Detoxing from Heroin

Detox refers to the managed set of interventions that help manage the withdrawal process while the body clears itself of heroin or other substances.

Safely detoxing is critical for physical and mental well-being. Even though the process may be uncomfortable or seem frightening, it is often a necessary first step toward a sustained recovery.

Signs and Symptoms of Withdrawal

Heroin belongs to a class of drugs known as opioids. Withdrawing from opioids can be highly distressing for people who have chronically used them.

The combination of these withdrawal effects can lead to relapse, as many users struggle to deal with these painful physical and emotional symptoms.

How Long Does it Usually Take?

The physical symptoms of heroin withdrawal typically start between 6–24 hours after the last use, peak in severity between 2-4 days, and taper after about 1 week.¹

That said, a post-acute-withdrawal syndrome (PAWS) can persist for several months or years after the last use. PAWS symptoms can include the following:⁴

• Depression
• Anxiety
• Irritability
• Cognitive difficulties (issues with problem solving and overall memory)
• Relationship impairments
• Obsessive-compulsive behaviors
• High levels of cravings
• Pessimistic attitude
• Sleep problems
• High levels of stress

Though these symptoms can manifest during trigger situations, they can also appear without any clear cause.

Can Detoxing be Dangerous?

Although withdrawal from heroin is painful, detox is not generally life-threatening. However, possible medical complications can certainly arise during the withdrawal stage.⁵

Common medical issues include vomiting and aspiration, which occurs when someone breathes stomach contents into their lungs. In turn, this can cause lung infection. Further, vomiting and diarrhea can lead to dehydration and electrolyte disturbances.⁵

In general, the greatest risk of heroin detox is relapse. Many overdoses occur in people that have just detoxed. Heroin tolerance lowers over the course of any abstinent period, such as that required for detox, making it easier for a person to overdose if they resume using the amount they previously used.⁵

Available Options to Choose From

Detox program options range from those conducted in outpatient settings to 24-hour inpatient or residential care.

Typically, users that may be a good fit for inpatient care have:¹

• Moderate to severe opioid addiction.
• Unstable medical/psychiatric conditions.
• Simultaneous withdrawal from multiple drugs (alcohol, benzodiazepines, stimulants).
• Repeated failure at outpatient withdrawal and/or a history of chronic relapse.
• An unsupportive home environment.

Trained medical professionals can best assess the optimal detox program for those seeking care for heroin withdrawal.

Prescribed Medications

Certain medications used during detoxification can alleviate withdrawal symptoms and minimize cravings. Such medications include:

• Methadone. Methadone has been used for decades to treat heroin addiction. It helps decrease symptoms of opiate withdrawal. Patients initially receive it under physician supervision at an approved opioid treatment program. Eventually, they may be able to take methadone at home in between visits.⁷ According to the World Health Organization (WHO), initial methadone doses should be 20 mg or less and gradually increased to 60–120 mg per day.⁸
• Buprenorphine (Suboxone). Buprenorphine is the first medication that can treat opioid addiction without the patient needing to go to a clinic. Qualified U.S. physicians can prescribe it in various settings. Buprenorphine can reduce withdrawal symptoms and cravings.⁹ The WHO indicates that the initial buprenorphine treatment dose should match the pattern of opioid use, including the person’s tolerance and timing of last heroin use. From there, it should increase to 8–24 mg.⁸
• Clonidine. Clonidine is an alpha-2 adrenergic agonist that can provide relief for the physical discomfort associated with heroin withdrawal such as sweating, diarrhea, vomiting, and abdominal cramps. It may be used with other treatment methods.¹⁰

Seeking Help from Professionals

Detoxing at home, or “cold turkey,” can be very uncomfortable for heroin users. Without the safety, structure, and support associated with medical assistance, it can be challenging to manage withdrawal symptoms.

Further, it may be easier for heroin users to relapse, as they are still in an environment where they have access to the drug.

People who attempt to detox on their own also frequently forego treatment for the underlying issues that may have led to the addiction. They may be more likely to relapse compared with those who receive formal therapy.

Opting for the Natural Approach

Some people may attempt to detox through natural methods, such as different herbal supplements, vitamins, and nutrients. Or they may try detox kits that promise quick results.

