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Heroin Withdrawal & Detox

Medically Reviewed By: Benjamin Caleb Williams RN, BA, CEN

Written By: Phillippe Greenough

Article Updated: 09/24/2020

Number of References: 10 Sources

Heroin is one of the most dangerous and addictive drugs known today. This is due not only to the sudden and intense euphoria it produces, but also the extremely uncomfortable and even painful experience of detoxing from heroin. The effects produced by long term heroin use result in the body adapting to its presence, and subsequently removing heroin has very severe repercussions for the user, both psychological and physical. Here, we will take a look at heroin withdrawal including the symptoms, the timeline involved, the physical and psychological effects of withdrawal, and some effective detox treatments.

In This Article:

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Symptoms of Heroin Withdrawal

While the symptoms of heroin withdrawal are fairly standard, there may be minor differences between individuals. For the most part, everyone who undergoes heroin withdrawal can expect to experience similar symptoms. These are both mental and physical, and while the “acute” phase of heroin withdrawal has a variety of very intense symptoms, the “post-acute” phase has milder symptoms which are mostly psychological in nature. Anyone who is expecting to go through heroin withdrawal is strongly encouraged to enter a heroin detox center.

Prolonged heroin addiction produces a series of changes in the body over time. Heroin is an extremely potent depressant and slows or dampens many of the vital processes in the body. This is achieved through potent stimulation of opioid receptors in the body and brain, particularly the mu (µ), kappa (κ), and delta (δ) opioid receptors. This causes a cascade of other neurotransmitter effects which include changes in norepinephrine, dopamine, serotonin, and GABA systems. When heroin is suddenly removed, the body becomes hyperactive in an attempt to regain neurotransmitter balance.

After extended exposure to heroin, the body will respond by decreasing the sensitivity and number of these receptors through a process called downregulation. After downregulation has occurred and heroin is removed, the normal opioids produced by the body (known as endogenous opioids) will have an extremely reduced effect. This has the result of boosting many of the normal biological processes into overdrive since the powerful depressants whose presence they had adapted to are now missing.

The brain is capable of correcting the imbalances caused by chronic heroin use but this is a slow process. While the timeline of recovery from heroin addiction is unique to everyone, depending on several factors including genetics, there are a few rough roadmaps for the time required. The time for “acute” detox, or the most dangerous phase of detox, is fairly standard at between 4 to 10 days depending on someones using habits. If someone had used small amounts (less than 1 gram per day) then this may be around 4 to 5 days while if someone used larger amounts (1+ grams per day) then this could lean towards 7 to 10 days.

Acute Withdrawal Symptoms

This is the most painful part of heroin withdrawal. The term “acute” means that it is sudden and severe in onset, producing a wide range of symptoms both physical and mental. Some of the earliest symptoms may begin within hours of the last time someone used heroin. The most uncomfortable phase of heroin withdrawal may be characterized by symptoms which include:

  • Pain in the muscles, joints, and bones
  • Nausea and vomiting
  • Abdominal cramping and diarrhea
  • Reduced or absent appetite
  • Tremors and muscle spasms
  • Excessive tears and runny nose
  • Dilated pupils
  • Goosebumps
  • Repeated yawning
  • Chills and hot flashes
  • Profuse sweating
  • Exaggerated reflexes (similar to spasms)
  • Insomnia
  • Severe restlessness (tossing and turning)
  • Increased anxiety
  • Severe depression
  • Rapid pulse
  • Increased blood pressure
  • Elevated body temperature

These symptoms will begin within 24 hours of the last use and will increase in severity over the first few days of heroin withdrawal.

Post-Acute Withdrawal Symptoms

This is a much longer-lasting form of heroin withdrawal which may take weeks, months, or in rare cases years to fully resolve. The term “post-acute” simply means that it is after the acute phase, therefore is of a milder intensity and not physically dangerous. The post-acute symptoms are psychological in nature, but nonetheless still extremely unpleasant to experience. Different people experience these symptoms to different degrees, and some people may experience combinations of symptoms or isolated symptoms.

