Heroin Withdrawal: Detox Medications, Treatments and Advice

“Though no one can go back and make a new start, anyone can start from now and make a brand new end.” Carl Bard¹

Heroin withdrawal - it’s terribly uncomfortable but rarely dangerous. You can do it safely on your own, but getting professional support and appropriate medication increases your odds of success.

Read on to learn more about:

• Withdrawal: what to expect and when to expect it.
• The benefits of a supportive detox program (though you can safely detox on your own.)
• How to decide between outpatient, residential and medical inpatient care.
• The different medications used to treat heroin withdrawal symptoms and why buprenorphine has become the treatment medication of choice.

Heroin Withdrawal Symptoms

Heroin withdrawal symptoms may begin as early as 6 to 12 hours after your last dose, they are most severe at between 2 and 4 days of abstinence and mostly gone by the seventh day. Typical withdrawal symptoms include:

• Anxiety, irritability and agitation.
• Muscle twitches and spasms.
• Muscle and joint pain.
• Headaches.
• Insomnia.
• Tearing.
• Runny nose.
• Increased sweating.
• Increased urination.
• Frequent yawning.
• Stomach cramping and diarrhea.
• Nausea and vomiting.
• Quickened heart rate and increased blood pressure.
• Dilated pupils.
• Goosebumps.
• Insomnia and heroin cravings.

Though severe physical symptoms subside within a week, lingering anxiety, depression, insomnia and drug cravings can persist for weeks or months. This is known as post acute withdrawal syndrome, or PAWS.

Heroin Withdrawal Risks and Dangers

Though heroin withdrawal feels pretty uncomfortable, it is almost never dangerous for people in reasonably good health.

Heroin withdrawal can be more dangerous for anyone with a co-occurring physical or mental health condition, for example:

• Withdrawal- related dehydration is more dangerous for a person with diabetes, or, a person with managed schizophrenia is at increased risk of an acute psychotic episode during the intense withdrawal period.

If you have a current psychiatric or medical condition, you should discuss your withdrawal plans with a health professional prior to detoxing.²

Rare but possible complications include:³

• Breathing vomit into the lungs (aspiration).
• Dehydration from excessive diarrhea and vomiting.

The Biggest Risk Is Relapse Overdose

Though heroin withdrawal symptoms probably won't hurt you, relapse overdose can kill you.

You are at significantly elevated risk of fatal overdose if you relapse after even short periods of abstinence. Most opioid deaths occur in people who have just detoxed.  If using after a break – be sure to use a much smaller dose than what you took prior to your break.

• A week or two of abstinence can reset your tolerance to zero and your old ‘normal’ dose could be potent enough to kill.

So Why Get Professional Help?

Most people can safely attempt a heroin detox without needing professional assistance. That being said, entering an outpatient or residential detox program offers some significant advantages.

Heroin withdrawal symptoms are rarely dangerous and people kick heroin without help all the time – so what’s the point of spending time, energy and money going to a detox program for the withdrawal period?

Well, some of the benefits of professional help include:

• Increased comfort – Getting appropriate medications at appropriate times can reduce discomfort. For most people, this is a significant benefit.
• Improved safety – Though heroin withdrawal alone is rarely dangerous, complication risks increase when heroin withdrawal co-occurs with a psychiatric or medical health condition.
  
• Getting into an ongoing treatment program – Just getting through the detox period does little to keep you clean over the long run.  Staff at a professional detox program will assess you and help you find an appropriate treatment program for continuing treatment at the end of the managed withdrawal period. Since many people with heroin addictions also have co-occurring mental illness, you may also get linked to appropriate mental health care.
  
• Getting linked to other service agencies – A detox program may also help you make contact with other social and governmental service agencies.

Though you can safely attempt a cold-turkey detox on your own, doing it alone leads to more discomfort and greater odds of early relapse. Getting professional assistance and appropriate medication increases your chances of a successful outcome.⁴

The Importance of Regular Monitoring

Why do you need to see a health worker each day?

Typically, on an outpatient basis you will see a health professional at least once daily for a check-in. In a residential detox, monitoring occurs more frequently. When observing your progress, health professionals will evaluate:

• Your overall progress (looking for any complications or excessive difficulties).
• The severity of your current withdrawal symptoms.
• Your response to any withdrawal medications.
• Your current motivation level.
• Your current other drug use.

Frequent monitoring helps to stop small complications from becoming serious problems, it facilitates a move from outpatient to residential care for anyone not doing well at home and it allows for medication adjustments to ease discomfort and reduce side effects.

Inpatient, Residential or Outpatient Detox?

Professionally supported and supervised heroin withdrawal can occur in three primary settings:

• In a medical inpatient facility, such as a hospital.
• In a non-medical residential setting – such as a community withdrawal center.
• On an outpatient basis (you sleep at home each night).

Most people can detox safely and effectively on an outpatient basis. 

