When someone takes heroin, it is converted to morphine.
It then binds to receptors in the brain that are specialized to respond to naturally occurring neurotransmitters that resemble morphine in their chemical structure. The immediate effect of taking heroin is euphoria, or a pleasant sensation referred to as a “rush” by heroin users. Euphoria typically presents as flushing of the skin, a warm feeling all over the body, pleasant heaviness in the extremities, relaxation that includes decreased breathing rate, dry mouth, and suppression of any pain. Following the initial rush, other effects will occur that include extreme drowsiness, slowed thinking processes, decreased breathing, and decreased heart rate.
There are potential numerous side effects that are associated with long-term or chronic use of heroin. These occur throughout the body in a number of different systems and can include:
- Prolonged issues with sleep that can include either insomnia or lethargy and consistent drowsiness
- Issues with constipation
- Changes in the rate of respiration that occur as a result of heroin use, leading to an increased potential to contract diseases, such as pneumonia or tuberculosis
- Risk of potential lung damage and scarring in people who snort heroin
- Issues with infections (see below), scarred or collapsed veins, blockages, and abscesses of the heart or other areas of the cardiovascular system in people who inject heroin intravenously
- Menstrual issues in women and sexual dysfunctions in both men and women
- Issues with pregnancy, including the potential for neonatal abstinence syndrome for pregnant mothers who use heroin, resulting in dependence on heroin in the fetus
- Changes in the central nervous system (the brain and spinal cord); issues with memory, problems with decision-making, a loss of motivation, changes in the structure of the brain itself, and increase in the risk of infections to the central nervous system with chronic use
- Psychiatric issues, including issues with depression, anxiety, and even psychosis (hallucinations, paranoia, etc.)
- Issues with motivation, such that a person neglects their health in favor of using heroin
- The development of physical dependence on heroin (tolerance and withdrawal)
- The development of a heroin use disorder (heroin abuse and heroin addiction)
A heroin use disorder can result in a number of other detrimental effects that can include:
- Failure to maintain important commitments at work, with family, at school, or in other important areas
- Financial issues as a result of heroin abuse or as a result of the loss of one’s occupation
- Using heroin in potentially dangerous situations, such as while driving or operating machinery
- Legal issues as a result of heroin abuse
- Divorce, loss of children, or other ramifications to family as a result of heroin use
- Issues with control regarding use of the drug
Of course, chronic use of heroin also increases the potential for a person to experience a heroin overdose. This can result in a number of potential fatal consequences, such as slipping into a coma as a result of the extremely slowed breathing brought about by the drug and experiencing brain damage or even death due to overdose.
Substance use disorders in general are hard to overcome for a number of reasons. First, substance abuse is a learned habitual behavior that is done in response to a set of environmental triggers, such as stress, opportunity, boredom, and even positive situations, such as feeling good, getting a promotion, etc. Habits that are reinforcing are extremely hard to break.
For many individuals with substance use disorders, such as a heroin use disorder, these behaviors actually fulfill certain needs in the individual. If a particular behavior or practice fulfills a specific need, even if the behavior or practice is dysfunctional, it is extremely difficult to overcome. People who have never had an issue with substance abuse find this difficult to understand; however, many substances such as heroin represent real relationships that fulfill needs in people who continue to abuse them. Thus, even if the relationship has a serious dysfunctional aspect to it, since it fulfills certain needs in the individual, it is very hard to give up. The person concentrates on the reinforcing aspects of the relationship and not on the negative side to it.
The process of addiction or of a substance use disorder entails certain changes in the central nervous system (particularly in the brain) that have literally programmed the person to “want” to engage in the addictive behavior despite any potential negative consequences. While these changes in the brain can be altered slowly by changing one’s behavior, they will always remain to some extent, and certain triggers can result in activating and producing an impulse to return to substance use. Interestingly, many of the pathways in the brain that are altered by chronic substance abuse are shared with neurobiological pathways involved in the development of relationships and in the reinforcement of behavior that is repeated.
Related to the above, using drugs like heroin is positively reinforcing. Individuals enjoy the experience of using the drug, and this leads to the desire to use it more to get that experience, which changes the reward system in the brain to a state of enhancement for heroin use.
Drugs like heroin that have a high potential for the development of physical dependence offer the phenomenon of negative reinforcement. Negative reinforcement occurs when bad or undesirable effects are thwarted by engaging in a particular behavior. For instance, the effects of physical withdrawal can be easily canceled out by using heroin. This reinforces heroin use.
Many individuals with substance use disorders do not know how to change their lifestyle in order to get benefits that they associate with heroin use or with other drugs in the absence of using the drug. For many, this is a learning process that is long and often difficult, and that requires professional help.
The withdrawal process from heroin can be variable, depending on several different factors, such as:
- The amount of heroin a person regularly used: People using higher doses of heroin on a regular basis will tend to experience longer and more severe withdrawal.
- The length of time the person used heroin: People who have used heroin for longer periods of time will have longer and more severe withdrawal symptoms.
- The method of use: Individuals who inject or snort drugs such as heroin develop higher levels of tolerance and therefore will tend to have longer and more severe withdrawal syndromes.
- How heroin use is stopped: People who stop using heroin altogether will experience longer and more severe withdrawal symptoms than people who are able to slowly taper down the dosage or use medically assisted treatments.
- Personal variability: Differences in metabolism and psychological makeup will also contribute to the length and severity of the withdrawal syndrome.
