What is the Timeline for Heroin Withdrawal?

While heroin withdrawal is rarely fatal in and of itself, it can lead to potentially dangerous conditions that can be life-threatening, especially in conjunction with other preexisting medical conditions (such as diabetes or heart disease for example). 1

Additionally, vomiting and diarrhea are very common during heroin withdrawal, and these issues can lead to dehydration. Coupled with sleep deprivation due to insomnia, a person can easily become delirious if their withdrawal symptoms are severe enough and they are not under medical supervision.

Heroin Withdrawal Symptoms

The symptoms of heroin withdrawal range from mild to severe, depending on someone’s heroin use habits. While the same symptoms may be present during any level of withdrawal intensity, they can vary in severity.

Moderate symptoms of heroin withdrawal can include:

  • Gastrointestinal Distress (pain in the abdomen & writhing stomach)
  • Diaphoresis (excessive sweating)
  • Insomnia
  • Anxiety
  • Depression
  • Feeling Cold (no matter the ambient temperature)
  • Creeping Feeling in the Skin
  • Frequent Yawning

Some of the more severe symptoms of heroin withdrawal may include:

  • Insomnia
  • Severe Anxiety
  • Severe Depression (with or without suicidal ideation)
  • Feeling Both Hot and Cold Simultaneously (typically expressed as cold skin, hot insides)
  • Crawling Sensation Under the Skin (typically expressed as bugs crawling or pin pricks)
  • Incessant Yawning and Stretching
  • Excessive Diarrhea
  • Severe Gastrointestinal Distress (pain in abdomen)
  • Frequent Vomiting
  • Diaphoresis (excessive sweating)
  • Psychomotor Agitation (constant foot tapping, pacing, or tossing & turning in bed)
  • Pain in the Muscles, Joints, or Bones
  • Allodynia (perceiving pain from typically non-painful stimulus)

Aside from the direct symptoms of heroin withdrawal, it's common to get sick either during or shortly after withdrawal. Opioid withdrawal has a severe impact on immune system function through mechanisms which are not fully understood. Conflicting studies have shown both increased and decreased immune function immediately after withdrawal.

Heroin Withdrawal Timeline

Heroin withdrawal is unpleasant no matter the severity, but the duration and intensity of symptoms are dependent on the amounts used and the length of time someone used. On average, heroin withdrawal can last around 5 days. The symptoms will increase, peak, and resolve during this time, but lingering symptoms may persist for several weeks or months.

Day 1

Heroin withdrawal typically begins between 8 to 12 hours after the last time it was used. The first symptoms are usually increased anxiety and cravings, followed by sweating and runny nose. Muscle and joint pains will begin during the first 24 hours, but may be minor at first. Nausea and lower stomach pain appear, and appetite will decrease throughout the first day and be nonexistent towards the first night. Insomnia will also be an issue along with an inability to sit still, resulting in constant tossing and turning.

Day 2

The second day usually exhibits excessive sweating, runny nose, and increased joint and muscle pain. A simultaneous feeling of hot and cold can be felt and is often described as cold skin, hot insides. Constant goosebumps and repeated yawning are also common features during this time. Nausea will intensify and diarrhea will be frequent along with intense stomach pain. Anxiety and cravings will also intensify and be joined by depression. Appetite remains nonexistent and insomnia will be severe. Shaking or tremors may begin during the second day.

Day 3

This is when the symptoms typically reach their worst. All of the symptoms from the second day are still present, they have just intensified to their maximum. This is when danger from dehydration peaks, as several days of vomiting and diarrhea can lead to electrolyte imbalance and subsequent heart failure. Protracted insomnia and anxiety may make the perception of these symptoms worse.

Day 4

The fourth day tends to be a little less severe. Muscle and joint pain may begin to lessen gradually. The diarrhea and vomiting may decrease in frequency but the stomach pain is often still present. Appetite may return somewhat and the feeling of hot and cold may reduce in intensity. Anxiety may lessen some, but cravings and depression will still be present. Shaking and tremors may begin to subside as well.

Day 5

The fifth day is usually when most symptoms begin to resolve. Sweating, runny nose, and muscle or joint pain are usually still present, but greatly reduced. The feeling of hot and cold will subside and goosebumps may be less frequent. Stomach pain and nausea should resolve, but minor diarrhea may still be present. Appetite should be returning gradually. Insomnia should be less prevalent and anxiety may lessen some. Cravings and depression will probably persist for some time. Excessive yawning will probably linger for some time as well.

