As the opioid crisis in the United States rages on, heroin remains a key player, with both incredibly high addiction rates and overdose deaths. Currently, the American Society of Addiction Medicine (ASAM) estimates that at least 517,000 Americans are battling an addiction to heroin, while it is calculated to have been the cause of about 15,500 overdose deaths in 2016.
Heroin is what’s known as an “opioid,” which used to mean any synthetic drugs that were created to work the same way as naturally derived “opiates” such as morphine or codeine, which were themselves made from opium. Today, however, the term “opioid” is now used to refer to the entire family of opiate drugs, both natural and synthetic.
Heroin is derived from morphine and was created for and marketed as an over-the-counter cough medicine in the late 1800s. It was actually meant to be a safer and less addictive alternative to using morphine, but it was not long after that heroin had a far higher addiction rate than morphine among those who used it.
Eventually, in 1924, the United States banned all sales, imports, and manufacturing of heroin. The U.S. Drug Enforcement Administration (DEA) now classifies it as a Schedule I substance, which means that because of its high potential for abuse and no recognized medical use, it is illegal to either possess or manufacture.
Heroin is also more dangerous now than it ever was before as it is increasingly being cut with fentanyl, a synthetic opioid that is much cheaper and easier to make than heroin. Fentanyl also is significantly stronger and deadlier.
Most heroin users are unaware that what they’re buying is partially, and sometimes even completely, fentanyl, and since a lethal dosage of fentanyl is roughly the size of a single snowflake, the risk of death from accidental overdose is high.
While the severe health issues associated with heroin abuse have certainly never been trivial, this new danger only highlights how important it is to get treatment and break from heroin dependence. As such, the first step is medical detoxification and going through the process of heroin withdrawal.
Heroin works by rapidly entering the brain and binding to its opioid receptors.
The body naturally produces its own endogenous opioids and uses them as neurotransmitters, physiologically to painful stimuli.
Opioid receptors are the channels that allow the signaling process to take place.
Here is how opioids affect the neurotransmitters (GABA and dopamine): Opioids such as heroin mimic the effects of endogenous opioids (e.g. endorphins) that the body produces naturally.
When opiates bind and activate opioid receptors found on pain-signaling neurons, they exert their effect by increasing dopamine release that produces euphoric effects.
Normally, GABA inhibits dopamine www. By binding to receptors on GABA inhibitory neurons, opioids reduce GABA activity and ultimately increase dopamine release and induce pleasurable feelings.
What heroin does when it binds to these receptors is heighten this effect, blocking the brain from receiving pain signals and also increasing the levels of dopamine, which is a neurotransmitter that controls the brain’s pleasure centers. This is why using heroin creates such a huge spike in feelings of euphoria and pleasure while at the same time masking pain and discomfort.
When the body becomes physically dependent on heroin to provide a certain amount of dopamine and block out pain, it also builds up a tolerance, so that you need more to achieve the same effects. This is why when someone who has regularly been abusing heroin stops, their body “crashes” and struggles to cope with the sudden loss of dopamine, which is what brings on heroin withdrawal symptoms.
The symptoms of heroin withdrawal are consistent with general opioid withdrawal symptoms, which are extremely uncomfortable and sometimes even painful but rarely ever fatal. In the early stages of heroin withdrawal, someone in detox is most likely to experience at least some of the following mild, flu-like symptoms:
These are typically followed by more moderate heroin withdrawal symptoms that start and eventually reach their full intensity at the peak of the withdrawal timeline and include:
Finally, the most intense symptoms that someone in heroin detox might experience during withdrawal, especially if they have been abusing large amounts of the drug for a long time, include:
While these are the typical heroin withdrawal symptoms, if someone attempts to immediately stop using heroin altogether, usually referred to as “cold turkey,” heroin withdrawal can cause hallucinations, seizures, and convulsions. For these reasons, it is never recommended that someone who has been dependent on heroin for a long time attempt to detox by going cold turkey.
As mentioned before, heroin withdrawal is rarely, if ever, deadly. However, heroin withdrawal symptoms can be very painful and unpleasant to deal with, which can cause someone attempting a heroin detox to relapse and go back to using.
Intense heroin cravings are one of the major symptoms of heroin withdrawal. Someone relapsing while trying to remove the drug from their body is likely to do a larger dose of heroin than usual, which puts them at an increased risk of overdose.
Another dangerous symptom of heroin withdrawal is depression; it can provoke thoughts of suicide and an increase in suicidal behavior, which, if not carefully monitored, can have fatal consequences.
So while heroin withdrawal will not kill you, complications from the side effects of some heroin withdrawal symptoms can indirectly result in death.
Pregnant women should be especially careful, as heroin withdrawal can cause miscarriages, and greatly increases the risk of having one. Because of this, it is recommended that pregnant women who are dependent on heroin or other opioids slowly taper use with methadone maintenance treatment, which we’ll explain more about further down.
