2018). TIP 63: Medications for Opioid Use Disorder.
. Substance Abuse and Mental Health Services Administration. (2011). Medication-Assisted Treatment for Opioid Addiction: Facts for Families and Friends.
. Substance Abuse and Mental Health Services Administration. (2006). TIP 45: Detoxification and Substance Abuse Treatment.
. Centers for Disease Control and Prevention. (2015). Today’s Heroin Epidemic.
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