KEY TAKEAWAYS
What Is Heroin Detox?
Heroin detox treatment is a Medication Assisted Treatment (MAT) programme for supervised heroin withdrawal involving urgent treatment and trauma-informed care [3].
Buprenorphine is a partial opioid antagonist and is the most commonly used treatment in inpatient settings, resulting in treatment retention of 90% [4].
Withdrawal symptoms are monitored regularly throughout the 7-10 day addiction treatment and are treated medically as required, for example, SSRIs for opioid-induced depression.
Medical detox from heroin addiction takes longer when it has been used for more extended periods, as physical dependency is increased.
Physical Symptoms Of Heroin Detox
Physical symptoms of heroin withdrawal are managed professionally using appropriately prescribed detoxification medication such as Buprenorphine or Suboxone.
Yawning occurs in withdrawal due to a 50% reduction in dopamine receptor expression [5].
Excessive tearing and a runny nose appear 8-10 hours into abstinence [6].
A 4-fold increase in interleukin-2 levels occurs over four weeks of abstinence compared to non-users, resulting in a runny nose and watery eyes [7].
Excessive sweating during treatment is caused by the release of histamine [8].
Restless legs syndrome appears, on average, two days into heroin withdrawal due to the downregulation of dopamine receptors [9].
One study suggests that 38% of patients experience vomiting at around 72 hours, but this can be managed using cyclizine [10].
Increased sensitivity to pain in detox means that comfort levels are continually monitored throughout the programme.
Pain is decreased by 56.5% after buprenorphine administration, and this can be further managed with naproxen [11].
Physical symptoms may include pain and muscle aches due to increasing prostaglandin levels (1,030 ± 373 pmol/μl), primarily if naloxone is used to treat heroin addiction [12].
Pre-existing injuries experienced in 65% of patients are professionally managed using naproxen and ibuprofen as necessary [13].
Psychological Symptoms Of Heroin Detox
Psychological symptoms beyond the effects of detox medication, can be managed professionally by prescribing on a symptom management basis.
Depression occurs in 14.6% more heroin addiction patients than cocaine addiction patients, and anxiety occurs in 26.5% more heroin addiction patients than cocaine addiction patients [14].
Anxiety occurs due to an 80% reduction in endorphins in patients receiving buprenorphine compared to naloxone treatment [15].
Depression in heroin detox is caused by a 50% reduction in dopamine that has not yet been restored since active use [16].
Patients may experience an irritable mood when heroin is no longer available to release dopamine, resulting in mood imbalances as heroin is highly addictive.
Discontinued heroin use leads to intense psychological and physical cravings due to heroin's potency (2-3 times more potent than morphine), resulting in emotional distress during withdrawal.
Patients experience a 12.7% reduced sleep efficiency compared to controls, with a 16% reduction in total sleep time; however, melatonin supplements are prescribed to manage sleep problems [17].
Heroin Detox Recovery Markers
Gastrointestinal System Regulation
Symptoms of patients experiencing diarrhoea in detox typically diminish within 7 days and will be treated with loperamide in a rehab setting.
In heroin detox, easily digestible and nutritious foods are provided and have been reported to help 92% of those undergoing heroin detox [18].
Gastrointestinal regulation typically occurs within 7-14 days of detox, though this varies from patient to patient.
Animal studies on mice demonstrate that during heroin withdrawal Claudin-1, a protein found in the gut, increases by 17%, indicating an improvement to the endothelial barrier in the intestines in 5 days [19].
Body Temperature Improvements
Although animal studies show a four-fold increase in corticosterone levels in rats within 12 hours of detox, thermoregulation recovers to baseline within 8 days of withdrawal in humans [20].
Animal studies suggest that most thermoregulation recovers within 16 days of detox, though this may vary [21].
In detox, homeostasis is achieved through hypothalamus regulation, as evident from day 7.
Thermoregulation aids weight gain in heroin withdrawal, and rat studies indicate a 60+ gram weight increase over 16 days of abstinence [22].
Flu-Like Symptom Reduction
Heroin detox reduces flu-like symptoms by administering buprenorphine in detox, reducing flu-like symptoms over one day by 56% as measured by the Clinical Opioid Withdrawal Scale (COWS) [23].
Research indicates that over 5 days of detox, flu-like symptoms, for example, sweating and runny nose, are reduced by 95% [24]
For patients experiencing later onset of sweating and body aches (48+ hours), these symptoms will persist for up to 10 days, patient-dependent.
Suboxone used in detox reduces clinically measured flu-like symptoms by 94% over 5 days of use and is the primary method of medicated-assisted treatment at Abbeycare [25].
Heroin Detox Timeline
Heroin Detox Time Period | Presentation | Medical Interventions |
|---|---|---|
6-12 Hours | Intense craving for heroin Anxiety/ Depression Heroin-seeking behaviour Watery eyes Runny nose Yawning Restlessness Agitation | SSRIs Clonidine, buprenorphine, suboxone |
12-24 Hours | Vomiting Sweating Fever/chills Diarrhoea | Anti-nausea medications Naproxen, ibuprofen Loperamide |
48 Hours | Muscle aches Insomnia Palpitations | Naproxen, ibuprofen Melatonin Lofexidine as needed |
5 Days | Difficulty sleeping Weight loss | Melatonin |
5-10 Days | Increased blood sugar Physical weakness Lack of energy Symptoms begin to subside (day 10) | The above as needed |
Clinical Opioid Withdrawal Scale (COWS)
The clinical opioid withdrawal scale (COWS) in heroin detox is an 11-item scale used to assess the severity of the following withdrawal symptoms:
COWS is used in initial assessment and at 15-minute increments during treatment to monitor withdrawal symptoms and whether additional medication is required.
