How bad is Heroin Withdrawal?

An excerpt from:

Heroin, Myths and Reality

by: Jara A. Krivanek pub. 1988, Allen & Unwin

and a general discussion, with references of the dangers of heroin.

"The development of physical dependence depends as much on regularity of use as on the amount actually used. In practice, the vast majority of addicts of not use heroin consistently on an ongoing basis. Less than half of the addicts who have been on the streets for more than a year will have used daily for that period (Johnson, 1978). They may voluntarily withdraw to reduce their tolerance, or the scene may be temporarily too much of a hassle, or they may have an important engagement such as a trial, at which an appearance of addiction would be undesirable. Or they may simply need a rest. During such times, physical dependence may virtually disappear, yet they will still think of themselves and describe themselves as addicts. In other cases, the users may never use enough drug to develop significant physical dependence. Senay (1986) estimates that between 25 per cent and 40 per cent of street addicts are not physically dependent. Nevertheless, such 'chippers' may wish to see themselves as addicts for reasons of their own, and will so describe themselves.

The withdrawal syndrome we have been discussing is what is termed 'primary' or 'early' abstinence. A substantial portion of the physical symptoms of this stage seem to depend on the activity of a part of the brainstem called the locus coeruleus. Opiates depress this area and it would therefore be expected to become hyperactive during withdrawal. The locus coeruleus is an important center in the brain's fear-alarm system, and such hyperactivity would be consistent with the marked anxiety and agitation withdrawing addicts report. Fortunately for withdrawing addicts, other drugs beside the opiates can depress this region and one of them is clonidine.

Clonidine is generally used as an anti-hypertensive agent, but in 1978 Gold and his colleagues reported that it could suppress or reverse the symptoms of opiate withdrawal. Subsequent work has shown that this reversal is by no means complete, but there seems no doubt that clonidine can make opiate withdrawal much more comfortable.

Even if clonidine is not used, medical detoxification is usually accomplished by giving decreasing doses of a long-acting opiate like methadone. After a few weeks of this, the patient is usually opiate-free without having suffered any appreciable physical discomfort. Since a percentage of the methadone marketed for medical use finds its way into the streets, many addicts also detox themselves this way without formal medical help. Still others detox 'cold turkey'--without any pharmacological help at all. They simply tell their friends they have the flu, go to bed, and suffer in relative silence.

Medical supervision and assistance is certainly not essential for successful withdrawal." --pages 88 and 89

That was immediate withdrawal. The author goes on to say, "the duration of early abstinence depends on the drug's rate of elimination and in the case of heroin most major symptoms should be gone within seven to ten days."

He then describes, "A protracted abstinence syndrome follows withdrawal from both heroin and methadone and... lasts at least 31 weeks after withdrawal, and perhaps longer. Blood pressure, pulse rate, body temperature and pupil diameter seem to be the main physiological variables affected. Behaviorally, the subject shows an increased propensity to sleep and there are negative changes in mood and feeling state."

Heroin in itself seems to pose no real health problems, even when it is used for long periods of time. G. Dimijian in "Contemporary Drug Abuse" (in _Medical Pharmacology: Principles and Concepts_ ed A. Goth, p. 299) describes an 84-yr old physician who had been a morphine addict for 60 years and seemed to have no mental or physical problems from the addiction. In general, it seems that middle-class heroin/morphine addicts are no less healthy than the general population (see D. Musto and M. Ramos (1981) "Follow-up Study of the New England Morphine Maintenance Clinic of 1920," _New Eng J Med_ 308(30): p. 1075-76; J. Ball and J. Urbaitis (1970) "Absence of Major Medical Complications among Chronic Opiate Addicts" in _The Epidemiology of Opiate Addiction in the United States (eds J. Ball and C. Chambers), p. 301-6.)

There may be some problems associated with long-term controlled use of H, but they aren't well documented and they are certainly not comparable to those associated with either tobacco or alcohol.

So where do the health problems of heroin come from? Primarily from the use of needles, the presence of adulterants in the drug, the poor nutrition and health care associated with the hard core addict liife-style; and the violence associated with said life-style. Before I discuss these, we should note that all of these factors except adulterants are controllable by the user. The many "chippers" (that being the term for non-addicts who use addictive drugs in a controlled fashion; see, for example N. Zinberg and R. Jacobson's (1976) "The Natural History of 'Chipping,'" _Amer J Psych_ 133(1): p. 37-40.) who avoid injections (usually by "chasing the dragon" ie smoking it) have few problems.

Let's start with needles. There are two reasons to use needles: it gives a bigger rush, and it makes more effective use of the drug. This second reason is, of course, only a consideration because the drug is expensive and difficult to get. The problems with needles are that you inject a lot of crap into your body (adulterants and dilutants), you run the risk of infecting yourself with something (HIV or a Hepatitis virus), and you wreck your veins and skin. Most IV Heroin users are constantly plagued by irritated, infected skin. Hey, you inject talc into your skin, that's what you get. Even the quinine (which is believed to have originated in heroin during an outbreak of malaria among addicts) can cause numerous health problems (there's a large literature on the problems of adulterants and dilutants in heroin and cocaine).

