The early symptoms of the withdrawal include anxiety, agitation, increased tearing, runny nose, yawning, insomnia, sweating, and muscle aches. Late symptoms of the withdrawal are abdominal cramping, diarrhea, goose bumps, nausea, vomiting, and dilated pupils. Though the reactions of heroin withdrawal are usually uncomfortable, these effects are not life-threatening. The symptoms of this withdrawal last for 12 hours of the last usage of the drug [6].

• Laboratory Studies: For abuse and dependence, urine drug screen, and detection of drug in sweat and hair is suggested. In patients with withdrawal, concentration of electrolytes, complete blood counts and urine drug screen are used. For intoxication, comprehensive urine drug testing, enzyme immunoassay, radioassay, gas-liquid chromatography, and gas chromatography-mass spectrometry (GC-MS) are performed. These tests are specific and sensitive, but time consuming and expensive. Blood alcohol levels (BAL) are also tested in patients with symptoms of heroin withdrawal. Addiction is tested by rapid plasma reagent (RPR), hepatitis viral test, HIV test, and blood cultures.
• Imaging: X-ray of the lungs must also be performed [5].

Though heroin withdrawal rarely causes severe morbidity and mortality, detoxification can be performed as a therapy in most of the patients. Alpha-2 adrenergic agonists have shown to be highly effective in the suppression of mediated signs and symptoms. In one study, it was concluded that the use of naltrexone implant is effective in combating the relapse of the regular heroin use.

Apart from the medication therapy, psychotherapy and support groups can help support these patients. Cognitive behavior psychotherapy focuses on the thoughts and behavior of the patients; hence the introduction to such therapeutic measures becomes important. Group therapy is the most effective method to manage heroin withdrawal as it targets the social stigma. The support and acknowledgement of the condition from the group members can help in abstinence. Aversion therapy, where the aversive stimuli to cognitive images of the drug use is also recommended [7] [8] [9] [10].

Though the withdrawal of heroin is painful, it is not life-threatening.

Complications

The complications of the withdrawal are as follows:

• Vomiting and aspiration, which can cause dehydration, lung infection and electrolyte disturbances. 
• Return of drug use: Overdose deaths are common in this group of population, due to the reduction of tolerance of the drug. Longer treatment is recommended for the people who follow withdrawal. 
• Patients who are in the phase of withdrawal must be checked for depression or other mental conditions. 
• If a patient suffers from withdrawal repeatedly, the methadone maintenance is recommended [6].

Heroin causes physical dependence. Over a period of time, the amount of the drug to produce the same effect increases. This time varies with each individual. After the discontinuation of the chronic use of heroin, the body needs the time to recover, and manifests as withdrawal symptoms [2] [3].

About 9% of the population across the globe misuses opiates in their lifetime, which includes illegal drugs such as heroine and other prescription drugs. Opioid is powerful painkiller, but is also highly addictive.

Heroine dependence leads to approximately 17,000 deaths each year. USA, though forms just 4.6% of the world’s population, accounts for 80% of the consumption of the opioid. Prescription opioids form an important gateway drug [4].

About 20 medications bind to the mu opioid receptor, and most of them are the prototypical mu receptor full agonists, often associated with the constellation of effects such as pain relief, mood alteration, respiratory and cough, depression, decreased gastrointestinal motility, pinpoint pupils, nausea and vomiting.

The euphoria associated with this receptor activation is high, and the rush is a brief, intense and pleasurable sensation. Patients with addiction often try to avoid the unpleasant withdrawal symptoms. Short term use of opioid is associated with gray matter changes in patients with chronic pain. Mu receptor agonists have the potential for the destructive addictive behavior. The following destructive behavioral pattern is seen:

• IV injection of heroin causes a rapid high followed by unpleasant withdrawal symptoms within hours.
• Unpleasant symptom of the withdrawal symptom is seen with the use of heroin.
• This entire cycle is repeated until the patient no longer access heroin.

Long-term potential for relapse is common in heroin addiction. The cause of this type of relapse is stress, administration of a dose of drug with similar properties and exposure to the conditioned cues, which is related to the past drug use. It is known that the long-term use of heroin can alter the density of dendritic spines. These permanent changes can have long-lasting vulnerability to relapse [5].

Dependence on heroin can be prevented by being careful of the dosage and frequency of opioid analgesics. Most of the teenagers, under peer pressure, start using these drugs, but the impact of the same on their body is understood only later. Hence, the vulnerable group must be sensitized about the signs and manifestations of heroin dependence.

The heroine-specific syndrome, which occurs due to the reduction of the prolonged and heavy usage of the drug, is called heroine withdrawal. Heroine withdrawal causes symptoms of distress and impairment of the social well-being. Some of the characteristic features of heroin withdrawal are: increased sweating, urinary frequency, lacrimation or rhinnorhea.

Diarrhea, nausea, vomiting, abdominal cramps, muscle spasms, piloerection, hypertension, tachycardia, anxiety, irritability, disturbed sleep and increased craving for heroin are some other symptoms associated with heroin withdrawal. Psychological features of this withdrawal are dysphoria, sleep disturbances, and increased cravings for the drug, which can continue for weeks or months. It is a life-threatening condition even in physically fit people [1].

Definition

Heroin can cause a sense of well-being, which attracts people towards it. There is a suspension from reality and people suffering from failures or loneliness resort to its usage. However, prolonged and heavy dose of the drug can cause withdrawal symptoms and impair the general functioning of the body. 

Cause

Heroin causes physical dependence, which means that the patient is dependent on the drug to prevent the symptoms of dependence. 

Symptoms

Increased sweating, urinary frequency, rhinnorhea, diarrhea, nausea, vomiting, abdominal cramps, muscle spasms, hypertension, tachycardia, anxiety, irritability, disturbed sleep and increased craving for heroin are some of its symptoms. There are some psychological features of this withdrawal such as dysphoria, sleep disturbances, and increased cravings for the drug. 

Diagnosis

Laboratory studies including urine drug screen, concentration of electrolytes, CBC count, immunoassay and radioassay are some of the important tests. X-ray of the lungs may also be performed.

Treatment

Though heroin dependence rarely causes significant morbidity and mortality, the dependence can destroy families. Some drugs (Alpha-2 adrenergic agonists) have shown to be highly effective in the suppression of mediated signs and symptoms. Group therapy and aversion therapy are also effective methods to manage heroin withdrawal as it targets the social stigma. 

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2. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. Fifth Ed. Arlington, VA: American Psychiatric Association; 2013:541-46.
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4. Substance Abuse and Mental Health Services Administration, Results from the 2011 National Survey on Drug Use and Health: Summary of National Findings, NSDUH Series H-44, HHS Publication No. (SMA) 12-4713. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2012.
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8. Gowing L, Farrell M, Ali R. Alpha2 adrenergic agonists for the management of opioid withdrawal. Cochrane Database Syst Rev. 2004
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10. Marsch LA, Bickel WK, Badger GJ, et al. Comparison of pharmacological treatments for opioid-dependent adolescents: a randomized controlled trial. Arch Gen Psychiatry. Oct 2005;62(10):1157-64