Some of the most commonly reported symptoms of post-acute withdrawal syndrome from heroin can include:

  • Deep depression (with or without suicidal ideation)
  • Increased anxiety (particularly social anxiety)
  • Mood swings (sometimes very wild and intense)
  • Insomnia or hypersomnia
  • Vivid dreams or nightmares
  • Increased appetite or sugary food craving (and subsequent weight gain)
  • Lethargy and fatigue (reduced or zero motivation and enthusiasm)

Some or all of these symptoms may be fairly long-lasting and may require medication to manage until the body and mind return to balance. While everyone’s experience with post-acute withdrawal is distinct, there is a treatment for many of the symptoms which may arise.

Heroin Withdrawal Timeline

While acute heroin withdrawal is fairly standard and easy to determine through heroin use history, the prolonged heroin withdrawal symptoms can be somewhat unique to the individual. Heroin use habits do play a role in the withdrawal duration as does genetics, although both of these factors are hard to quantify with regards to their effect on the length of heroin withdrawal.

The onset of withdrawal symptoms will depend, to a degree, on how much someone used heroin but more importantly the route that they chose to use it. For someone using upwards of a gram a day by injection, the symptoms may begin within 6 to 8 hours of their last use. Conversely, if someone had snorted more than a gram per day, it may take 12 to 24 hours before withdrawal symptoms began. The earliest signs of withdrawal can often be a feeling of hollowness or unnatural cold and can progress to the full set of symptoms within 24 hours of these first signs.

The length of acute withdrawal is fairly standard to a certain extent, typically lasting between 4 to 10 days. The variation is based solely on the amounts used and length of time someone used heroin, with longer-term and higher quantity users having to endure longer and more intense withdrawals.

For the example below, we will take the example of a “moderate” heroin user. This person snorted just under a gram per day, and this is a rough outline of the withdrawal duration and intensity that they might expect to face.

Days One & Two

Chills and hot flashes begin as does sweating and goosebumps. There is a gross creeping or itching feeling just under the skin. Depression and anxiety increase dramatically and tremors begin. Stomach cramps and nausea begin the first day followed later in the second day by diarrhea and vomiting. Heart rate and blood pressure begin to increase slowly, but by the end of the second day, they have increased more rapidly and plateaued.

Days Three & Four

Insomnia is dominating the nights due to constant tossing and turning. Diarrhea, vomiting, and intense sweating cause an increased risk of dehydration which makes the symptoms worse, as does lack of food. Aches have now reached their maximum causing joints, muscles, and bones to feel as if they are badly bruised. Depression and anxiety have likely increased substantially by this point.

Days Five & Six

Typically, the symptoms of acute withdrawal will begin to recede by this time, if they haven’t already. The physical symptoms such as increased heart rate and blood pressure, tremor, and aches will probably be the first to go. Vomiting should abate but diarrhea and abdominal cramping may persist for some days with reduced intensity and frequency. Anxiety, depression, and sweating can be expected for a while longer, with sweating being the first of these to disappear. The rest of the physical symptoms should fade around this time.

Second Week and Onwards

The timeline for the prolonged symptoms of heroin withdrawal is difficult to map out since it varies greatly between individuals. Diet and genetics certainly play a factor, although the length of time heroin was used is probably the greatest contributor to the duration. Depression, anxiety, and fatigue should be expected for at least several weeks after acute withdrawal has been completed. Fatigue will be more due to lower energy levels in general and not necessarily insomnia. As mentioned, these may persist for months or possibly even years, however, the latter is very rare. Medications may be used for treating these symptoms and this is recommended. Managing the symptoms so that someone can build a solid foundation in recovery is often the best strategy for dealing with extended heroin withdrawal symptoms.