The life-style that an addict leads is generally pretty unhealthy as well. Often, addicts don't get an adequate diet. Vitamin deficiencies are not uncommon. Constipation caused by a combination of poor eating that the effects of the drug on the bowels can lead to hemorrhoids. Chest infections seem pretty common too, especially among cigarette smokers.

Then you've got the problems of trafficking in the (potentially) violent underworld. Joe and Leishman (et al (1982), "Addict Death Rates During a Four-Year Post-Treatment Follow-up," _Amer J of Public Health_ 72: p. 703-9.) found that 28% of deaths among addicts were from violence (17% were from natural causes, and 44% were drug related).

So, it would seem that if one had clean heroin from a reliable source and avoided the IV route, there'd be few health problems. Potential problems would arise from becoming addicted and becoming unproductive or from accidentally ODing. It seems that "Chippers" avoid addiction by setting strict limits on their use ("I'll only do it on weekends" being a common limit). In the lab, it takes a couple weeks of 3 shots a day before one gets withdrawal symptoms. So, if you avoid hanging around hardcore addicts, it is not that hard to avoid an addiction.

The existence of non-addict users shouldn't be surprising. It is only because of silly people like Anslinger and Henry Giordano (head of the FB of Narc, who testified that anyone who used H more than six times would become an addict). Admittedly, controlled heroin use is difficult to locate, since the users stay out of trouble to the best of their abilities. However, if we look at who has used heroin daily (a nice substitute for the vague notion of 'addict'), we find substantial numbers of regular users who have never taken H on a daily basis (see, for example, J. O'Donnell's (1976) "Young Men and Drugs," _NIDA Res Mon_ 5, p. 13, where only a third of the users taken from a cross-section of American males had ever used H daily). In fact, considering the small amount of H in street samples, it is a wonder that users can even become true addicts. (As a side note, many of the people who present themselves or are presented by the Feds to clinics are not physicially dependent on cocaine, heroin, etc.) D. Waldorf's _Careers in Dope_ provides examples of H addicts who have held employment for long periods of time. So, even addicts can hold down jobs. Dr. William Halsted, a great surgeon and one of the founders of Johns Hopkins was a morphine addict.

Overdose is a probably largely due to people not knowing the purity of their H, the presence of adulterants which act in conjunction with the H, and addicts misjudging their tolerance. Using non-IV routes probably reduces the chances of ODing. R. Gardner (1970) in "Deaths in UK Opioid Users 1965-69" _Lancet_ 2: p. 650-3 found that 26 of the 42 accidental ODs recorded happened after a period of abstinence, so maybe 60% of ODs are from misjudging tolerance.

Since abstinence is often forced, I can only imagine that most Ods could be avoided entirely by proper measures.

Oddly enough, British addicts, who get clean heroin, have about as high a mortality rate as Americans who shoot street shit (see T. Bewley et al (1968) "Morbidity and Mortality from Heroin Dependence, 1: Survey of Heroin Addicts Known to the Home Office," _Brit Med J_ 23 March: p 725-26).

Tolerance is a funny thing. Addicts have been known to die from their second shot of the day after dividing their daily amount into three piles. It would therefore seem that their tolerance had been reduced since the first shot. Someone conjectured that tolerance was partially a matter of place-conditioning and that addicts who shoot in a particular gallery get conditioned so that their body begins to gear up for a shot when they go their and that therefore they have higher tolerance there. When they shoot up someplace else, their body isn't ready and they OD.

Before I quit typing, I'll say something about the myth of "pushers." John Kaplan (1983), in his excellent book _The Hardest Drug_, points out the numerous holes in this myth. The idea of the "pusher" is that a dealer tries to get people hooked through free samples so that he can have a helpless and reliable market for high-priced drugs. This model works pretty well for cigarette companies. However, it is totally off the mark with respect to H sellers. To begin with, as Big Bill Burroughs has documented, the model is empirically wrong since there is no clear distinction between users and sellers. Most users sell to their friends, making a little profit. In the social network of users, some will sell on a large scale, but typically not for a long period of time, as it is a hassle. The only real organization in drug dealing is at the higher levels where the drugs are purified, smuggled, and cut. Furthermore, ignoring empirical facts, the image of the pusher is pretty unsound. It only makes sense to spend time hooking people if you plan on selling to them for a long time and they will not be able to go elsewhere. Neither condition tends to be true.

Addicts are notoriously unreliable customers. Furthermore, as I have already mentioned, it is difficult to get hooked on H. Addiction is rare within the first 6 months of H use. (See Kaplan, p. 27). So, you'd have to be giving out samples for a while before you had an addict customer. Finally, associating with non-addicts is the surest way to get busted. Dealers stick to themselves; they don't hang out on play grounds.