The withdrawal process from heroin follows this general timeline:
- Days 1-2: Usually withdrawal symptoms are experienced within the first two days after one stops using heroin. The first and second days following discontinuation of the drug often consist of the most severe symptoms. Some individuals with severe heroin use disorders who have been using the drug for many years may experience withdrawal symptoms only a few hours after stopping the drug. People initially begin to feel agitated, irritable, and achy. More severe symptoms, such as spasms, nausea, vomiting, diarrhea, sweating, fever, chills, insomnia, runny nose, watery eyes, anxiety (even panic attacks), depression, and severe cravings, will follow. Relapse potential at this stage is very high because the symptoms will abate when the person takes heroin again.
- Days 3-5: By the third to fifth day, the symptoms begin to lose their intensity. There will still be mild nausea, appetite loss, chills, mild fever, some cramping, and maybe even some mild vomiting. This is the time where individuals should try to eat and move around.
- Days 6-7: By the sixth or seventh day, the intense symptoms should be finished, and there might be some mild residual symptoms, such as nausea, anxiety, mild fever, headache, and very mild flulike symptoms. People may experience depression and may still have cravings. However, the severe symptoms will have passed in most people by the end of the seventh day.
There are some individuals who report a syndrome known as post-acute withdrawal syndrome (PAWS) that continues for weeks, months, or even years following discontinuation of heroin or any other substance. The symptoms are reported to be mostly psychological/emotional in nature and include issues with motivation, depression, irritability, anxiety, and cravings. Most of these symptoms appear to be triggered by associations with past drug use or stress.
Relapse after the acute withdrawal phase is always a potential issue and some clinicians blame this on the PAWS; however, its validity is highly questioned in formal medical circles, and it is not included in any formal diagnostic manual. While it is certainly true that many individuals who are in long-term recovery have periods of emotional and psychological distress, and are periodically vulnerable to cravings and relapse, it is not clear whether this is due to a formal withdrawal syndrome.
Preparing for and Executing an Intervention
An intervention occurs when someone who is engaging in some potentially self-destructive behavior is confronted in a nonthreatening manner by concerned family members, close friends, and sometimes coworkers in order to convince the individual to enter treatment for their issue. Interventions have been popularized recently on television and in other aspects of the media; however, these portrayals of interventions are often inaccurate.
Interventions should not be:
- Presented as an ambush to “trap” the person
- A venting session aimed at the person where participants become aggressive, become angry at the subject and vent, accuse the subject of engaging in poor choices or of being a bad person, or an attempt to force the subject to do something that they do not want to do
- Designed to be a release for people that are involved in them
The goal of an intervention is to convince the person that they need help. An intervention is often a last-resort approach to getting the individual into treatment.
In order for an intervention to be successful, the first thing to consider is who is going to be involved in the intervention. For the most part, interventions should include:
- Family members who are very close to the person
- Very close personal friends
- A professional mental health provider with experience in treating addictions and performing interventions or a professional interventionist
Do not include:
- People who do not have a very close personal relationship with the person
- Friends of friends who are just “along for the ride”
- Very young children who really do not understand the process
First, there is generally a planning meeting where a few concerned individuals get together and decide who will attend the intervention. Those people are then asked if they would be willing to be involved in the intervention, and then schedule an official planning session is scheduled. At this session, everyone who will be involved in the intervention discusses their role, including the professional interventionist or therapist who will likely also oversee the planning session.
In the planning stage, each person’s role in the intervention should be defined, and everyone should also clearly define what they plan to say the subject of the intervention. It often helps for individuals to write down exactly what they will say and then read it verbatim when the intervention is actually performed.
The intervention should:
- Rely as much as possible on the professional who is overseeing the process: The professional intervention specialist or therapist who is helping organize and run the intervention should be the person who continues to organize the actual intervention, and who also addresses any unforeseen or unplanned issues, such as resistance, arguments, threats to leave, etc. This person should be the “go-to source” for all issues in planning and the successful implementation of the intervention.
- Take place at a neutral location: It should not take place in the home of the person with the substance use disorder, at a bar, or at any other public place where others who are not involved in the intervention can hear and see what is happening.
- Be organized and structured: Stick to the program as closely as possible; however, be prepared to hear the individual, as well as their reactions and complaints.
- Not be confrontational: Each participant should only express facts concerning the subject’s substance use disorder and how it affects them. Each person should express their concern for the person and how they see the person’s behavior as dysfunctional or destructive. Again, stick to facts. Do not evoke the perception that the subject is being attacked.
- Be considerate: Listen to the person and be prepared for resistance. If the person gets angry, explain your concern and try to calm them down.
- Focus on treatment options: The goal of the intervention is to get the person to agree to enroll in treatment. Therefore, it is very important to have at least three treatment options to offer the person. These should be relatively different treatment options, not just three different meeting times for 12-Step groups. For example, one option could be a number of 12-Step groups, such as Narcotics Anonymous, that the person can attend. Another option could be the name of different therapists who treat substance use disorders. Another option could be the names of substance abuse treatment facilities.
- Tailor the options to suit the needs of the person and be realistic for the person: This means that during the planning stage, someone should be assigned the goal of finding realistic interventions and treatment options to present at the intervention.
- Not be considered to be a final solution in and of itself: If people are concerned enough to plan and execute an intervention, and actually do the research regarding appropriate treatment options for the person, at least some of them should also be concerned enough to follow through after the intervention is complete. People should provide support for the person that can include things like providing transportation to and from treatment sessions, attending initial meetings in 12-Step groups with them, scheduling the intake session for inpatient or residential treatment, and continuing to meet with the individual and monitor their continuation of treatment.
Anyone seeking professional help in organizing an intervention can contact the Association of Interventionist Specialists, a national organization that trains and organizes interventions for substance use disorders. This organization uses a model that is slightly different from the one outlined above, but it can be an excellent source for planning and implementing an intervention.