The Importance Of Detox

Finding a competent heroin detox center can make all the difference in the world when it comes to successful heroin addiction recovery. Modern heroin detox facilities are equipped with the most effective medications, therapies, and support treatments for minimizing the detox symptoms and reducing the risk of relapse. Aside from the immediate benefits of detox, the connections that most detox centers have with the larger recovery community can act as an invaluable resource for continuing treatment after a heroin detox program has been completed.

Heroin Detox Center Guide

What Happens To The Body During Withdrawal?

Heroin addiction can create deep changes in the brain and body, and heroin withdrawal uncovers these changes in a very painful fashion. The adaptation to, and subsequent removal of, heroin results in the body being very unbalanced and unstable for the time it takes to readjust to living in the absence of heroin. This has wide-ranging and very powerful effects on the body as a whole. For a more detailed examination of what happens to the body during heroin withdrawal, let’s take a look at how each different system is effected:

Cardiovascular Effects

The majority of cardiovascular symptoms of heroin withdrawal are due to norepinephrine. This is a neurotransmitter and hormone which helps maintain heart rate, contractility, and blood pressure. Heroin use has a suppression effect on norepinephrine, and similar to the endogenous opioids, norepinephrine gets downregulated as a result of chronic heroin use. When heroin is removed and this suppression effect is no longer present, norepinephrine levels soar. Heart rate increases along with blood pressure due to vasoconstriction and the sudden increase in norepinephrine can lead to heart arrhythmias or irregular heartbeats, although this usually only occurs in those with pre-existing heart conditions.

Gastrointestinal Effects

While the opioid receptors in the brain are responsible for the euphoria produced by heroin use, there are also a huge number of these same receptors all throughout the gastrointestinal tract. Endogenous opioids moderate the smooth digestion of food and healthy bowel movements. Again, due to downregulation, once heroin is removed during detox these receptors are unable to slow intestinal contractions and the result is stomach and abdominal cramping as well as diarrhea. This process can worsen the rest of the detox symptoms as any food that is eaten during this time will not be digested properly and frequent diarrhea will contribute to dehydration. It should also be noted that appetite will be almost non-existent throughout detox from heroin. This is probably due to the increase in norepinephrine and will likely be accompanied by vomiting.

Secondary Effects

While the cardiovascular and digestive systems receive the brunt of the physical symptoms of heroin withdrawal, there are a variety of other issues. These result from a variety of interactions such as the autonomic nervous system and includes:

  • Allodynia: A sensation of pain from things that are normally not painful. This is due to opioid system downregulation coupled with the hyperactivity of the sympathetic nervous system.
  • Increased Respiration: Due to norepinephrine and the resulting increase in heart rate.
  • Dilated Pupils: Due to norepinephrine and other “fight-or-flight” neurotransmitters and hormones whose levels surge during detox.
  • Piloerection (aka goosebumps): Technically a result of norepinephrine on muscle tone.
  • Diaphoresis (excessive sweating): Again, due to increased norepinephrine sensitivity, someone may sweat profusely regardless of the outside temperature.
  • Lacrimation (excessive tears): Aside from crying, the eyes may water constantly during the first few days of heroin detox.
  • Rhinorrhea (excessively runny nose): Like a faucet, the nose will run constantly. The mucus is typically very thin and watery and this is partly due to lacrimation.
  • Hyperreflexia (exaggerated reflexes): This is neurological in nature, but greatly heightened reflexes are common during heroin withdrawal. This may make a normal reflex response appear like an exaggerated, almost comical overreaction to a normal stimulus.
  • Muscle, Bone, and Joint Pain: Technically a component of allodynia, this is a constant ache deep in the body. Most likely due to endogenous opioid system disruption, this is most intense during the first few days of heroin detox.
  • Constant Yawning: The exact cause is unclear, but many people undergoing detox from heroin will yawn incessantly; sometimes as much as three or more yawns per minute.

Likewise, muscles become tense due to increased norepinephrine levels as well as psychological tension and stress and the body will release stored sugar causing blood sugar levels to spike. Finally, elevated body temperature is a result of increasing norepinephrine and reduced serotonin levels. This is all very sudden in a biological context; occurring only hours after someone last used heroin and growing in intensity over the first few days of heroin detox. These changes happen normally all the time, but the intensity and suddenness with which it happens during withdrawal can contribute to the uncomfortability of the experience.