The scale allows medical professionals to categorise heroin withdrawal symptoms into mild, moderate, moderately severe and severe to increase medical observations as necessary.
COWS is implemented in the heroin treatment programme at Abbeycare to assess severity of withdrawal symptoms.
Heroin Detox Complications
At Abbeycare, we are fully committed to minimising complications; however, if any occur, these are professionally and medically treated as necessary.
Dehydration occurs due to the loss of electrolytes and water from vomiting and diarrhoea.
One case of cardiomyopathy resulting from the physical stress of heroin withdrawal has been noted - this can be managed with Suboxone and anti-hypertensive medication [28].
Heart injuries from heroin use and withdrawal cause troponin levels to become elevated (> 0.015-0.045 ng/mL), and this is detected in blood tests [29].
Abdominal cramps and diarrhoea occur in 70-85% of detoxing patients, and this can be appropriately managed using loperamide [30].
Patients undergoing heroin detox have a 2-fold increase in norepinephrine, resulting in anxiety, sweating, muscle tension and "fight or flight" responses [31].
Patients in heroin detox have a 5-fold increase in epinephrine levels, leading to high blood pressure and panic attacks [32].
The high prevalence of depression-anxiety in heroin patients entering detox (46.42%) is caused by a reduction in dopamine receptor binding and release [33].
Heroin users show 20.2% lowered cortisol levels, resulting in fever and chills during withdrawal [34].
Heroin Detox Vs Heroin Maintenance
Detox | Maintenance | |
|---|---|---|
Aims Of Treatment | 100% abstinent from heroin No subsequent medication use after treatment | Replaces heroin with methadone Allows patient to be treated at home |
Setting Of Use | Inpatient | Outpatient |
Duration | 7-10 days | Months to years, on a case-by-case basis |
Drugs Used | Buprenorphine or Suboxone | Methadone |
Level Of Medical Supervision | Medication rounds 4x/day initially Medication rounds 2x/day on Day 3-4 | Initial doses are supervised in the clinic Medication is later self-administered |
Type Of User | Wants to detox from all drugs Allergic to methadone May forget regular methadone doses Illicit drug use | Is not ready to fully detox Allergic to buprenorphine or suboxone Incarcerated |
Rapid Detox Vs Regular Detox
Important: Rapid detox (e.g. 5 day) is no longer carried out in the UK and is not offered as part of the heroin detox programme at Abbeycare.
Rapid Detox | Regular Detox | |
|---|---|---|
Duration | 5 days inpatient | 7-10 days inpatient |
Withdrawal Symptoms | Extreme vomiting High temperature (40C) Side effects from intubation Dysphoria | Muscle aches Mood swings Anxiety/ depression Insomnia |
Type Of Patient This Is Used For | Those who want to detox quickly
Those who do not want to experience withdrawal symptoms | Does not want to be sedated Desire to uncover underlying core beliefs |
Relapse Rates |
What Changes Heroin Detox?
Method Of Use
Patients who are intravenously injected heroin are more at risk of relapse than non-injection heroin users, so mild injection-site abscesses are resolved in detox or sent to hospital for further treatment [36].
Detox focuses on combatting combined heroin and marijuana use, as smoking marijuana alongside injecting heroin results in a 2-fold increased risk of relapse at 9 months post detox [37].
Detox incorporates HIV testing when patients have been using needles to inject heroin, as 81% of intravenous heroin users share needles [38].
Co-Occurring Conditions
One case study showed that pre-existing bipolar disorder lowered treatment retention, but when medically managed, this led to 8 months of abstinence post-treatment [39].
For patients with hepatitis C in heroin detox programmes, HCV treatment is required alongside detox, as well as support in navigating the healthcare system [40].
Patients with hepatitis C tapering buprenorphine over 12 weeks have 40.2% less aspartate aminotransferase compared to tapering buprenorphine over 2 weeks, resulting in less liver damage [41].
Administering buprenorphine to injection heroin users in detox lowers the rate of subsequent HIV transmission to 0.2-0.4% two years post-treatment due to a decrease in HIV-risk behaviour [42].
37% of patients taking Quetiapine for co-occurring psychiatric symptoms in heroin detox report reduced cravings, whilst 24% reported an anxiety reduction [43].
Medications Used In Detox
Buprenorphine has a longer half-life than heroin (37 hours), so it helps to alleviate withdrawal symptoms.
For those with a risk of becoming addicted to methadone, buprenorphine is the treatment of choice, as buprenorphine involves detoxing from heroin and all substitution medication entirely.
Methadone is typically used for maintenance treatment used from months to years, and is mainly used when full detox is not possible; however, this extends the total treatment period.
Both clonidine and lofexidine are effective at reducing symptoms related to heroin withdrawal, making the detox process more comfortable.
For individuals with pre-existing hypotension, lofexidine is preferred by medical professionals, as clonidine causes decreased blood pressure [44].
For patients at risk of low treatment compliance, buprenorphine is more appropriate as it increases retention rates by 19% compared to lofexidine [45].
Patients on buprenorphine are 40% more likely to complete heroin detox compared to clonidine, making it practical for treatment compliance [1].
Heroin Detox At Abbeycare
Heroin detox is provided at Abbeycare as part of a full rehab programme.
The medically assisted treatment used in the Abbeycare programme for heroin dependence is selected on a individual case-by-case basis and considers:
- Any allergies to medication
- Previous history of heroin use
- Any other drugs used concurrently (prescribed or illicit)