You should talk with your doctor or with another addiction treatment professional to decide on the most appropriate detox-setting. Everyone has individualized needs, but you can use the following recommendations to get a general sense of which setting makes most sense for you.

Consider a medical inpatient facility if:

• You have an unstable medical or psychiatric condition that could worsen your withdrawal experience.
• You are dependent on more than one drug, for example heroin and benzodiazepines. Polydrug dependence greatly complicates withdrawal.
• You have a history of medical or psychiatric complications during past withdrawal periods.

Consider a general residential detox if:

• You don’t have any co-occurring medical or psychiatric conditions or polydrug dependence that could complicate withdrawal.
• Your living situation complicates your quit attempt - People with unstable living environments, those living with active drug users and those lacking a supportive person for detox assistance should consider a residential detox.
• Outpatient detox has not worked for you on repeated past occasions.
• You live in a very rural setting and can’t easily travel to see a health professional each day during an outpatient detox.

Consider an outpatient detox if:

• You have no medical or psychiatric complications
• You are not addicted to any other drug or alcohol.
• You have a stable living environment and people around you support your efforts.
• You have not tried detoxing on an outpatient basis yet (as a general rule of addiction treatment, the least intensive/intrusive treatment that gets results is the best options.)

Preparing for an Outpatient Withdrawal

When detoxing on an outpatient basis, advance preparation helps you avoid relapse through the first 7 days of withdrawal. To get ready, be sure to:

• Find a stable environment where you won’t have easy access to drugs and where you won’t be exposed to other people who are using heroin or other drugs.  Trying to detox among other people still using heroin is extremely difficult.
• Enlist a supportive person to care for you throughout the detox period. Make sure this person knows what to expect and what they can do to help you.
• Learn as much as you can about the withdrawal symptoms you can expect and about how long these symptoms will last.
• Research in advance how to cope with withdrawal symptoms. If you need medications to manage withdrawal symptoms, be sure to have these bought in advance of your detox attempt.
• Prepare for strong cravings and have a plan to deal with your cravings.

Remember, sweating, vomiting and diarrhea can lead to dehydration and dehydration increases your risks of serious complications. Make sure to stay hydrated, even when it’s difficult, and if you can’t, consider checking into a residential clinic.

Predicting Your Withdrawal Symptoms Severity

With withdrawal, you can at least partially predict the future by looking at your past. Two factors that can help to predict symptoms severity are:⁵

1. Past withdrawal episodes – Past episodes of severe withdrawal symptoms predict future tough withdrawals
2. Your recent use history – In general, the more you’ve been using, the tougher the withdrawals. You are considered to be on the low end of use if you use/inject once or twice a day and on the high end of use if you use/inject 4 or more times per day. 

Don’t Try to Fix All Your Problems at Once

Though you may consider your detox a new start on a better life, and though you might look forward to major life-improvements, don’t try to fix personal, legal or relationship problems while dealing with heroin withdrawal symptoms.

• During the detox period, you will struggle with irritability, anxiety, moodiness and lack of focus and concentration; this reduces your ability to think clearly and make good decisions.
• Trying to handle life problems while detoxing increases stress and this can increase drug cravings.

Heroin Withdrawal Treatment Medications

One of the most compelling benefits of any form of professionally supported heroin detox is complete access to a range of medications that can ease symptoms and drug cravings, such as:

1. General withdrawal symptoms medications
2. Clonidine
3. Buprenorphine or methadone
4. Naltrexone
   

General Withdrawal Symptoms Medications

A range of over the counter and prescription medicines can help to ease individual withdrawal symptoms. Examples of medications you might use include:⁶

• Acetaminophen or ibuprofen – for muscle and joint pain.
• Benzodiazepines – for anxiety
• Imodium – for diarrhea.
• Hydroxyzine (Vistaril) or diphenhydramine (Benadryl) – for restlessness, anxiety and insomnia.
• Promethazine (Phenergan) or metoclopramide (Reglan) – for nausea.
• Calcium carbonate (Tums) or milk of magnesia - for abdominal pain.

Since detox medications can interact with each other, and since benzodiazepines have a significant overdose risk, use under a doctor’s care and use with caution.

Clonidine

Clonidine is a high blood pressure medication that is also commonly used to treat opioid withdrawal symptoms.

Clonidine can reduce:

• Anxiety and agitation.
• Muscle aches.
• Sweating and runny nose.
• Cramping.
  

It is typically combined with other medications, such as medications to control nausea and diarrhea.

Note* Recently, buprenorphine has proven a more effective choice than clonidine + other symptoms medications.

Buprenorphine (Suboxone)

Buprenorphine is a partial opioid agonist that’s used to replace heroin in your body. When on an appropriate dose of buprenorphine, you feel reduced drug cravings and opioid withdrawal symptoms.

Studies indicate that people who get buprenorphine for heroin withdrawal have better outcomes than people who use clonidine combined with other withdrawal symptoms medications.