Psychological Effects Of Heroin Detox

While the physical effects are certainly intense, the psychological effects may actually be the most dangerous with regard to someone’s chances of recovery. The neurotransmitter imbalances in the opioid system resulting from heroin withdrawal can have downstream and secondary effects on the dopamine, serotonin, norepinephrine, and GABA systems. In addition to downregulation, heroin use can produce further structural changes in the brain through a process known as remodeling. Remodeling is an attempt of the brain to operate more effectively in an opioid-downregulated environment. During heroin withdrawal, this can manifest as a series of emotional, mood, and behavioral changes in both the short and sometimes long term.

Depression

When using heroin, the amounts of the neurotransmitters dopamine and serotonin that are released in the brain get increased. Both of these neurotransmitters have an impact on mood; dopamine can produce please and positive emotional states, while serotonin is a mood elevator and regulator. These systems can also undergo downregulation and remodeling through chronic heroin use, and during withdrawal, this can produce a sometimes profound depressive mental and emotional state.

Dopamine imbalances can result in a lack of enthusiasm or pleasure, even from normally pleasurable stimuli. Serotonin imbalances can contribute to this depression, leaving someone feeling hopeless, unmotivated, and even that life without heroin is not worth living. This is absolutely not the case, but it will take time and continued abstinence from heroin for someone to be able to see hope. Medications and behavioral therapies can reduce the symptoms, but it may take weeks, months, or sometimes even years for the brain to return to pre-heroin levels of function.

Increased Anxiety

Similar to depression, anxiety during heroin withdrawal is caused by dopamine and serotonin imbalances, as well as an increase in norepinephrine. The physical symptoms may actually contribute to the psychological state of anxiety since the body is hyper-aroused during the detox process as well. The increase in dopamine and norepinephrine plus the decrease in serotonin will conspire to create a state of intense anxiety which escalates during the first week or so of detox and may persist in a minor form for many weeks after detox. The brain needs time to regain chemical balance, and the subjective experience during this time will be tense and mentally exhausting. These symptoms may be minimized through medications, but some degree of anxiety should be expected during and after heroin detox.

In addition to the neurological causes, there are also behavioral or psychological causes for anxiety. Heroin can become a very powerful coping mechanism, even though it is an extremely unhealthy one. Having that mechanism suddenly removed can leave someone feeling lost, overwhelmed, and scared. This can manifest as a constant state of anxious unease that may persist for many weeks or months after heroin use ceases. This may also benefit from medications as well as behavioral therapies, but it often takes time for anxiety to resolve completely.

Mood Swings

Similar to the symptoms of both depression and anxiety, wild mood swings are very common symptoms of heroin withdrawal. This is due to the general neurological hyperactivity which results from the heroin detox process. The downregulation and further remodeling of neurotransmitter systems, as well as the brain’s attempt to correct this imbalance, can sometimes result in very intense mood swings which may happen frequently. This can result in someone alternating between feeling fine and abysmal depression over the course of hours. This may be dampened through mood stabilizers or various other medications, but must be taken very seriously and monitored by medical professionals.

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What Factors Influence the Intensity of Heroin Withdrawal?

The acute phase of heroin withdrawal is almost entirely influenced by the amounts of heroin someone used as well as the length of time that someone used. Even though use habits span a wide range among users, acute withdrawal very rarely lasts shorter than 4 days or longer than 7 days. Someone’s heroin use habits are probably the largest contributor to the intensity and duration of heroin withdrawal symptoms, but there are other contributors as well, including:

  • Amounts of heroin used
  • Duration of heroin use
  • Genetic predisposition to addictive behavior
  • Co-occurring mental health issues

The intensity of the withdrawal symptoms is most greatly affected by the amounts of heroin that someone used as well as the route that they chose to do it. Shooting up heroin delivers much more of the drug directly into the brain. By more heroin reaching the brain more quickly, greater downregulation takes place, and therefore the greater the withdrawal symptoms once heroin is removed. Likewise, since downregulation occurs to a greater degree, more time is needed for the brain to correct this imbalance once heroin is removed.