The main question people detoxing from heroin have is, “How long can heroin withdrawal last?” The answer is that the length and the intensity of heroin withdrawal are going to be a bit different for any given person as it is based on how dependent on heroin someone has become, as well as other factors such as:
While those factors will ultimately determine the exact length of an individual’s heroin withdrawal process, the established timeline for heroin withdrawal based on common opioid withdrawal symptoms and length, as well as how long heroin remains in your system, is generally as follows:
Because heroin enters the brain and take effects so quickly, that means it has a short half-life and that heroin withdrawal symptoms can start as soon as six hours after the last dose, and usually will have started within at least 12 hours. At this point, you can expect the milder, mostly physical, flu-like symptoms to start.
During the next couple of days, the more moderate-to-severe heroin withdrawal symptoms, such as exhaustion, vomiting, depression, and drug cravings will start and eventually reach their peak strength. This is the time when those who are undergoing heroin detox are most vulnerable to relapse.
Usually seven but sometimes as long as 10 days after the last dose, the majority of the physical symptoms of heroin withdrawal should have stopped, or at least greatly diminished. Cravings may still be present but will have become more manageable. Some of the psychological symptoms also will have faded but others, like anxiety or depression, may persist.
Past the first 10 days of heroin withdrawal, the body will have finished detoxing from heroin, but cravings, depression, and other mental health-related symptoms can continue for weeks or even sometimes many months after someone has stopped using heroin.
It is also possible that someone who has undergone heroin withdrawal may experience a secondary withdrawal phase known as post-acute-withdrawal syndrome, or PAWS. Signs of PAWS that can occur months after withdrawal include:
PAWS is typically more common in individuals who have detoxed from alcohol or benzodiazepines, but if you are experiencing symptoms of PAWS after your heroin detox, know that there are many resources available to you.
While a heroin detox is generally not life-threatening, you should still avoid attempting to detox from heroin at home or on your own, as some of the symptoms of heroin withdrawal can pose a significant danger. Because of this, it is much safer to detox from heroin in the care of a medical detox center.
Heroin also has an incredibly high relapse rate, with many users returning to use the drug not only after detoxing and getting clean but before they have made it all the way through the withdrawal process. Part of why this happens is that people detoxing on their own will try to quit cold turkey, which, as previously stated, can cause hallucinations, seizures, and other complications.”
When a heroin user abruptly stops using the drug completely, after abusing it long enough for the brain and body to become dependent on it, the person will experience a sudden and immediate cessation of heroin’s effects on the brain.
The rush of pleasure disappears, and the brain’s dopamine levels bottom out. Even without the risk of seizures, the intensity of this experience is more than enough to cut a detox short and drive someone back to substance use.
Detoxing under the supervision of expert medical professionals in a detox facility gives you a much higher likelihood of completing a heroin detox safely and successfully. They can provide you with medications to decrease the amount of discomfort caused by the symptoms of heroin withdrawal as well as put you on a tapering schedule with medication-assisted treatment.
Many detoxification centers will opt for medical maintenance therapy when treating people with an opioid dependency. This can allow them to slowly wean off heroin instead of all at once, through the use of drugs that can provide similar effects but at a much weaker level to decrease drug cravings.
The typical medications used to help people with heroin withdrawal taper down their usage include:
Methadone, which lessens cravings while blocking the euphoric effects of heroin (although this medication requires strict doses and monitoring, as it carries its own addictive qualities).
Buprenorphine is what’s known as a “partial opioid.” It works like methadone but has less potential for addiction.
Suboxone, the brand name for a combination of buprenorphine and naloxone, a drug that completely cuts off the effects of opioids like heroin and is only used on its own to reverse overdoses.
Naltrexone, a drug that works differently from the ones mentioned above in that it is not addictive and carries no opioid qualities. Instead, it completely negates the feeling of getting high. Naltrexone is also available in the form of an extended-release injection called Vivitrol.
Clonidine, which is primarily a blood pressure medication but has been shown in several studies to help with stress-induced cravings.
Successfully recovering from heroin addiction is simply not possible without first detoxing. However, detoxing from heroin is only the beginning of the rehabilitation journey.
Choosing to go without any aftercare treatment or rehab programs once you have completed the heroin withdrawal process is a sure path to relapse. A study shows that 91 percent of people who completed heroin detox but did not follow up with any kind of aftercare treatment suffered a relapse, with 59 percent using heroin again just one week after being discharged.
Rehabilitation treatment is crucial to remaining abstinent from heroin use. There are many different kinds of recovery treatment programs available, including counseling, therapy, support groups, and even sober living communities. Your treatment program will be customized based on what works best for you. The important thing is to not stop at detox and instead move on to the next phase of treatment.