Can You Safely Taper off Heroin?

Heroin is one of the most addictive opioid drugs, which led the Drug Enforcement Administration (DEA) to list the substance as Schedule I under the Controlled Substances Act (CSA). This drug was synthesized in the 19^th century as a less addictive alternative to morphine after an epidemic of painkiller addiction among Civil War veterans caused concern. 

However, heroin becomes active in the brain after a few seconds. If it is injected, the drug takes only seven to eight seconds to bind to the brain’s opioid receptors, and the high lasts for 15 minutes or less. Drugs that rapidly cycle through the body like heroin often lead to compulsive behaviors and substance abuse because coming down from such an intense high can be uncomfortable.

This potent synthetic opiate also quickly leads to physical tolerance, so someone who abuses this drug will soon find that they need a larger dose to achieve the original high. Heroin quickly causes physical dependence, so the person feels like they need a consistent high to feel normal or to be able to function. The compulsive drug-taking behavior, tolerance, and dependence all mean that it is very difficult to quit taking this drug once you start.

Many people attempt to quit heroin cold turkey, or suddenly, without help. Quitting like this is more likely to lead to relapse and overdose than a slower withdrawal process. Although opioid withdrawal symptoms are not life-threatening, they can be uncomfortable, and the physical and emotional discomfort can trigger relapse if the individual does not have medical supervision.

Heroin’s Withdrawal Symptoms Cannot Be Managed Alone

Heroin is a synthetic opioid drug, derived from morphine, which is, in turn, derived from the opium poppy. Regular use can lead to tolerance, dependence, and addiction. Many users feel like they need to constantly take this drug to feel normal. Intense cravings begin as the body metabolizes the drug out, so people who abuse heroin often take several doses a day.

Once the initial rush from heroin wears off, users may be “on the nod” or “nodding” for several hours, where they alternate between wakefulness and falling asleep since it is such a powerful central nervous system (CNS) depressant. Too much heroin and breathing may become shallow, irregular, or very slow. In some cases, breathing could stop altogether. These are signs of an overdose that could lead to death.

Often, people who become addicted to heroin try to stop using on their own. The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) cites multiple attempts to stop or being unable to control drug consumption as one of the 11 signs of addiction. When trying to quit, a person struggling with any addiction, including opioid abuse, will be unable to control their behavior, and this will lead to relapse.

According to the Substance Abuse and Mental Health Services Administration (SAMHSA), there were 586,000 people in the United States struggling with heroin addiction in 2014.

For most people, heroin withdrawal symptoms themselves are not life-threatening. However, the risk of relapse can be deadly because of the potential for overdose. As a result, the discomfort associated with heroin withdrawal must be monitored and treated.

Withdrawal symptoms come in two stages, early and late. Early stage symptoms include:

• Agitation or restlessness
• Anxiety
• Muscle aches and pains
• Watery eyes
• Runny nose
• Yawning excessively
• Sweating

Later withdrawal symptoms include:

• Diarrhea
• Abdominal cramps
• Nausea and vomiting
• Goosebumps
• Dilated pupils

Cravings for the drug will persist through both phases, and they may continue after the physical symptoms of withdrawal go away. The most intense and uncomfortable heroin withdrawal symptoms, even for heavy users, typically go away within two to three days; however, psychological symptoms like anxiety, sleeplessness, and cravings may continue, especially if the person does not have social support.

Tapering Off Heroin Addiction Through Medication-Assisted Treatment

The safest approach to ending a heroin addiction is to work with addiction specialists using medication-assisted treatment (MAT) to taper off the physical dependence on opioids. Tapering heroin use itself will not work because it is illegal in the U.S., and the substance rapidly leaves the body. MAT replaces the opioid with a longer-lasting drug, and this can begin to change the person’s behavior around compulsively taking several doses of the drug. At the same time, the replacement drug will be slowly tapered until the body no longer needs opioids to feel normal.

This detox process is slower than quitting cold turkey, but it is much more effective for lasting sobriety. The process of MAT combines therapy with a prescription drug approved by the U.S. Food and Drug Administration (FDA) as a tapering medication. There are three medications with FDA approval that can be used to treat opioid use disorder (OUD) or addiction to narcotics. 