Likewise, the length of time that someone used plays a role as well, although that mostly affects the length of time before the brain is able to regain balance. Neurological remodeling, while beginning alongside downregulation, takes time to occur, and subsequently to reverse. The longer someone used heroin, the more remodeling their brain performed, and thus the longer it will take them to experience relief from these symptoms once heroin use is ceased.

Both genetics and co-occurring mental health issues may play a role in heroin withdrawal symptoms as well, although these contribute in a more indirect way. Addiction tends to run in families, and if someone is genetically predisposed to addiction, then they may begin using heroin earlier in their life or begin using more heroin more quickly whenever they do begin using it. This can subsequently impact their withdrawal symptoms. Mental health issues may also contribute to the severity or duration of symptoms. Since depression and anxiety are such common symptoms of heroin withdrawal, if someone were already struggling with mental health issues of this nature, they may experience worse psychological symptoms than someone with no such pre-existing mental health issue. Likewise, it is possible that these psychological symptoms may persist for longer than in someone with no such mental health issue.

Heroin Withdrawal Treatments

he greatest challenge to heroin treatment is getting overcoming heroin withdrawal symptoms. There are programs specifically designed with this goal in mind. Heroin detox centers have undergone explosive growth in the last 15 years as the opioid epidemic has swept America. There are many effective therapies and medications that are used very effectively to reduce the withdrawal symptoms from heroin, both physical and mental. Furthermore, researching newer medications to help manage the withdrawal symptoms which result from heroin and opioid addiction has become a major priority in the medical community at large in recent years.

-Medications

Recently, the FDA approved a medication specifically for the treatment of heroin withdrawal, in the form of lofexidine (Lucemyra). Before this, there was still a wide range of medications that were effective in treating the psychological and physical symptoms of heroin withdrawal. These were used to address individual symptoms, and are still commonly used today.

Some of the most effective medications for treating heroin withdrawal include classes such as:

  • Opioid Antagonists (typically only used for post-acute symptoms such as cravings)
  • Antidiarrheals
  • Certain Blood Pressure Medications
  • Anti-Anxiety Medications
  • Antidepressants
  • Non-Narcotic Sleep Aids
  • Certain Antihistamines

These are just some of the general classes of medications that are most often used. Again, the new medication containing lofexidine may treat many symptoms of heroin withdrawal but there are still many medications that can address specific symptoms as they arise.

-Therapies

There are also a variety of therapeutic techniques that have proven very effective at treating the behavioral and emotional symptoms of heroin withdrawal. While everyone will find certain therapies more or less useful depending on their individual needs, many of the most effective techniques have focused on rebuilding connections with others and being open and honest.

Some broad types of therapy that have proven very effective including:

  • Individual Counseling
  • Behavioral Therapies
  • Group Therapy
  • Nutritional Classes
  • Aftercare Planning
  • Coping Skills Development and Addiction Education

These are just a few of the therapies commonly used, but everyone will need to find the ones which are most effective and helpful for them. The clinical and psychiatric professionals at a heroin detox center can be a great help in exploring the landscape of available and effective therapies to find the most appropriate one for each individual.

Heroin detox is the first step towards lasting recovery, and greatly increases someone’s chances of success in overcoming this addiction. Not only will they be able to prescribe medications to safely manage the most painful and intense symptoms of acute withdrawal, but they will be able to assist someone in finding psychiatric help for the post-acute symptoms as well. Furthermore, these centers often have connections with the local recovery community in the form of continuing care programs, affiliated treatment facilities, and recovery fellowships of all kinds. There are helping hands available to overcome heroin withdrawal, all someone has to do is reach out and grab one.

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