• Buprenorphine works better to reduce withdrawal symptoms and people on buprenorphine are less likely to drop out of detox than people on clonidine.⁷
  

Buprenorphine can be used as a long term maintenance medication, or as a short term detox medication. When used for detox, you would take the medication for between 5 and 21 days. On the first day or two you stabilize on a dose that offers nearly full withdrawal relief, and then you taper down from that dose over the following days. Here is an example of a proposed 7 day buprenorphine detox schedule

You must wait at least 6 hours after your last dose of heroin. Taking buprenorphine too soon after taking a short acting opioid like heroin can lead to precipitated withdrawal (full and sudden onset).

• Day 1 - Once experiencing withdrawal symptoms, you would take between 4 and 8 mg of buprenorphine, split into 4 mg morning and 2 to 4 mg evening doses. The evening dose is given if needed, to alleviate overnight withdrawal symptoms.
• Day 2 – 4 to 8 mg of buprenorphine  (4 mg morning and 2 to 4 mg in the evening).
• Day 3 – 4 to 6 mg of buprenorphine (4 mg morning and 2 mg evening).
• Day 4 – 4 mg of buprenorphine (2 mg in the morning and 2 mg in the evening)
• Day 5 – 2 mg of buprenorphine in the morning
• Days 6 and 7  - 0 mg of buprenorphine. You stay under observation and get other medications for withdrawal symptoms as needed.

Ideally, you take a flexible approach and use only as much buprenorphine as needed to stay reasonably comfortable. Residential programs generally offer more frequent monitoring and assessment and this may lead to a more individualized dosing schedule.

Since buprenorphine is a CNS depressant, combining it with benzodiazepines, alcohol or other depressants increases your risks of severe respiratory depression and death. If you can’t abstain from other drugs and alcohol during an outpatient detox, you should either check into a residential program or avoid buprenorphine.

(Note* When using Suboxone for long term maintenance, your daily dose should eliminate withdrawal symptoms and cravings. When used for a short duration for detox tapering you won’t get full withdrawal/cravings relief, but you will see a substantial reduction in symptoms intensity.)

Methadone

Methadone can be used in the same manner as buprenorphine. However, since methadone withdrawal is tougher and longer than buprenorphine withdrawal, buprenorphine is considered the better choice for detox.

Because methadone is such a long-lasting drug, a tapered detox will take longer (typically a few weeks to a month) than a buprenorphine detox.

Naltrexone

Naltrexone is an opioid antagonist that’s often prescribed to people who have completed an opioid detox. When you take naltrexone, heroin or other opioids cause little or no effects. Naltrexone may increase your odds of avoiding relapse, but it can cause a very temporary upswing in withdrawal symptoms when first administered post-detox.

What about (Ultra) Rapid Opioid Detoxification?

With rapid opioid detox you are placed under anesthesia and an opioid antagonist is used to flush out any active opioids from your opioid receptors – thus accelerating and intensifying the withdrawal procedure. Since you are under sedation during this initial period, you avoid the worst of the discomfort.

It’s a procedure with some obvious appeal, but unfortunately, consensus statements from groups like the American Society of Addiction Medicine and the California Society of Addiction Medicine show that experts generally don’t endorse the procedure as worth the risks (or the high costs).

Criticisms of (ultra) rapid opioid detoxification include:⁸

• It turns normally safe heroin detox into a procedure with significant risks.
• Though it purports to reduce withdrawal discomfort, withdrawal symptoms can still be severe.
• There is little standardization between providers.
• Though it increases the risks, relapse rates are not reduced (when compared to relapse rates after conventional detoxification).

Research indicates that people getting rapid opiate detox:⁹

• Do not have better outcomes than people who get a traditional detox.
• Are at greater risk of serious adverse health consequences.

What If You Can Never Stay Clean?

Relapse following opioid detox is very common. Getting addiction treatment after detox reduces the risks of relapse, but if you find that you can never maintain abstinence, even after multiple quit attempts, experts recommend that you try longer-term medication assisted treatment (MAT) with methadone or buprenorphine (Suboxone). People on MAT are far less likely to relapse back to illicit opioid use.¹⁰

Though some people prefer the idea of unmedicted abstinence, there are significant benefits associated with switching from heroin to long-term methadone or buprenorphine, such as:

• Better health and a reduced risk of early death.
• Reduced risks of HIV, Hep C and other infectious disease transmission.
• Reduced consumption of harmful adulterants that are added when cutting heroin for street sale.
• 24 hours of freedom from withdrawal symptoms and drug cravings – this stability can help you turn your focus to building a satisfying life (rather than focusing on getting and using drugs every day).
• Reduced need to commit criminal acts. 

If you can’t stay clean without medication, it’s far better to stay healthy and alive on methadone or Suboxone than unmedictated and at high risk of jail, disease and death while relapsing chronically back to heroin.