Heroin

Heroin use disorder is a chronic, relapsing brain disease characterized by compulsive opioid seeking and continued use despite harmful medical, psychological, and social consequences. Heroin (diacetylmorphine) is a rapidly acting opioid that produces intense euphoria through activation of central nervous system μ-opioid receptors.

Repeated heroin use results in physical dependence, whereby cessation or reduction leads to opioid withdrawal syndrome. Although opioid withdrawal is rarely life-threatening, it causes severe physical and psychological distress and is a major contributor to relapse.

Effective management requires medically supervised detoxification followed by long-term opioid substitution therapy and psychosocial rehabilitation.

Risk Factors

• Previous opioid or substance use disorder

• Chronic pain treated with opioids

• Psychiatric illness (depression, anxiety, PTSD)

• Social deprivation or unemployment

• Peer influence and drug availability

• History of trauma or abuse

• Injection drug use networks

• Lack of social support

• Young adult age group

Signs and Symptoms

Withdrawal symptoms usually begin 6–12 hours after last heroin use and peak within 24–72 hours.

Early Symptoms

• Anxiety

• Restlessness

• Yawning

• Lacrimation

• Rhinorrhoea

• Sweating

• Insomnia

Established Withdrawal

• Myalgia

• Gooseflesh (piloerection)

• Dilated pupils

• Abdominal cramps

• Nausea and vomiting

• Diarrhoea

• Tremors

• Tachycardia

• Hypertension

Severe Withdrawal

• Agitation

• Severe craving

• Dehydration

• Electrolyte imbalance

Diagnostic Criteria

Diagnosis is clinical and based on opioid cessation followed by characteristic withdrawal features:

Presence of ≥3 of the following:

• Myalgia

• Gooseflesh

• Diarrhoea

• Rhinorrhoea

• Lacrimation

• Agitation or anxiety

• Insomnia

• Sweating

• Yawning

• Abdominal cramping

• Dilated pupils

• Nausea or vomiting

Symptoms must occur after reduction or discontinuation of opioid use and cause functional impairment.

Investigations

Laboratory Assessment

• Urine toxicology screening

• Full blood count

• Liver function tests

• Renal function tests

• Electrolytes

• Blood glucose level

In Patients Who Inject Drugs

• HIV screening

• Hepatitis B and C testing

• Syphilis screening

• Tuberculosis evaluation when indicated

Additional Assessment

• Mental health evaluation

• Assessment of overdose risk

• Pregnancy testing in women of reproductive age

Management

Management goals include:

• Relief of withdrawal symptoms

• Prevention of relapse

• Reduction of overdose risk

• Long-term recovery support

Non-Pharmacological Management

• Psychological counselling

• Motivational interviewing

• Behavioral therapy

• Peer-support and recovery groups

• Structured rehabilitation programs

• Social reintegration support

• Harm reduction education

• Family involvement where appropriate

Patients should be managed in supervised settings during acute withdrawal when possible.

Pharmacological Management

Opioid Substitution Therapy (First-Line Treatment)

Methadone Maintenance Therapy

• Methadone 30 mg orally daily (minimum dose)

• Titrate gradually up to 120 mg daily

• Duration: 1–2 years or longer

Benefits:

• Reduces withdrawal symptoms

• Decreases illicit opioid use

• Prevents overdose

• Improves social functioning

OR Buprenorphine Therapy

• Buprenorphine sublingual 2 mg daily (minimum)

• Up to 8 mg daily

• Duration: 1–2 years

Advantages:

• Lower overdose risk

• Partial opioid agonist effect

• Suitable for outpatient stabilization

OR Opioid Antagonist Therapy

(After complete detoxification)

• Naltrexone 25 mg orally daily, increasing to

• 50 mg daily for approximately 6 months

Indication:

• Relapse prevention after opioid abstinence

Symptomatic Treatment During Withdrawal

Anxiety, Agitation, and Insomnia

• Diazepam 5–20 mg orally, once daily or divided doses(Inpatient use only; taper over 5–7 days)

OR

• Promethazine 50 mg orally at night

OR

• Chlorpromazine 50–100 mg orally at night

Abdominal Cramps

• Hyoscine butyl bromide 20 mg orally up to three times daily as required

OR

• Diclofenac 50 mg orally every 8 hours

Diarrhoea

• Loperamide 4 mg orally initially, then

• 2 mg after each loose stool

Additional Supportive Care

• Adequate hydration

• Nutritional support

• Electrolyte correction

• Monitoring for complications

Complications

• Relapse and overdose

• Infective endocarditis

• HIV/AIDS

• Viral hepatitis

• Skin and soft tissue infections

• Respiratory depression

• Depression and suicide risk

Prevention

• Early identification of opioid misuse

• Prescription opioid regulation

• Harm reduction programs

• Needle and syringe programs

• Opioid substitution therapy access

• Community education

• Long-term rehabilitation services

Prognosis

Heroin dependence is a chronic condition with high relapse rates without maintenance therapy. Long-term opioid substitution treatment combined with psychosocial rehabilitation significantly improves survival and recovery outcomes.

Patient Education

• Withdrawal symptoms are uncomfortable but treatable

• Medication-assisted therapy greatly reduces relapse risk

• Sudden relapse after abstinence increases overdose risk

• Long-term follow-up is essential for recovery

• Avoid sharing needles to prevent infections