However, natural detoxification is risky because it is not under medical supervision and the effectiveness of such techniques may be untested. If physical (such as dehydration) or emotional (such as severe depression or anxiety) complications arise, the person may be more inclined to relapse.

Accelerated Methods

Clinicians have devised accelerated, rapid methods of detox through the monitored administration of opioid medications and sedative-hypnotic agents or general anesthetics.¹¹

However, the American Society of Addiction Medicine warns that there is insufficient evidence supporting this method and that there could be uncertain risks in clinical settings. The organization believes that further research examining the effectiveness and safety of such methods is needed.¹¹

Additionally, the National Institute on Drug Abuse (NIDA) concluded that withdrawal is not any easier with rapid detox. Further, the technique may create additional safety concerns including an increased risk of pulmonary issues and psychiatric complications. Those with preexisting physical illnesses appear to be especially vulnerable. In general, NIDA judged that rapid detox did not provide any advantage over other methods.¹²

Complications During Pregnancy

Pregnancy undoubtedly represents a complicated and stressful time, and those issues can be exacerbated if the woman is struggling with heroin addiction. Research shows that a medical detox for pregnant women with opioid dependence can be safe, though monitoring and support are highly recommended.¹³

Pregnant women may use methadone during pregnancy for treatment of opioid dependence. It can reduce or eliminate heroin cravings, prevent the onset of withdrawal, and block euphoric effects of other opioids. During pregnancy, unmanaged heroin withdrawal can be especially dangerous. It may lead to uterine contractions, which can result in miscarriage or premature birth.¹⁴

However, even babies who experience methadone withdrawal do just as well as other babies. The benefits of breastfeeding also often outweigh the risks of methadone entering breast milk. Generally, it is safe for women on methadone to breastfeed if they are not HIV-positive. Pregnant women should talk about their treatment options with their doctor.¹⁴

Additionally, NIDA-supported research found buprenorphine to be a safe alternative to methadone for pregnant women. In fact, when compared to methadone, babies were less likely to experience severe NAS symptoms.¹⁵ Clinical interest is on the rise, and further research is needed to determine efficacy.

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The Process of Recovery

Detoxification is only the first step any user must take before beginning rehabilitation.

Options for further treatment after detox. These programs help a person work through the root causes of their addiction and develop techniques to prevent relapse. After rehab, ongoing care through counseling, sober living, and 12-step groups can help keep a person on track once they resume their normal lives.

Recovery, after all, is often a lifetime process.

Sources

1. Health.gov.au. (N.D.) Guidelines for the Management of Heroin Withdrawal.
2. American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.
3. National Institute on Drug Abuse. (2018). What are the Long-Term Effects of Heroin Use?
4. Semel Institute for Neuroscience and Human Behavior. (2011). Post-Acute WIthdrawal Syndrome (PAWS).
5. Medline Plus. (2016). Opiate and Opioid Withdrawal.
6. Substance Abuse and Mental Health Services Administration. (2013). Detoxification and Substance Abuse Treatment.
7. Substance Abuse and Mental Health Services Administration. (2015). Methadone.
8. World Health Organization. (2009). Guidelines for the Psychosocially Assisted Pharmacological Treatment of Opioid Dependence.
9. Substance Abuse and Mental Health Services Administration. (2016). Buprenorphine.
10.  World Health Organization. (2009). Clinical Guidelines for Withdrawal Management and Treatment of Drug Dependence in Closed Settings.
11.  American Society of Addiction Medicine. (2005). Rapid and Ultra Rapid Opioid Detoxification.
12.  National Institute on Drug Abuse. (2006). Study Finds Withdrawal No Easier With Ultrapid Opiate Detox.
13.  Jones, H., Martin, P., Heil, S., Stine, S…Fisher, G. (2008). Treatment of Opioid Dependent Pregnant Women: Clinical and Research Issues, Journal of Substance Abuse Treatment, 35(3), 245–259.
14.  Substance Abuse and Mental Health Services Administration. (2014). Methadone Treatment for Pregnant Women.
15. National Institute on Drug Abuse. (2012). Buprenorphine During Pregnancy Reduces Neonate Distress.