1. Methadone: This drug has been used to help people struggling with heroin addiction in the U.S. since the 1970s. It is dispensed only through methadone clinics, so someone using this as an approach to tapering must sign up with a specific clinic for treatment. Methadone is dispensed once per day as either a pill, wafer, or liquid. Depending on the size of the dose, the drug may be active in the body for one to two days, reducing cravings and physical withdrawal symptoms.
   Methadone is not prescribed as often to treat opioid addiction, including heroin addiction, because the tapering process can take a year or more. Currently, methadone is prescribed for people who have abused large doses of heroin for many years because this group likely needs long-term therapy and medication management to overcome psychological symptoms and compulsive behaviors
2. Buprenorphine: While this drug was approved for prescription use as a form of MAT as recently as 2002, it is currently the preferred MAT approach for opioid use disorder, including heroin addiction treatment. Buprenorphine is a partial opioid agonist, meaning the substance binds to the opioid receptors in the brain but does not cause a high in people who have taken other opioid drugs like heroin. This medication can also be prescribed through physicians’ offices, as long as the doctor has specific FDA-approved training, so more people struggling with opioid addiction can see their doctor and get a buprenorphine prescription that they can take at home. This improves treatment accessibility since the person does not have to go to a methadone clinic for supervision.
   Buprenorphine treatment occurs in three phases:
   1. The Induction Phase, when the person has stayed off heroin for 24 hours and begins buprenorphine treatment with their physician
   2. The Stabilization Phase, during which the physician works with their patient to find the right dose of buprenorphine
   3. The Maintenance Phase, when the appropriate buprenorphine dose has been found and the patient feels norma
3. Naltrexone: Unlike buprenorphine and methadone, naltrexone is not an opioid replacement therapy. Instead, this drug blocks the euphoric effects of opioids and alcohol. Instead of being prescribed as an approach to tapering, naltrexone is typically given to people who have already detoxed from heroin, alcohol, or a prescription narcotic, and who need help maintaining sobriety. In the event of a relapse, naltrexone prevents the drug from causing pleasant sensations, so the person may stop associating good experiences with the drug. 

A New Drug to Manage Opioid Withdrawal Symptoms

In May 2018, the FDA approved a new drug to manage opioid withdrawal symptoms. Lofexidine is an oral tablet that will be prescribed first under the brand name Lucemyra, which will be available for prescription use in the U.S. by August 2018. Initial drug trials on the medication have been very positive, but the substance has not, as of 2018, been fully integrated into detox and rehabilitation programs.

If you have questions about this medication’s potential, speak with your physician, psychiatrist, or addiction counselor. Other very effective approaches to MAT can help you get started on overcoming heroin addiction right now.

Assessment and Treatment to Overcome Addiction

 The best detox process involves a discussion between you and your physician or an addiction specialist. When you enter treatment for heroin addiction, the very first step is an assessment of your needs. A physician will likely ask you a series of questions.

• How long have you abused heroin?
• Are you drinking alcohol or taking other drugs with heroin?
• How often do you take it?
• Have you been in treatment for abuse before?
• Has this treatment included tapering medications like methadone or buprenorphine?
• Have you had reactions to medications in the past?
• Do you experience physical or mental health problems?
• What are your goals for recovery?
• Do you have the support of friends and family during this treatment process?

A physician will begin to monitor you for withdrawal symptoms during your first day of detox. They may use a scale to understand the severity of your withdrawal, the most common of which is the Clinical Opiate Withdrawal Scale (COWS). This 11-item scale helps clinicians measure symptoms, so they can manage the detox process safely and effectively, which includes determining the appropriate starting dose of a medication like buprenorphine or methadone.

A scale like COWS will help your clinician understand if you need medication to manage withdrawal symptoms, and if so, which one is the most appropriate. Then, your physician will help you stabilize on the right dose of this drug, and slowly taper over a period of weeks or months. In the case of methadone, the tapering process may take years. It is important to know that, even if the tapering process seems like it will take a long time, stabilizing your body so you can participate in therapy to change your behaviors is crucial to your long-term sobriety and health. 

Evidence-Based Treatment in Both Detox and Rehabilitation

Medication stabilization with buprenorphine or methadone are valuable tools to taper off heroin addiction. However, this approach to detox is not the only important step in overcoming addiction. The National Institute on Drug Abuse (NIDA) is clear that a “whole patient approach” must include behavioral counseling through a rehabilitation program. Aftercare and social support from friends, family, and mutual support groups are also key factors in staying away from addictive substances like heroin.

Sources

(July 13, 2018) Symptoms of Substance Use Disorder. Psych Central. from https://psychcentral.com/disorders/addictions/substance-use-disorder-symptoms/

(September 28, 2015) Medication and Counseling Treatment. Substance Abuse and Mental Health Services Administration. from https://www.samhsa.gov/medication-assisted-treatment/treatment#medications-used-in-mat

(September 28, 2015) Methadone. Substance Abuse and Mental Health Services Administration. from https://www.samhsa.gov/medication-assisted-treatment/treatment/methadone

(May 31, 2016) Buprenorphine. Substance Abuse and Mental Health Services Administration. from https://www.samhsa.gov/medication-assisted-treatment/treatment/buprenorphine

(September 12, 2016) Naltrexone. Substance Abuse and Mental Health Services Administration. from https://www.samhsa.gov/medication-assisted-treatment/treatment/naltrexone

(May 16, 2018). Announcement: FDA Approves First Medication to Reduce Opioid Withdrawal Symptoms. National Institute on Drug Abuse. from https://www.drugabuse.gov/news-events/news-releases/2018/05/fda-approves-first-medication-to-reduce-opioid-withdrawal-symptoms

(November 2016) Effective Treatments for Opioid Addiction. National Institute on Drug Abuse. from https://www.drugabuse.gov/publications/effective-treatments-opioid-addiction/effective-treatments-opioid-addiction