Day 6

On average, the sixth day is when people begin to feel physically well again. Lingering symptoms such as minor diarrhea and mild stomach troubles will last for several more days, decreasing in severity. Depression, cravings, and repeated yawning will probably take several weeks or months to resolve. Anxiety may still be present but the more time spent away from heroin use, the less intense it will be.

Post-Acute Withdrawal

After acute withdrawal has been overcome, there may still be post-acute heroin withdrawal symptoms which may linger. Depending on how long someone used, it will take time for their body and brain to return to regular function. Medication may be able to provide some relief and help while the body heals.

Post-acute withdrawal syndrome (PAWS) is a common condition with people who have struggled with heroin addiction. It can happen with many drugs, and it seems to be especially long-lasting with heroin and opioids. While the brain is trying to re-balance itself, the chemistry changes can produce many negative psychological effects. Some of these may include:

  • Insomnia or Irregular Sleep
  • Depression
  • Anxiety (especially social anxiety)
  • Fatigue or Lethargy
  • Irritability
  • Heroin Cravings
  • Anhedonia (reduced ability to feel pleasure)
  • Inability to Concentrate or Focus
  • Frequent Mood Swings
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Heroin Detox

When detoxing from heroin it is highly recommended to seek medical assistance and supervision. There are detox centers all over the country and many large cities will have government-funded facilities. There are many benefits to being in a detox program as opposed to doing this by alone.

View our comprehensive list of detox centers in Atlanta, Georgia.

Medication-assisted treatment (MAT) is another benefit of going to a heroin detox center. MAT uses medications that reduce the worst of the withdrawal symptoms, and can help someone make it through withdrawal safely and with a minimum amount of discomfort.

Medications for Heroin Withdrawal

There are many medications available for heroin withdrawal. All medications are most effective when used in combination with detox and heroin addiction treatment programs. These are just a few of the medications that can reduce the risks and discomfort of withdrawal. Some of these medications may include:

  • Lofexidine (Lucemyra): This is the first non-opioid medication that has been FDA-approved to treat opioid withdrawal. Similar to clonidine, it is also an α-agonist that was originally used to treat high blood pressure and anxiety It can lessen the symptoms of opioid withdrawal and shorten the duration of withdrawal. 3
  • Buprenorphine (Subutex): Itself an opioid, it acts as a partial μ-opioid receptor stimulator. Buprenorphine has a long binding duration and can keep the worst withdrawal symptoms at bay for 24 to 36 hours from a single dose. It possesses a higher binding affinity for μ-opioid receptors than other opioids (including heroin), although it interacts with the opioid receptors without producing the same euphoric effects. Buprenorphine is also subject to the “ceiling effect” meaning that at a certain dosage, the effects plateau and do not increase anymore and this can help prevent abuse of this medication.
  • Naloxone (Narcan): Naloxone is an opioid antagonist with a very high affinity for μ-opioid receptors. At these receptors, it acts as an inverse agonist which means that it will essentially pull out any other opioids currently in the receptor and take their place. This feature enables it to reverse a heroin overdose, but this also means that if someone takes naloxone while they are high on heroin, they will go into precipitated withdrawal.
  • Buprenorphine/Naloxone (Suboxone): Similar to Subutex but with the addition of naloxone. If naloxone is already in someone’s body prior to heroin use, then heroin will not be able to get them high. The reason for this formulation is that naloxone is not well absorbed through ingestion but if someone were to inject suboxone to try and get high from buprenorphine, the naloxone would bind to the opioid receptors and prevent any euphoria.
  • Naltrexone (Vivitrol): An opioid antagonist, it will block the effects of opioid drugs. It is chemically similar to naloxone and it also It acts as a competitive opioid receptor antagonist, with a very high binding affinity for the μ-opioid receptor. It is commonly used to treat opioid addiction and is also helpful in the treatment of alcohol addiction.
  • Propranolol (Inderal): Originally used as a blood pressure medication, this -blocker can lessen nervous system hyperactivity such as high blood pressure and elevated heart rate. It is most often used for its secondary anti-anxiety effects.
  • Clonidine (Catapres): Also originally a blood pressure medication, it is an α-agonist and can also lessen nervous system hyperactivity such as high blood pressure. It is also used primarily for its anti-anxiety effects.
  • Methadone (Methadose): Itself a fully-synthetic opioid, methadone is used to moderate withdrawal symptoms. It is a full μ-opioid receptor agonist as well as having other neurotransmitter interactions. It has a long half-life, duration of action, and usually poses less risk of neurotoxicity compared to other opioid drugs.
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