What Is Heroin Tapering?

Lauren Smith
Dr. Jennie Stanford
Written by Lauren Smith on 23 January 2023
Medically reviewed by Dr. Jennie Stanford on 15 November 2024

Tapering the dose of an opioid (as opposed to stopping it immediately) can reduce unpleasant withdrawal effects that may promote relapse and continued use. Heroin itself isn’t usually tapered, as it is used illicitly, but patients are frequently stabilized on opioid agonists, which reduce withdrawal (yet aren’t addictive), and then the opioid agonist doses are gradually weaned.

A syringe with orange cap next to white powder.

What is heroin tapering?

The synthetic opioid heroin is one of the hardest drugs to quit, in part because of its unpleasant (and even dangerous) withdrawal symptoms, which can strike regular users after just hours of abstinence. Opioid withdrawals are so difficult they often push patients to continue using.

To minimize withdrawal symptoms from opioids, some doctors recommend a gradual reduction in the user’s doses, which is a process known as tapering. It’s not generally recommended that heroin itself is tapered. However, it can be replaced by medical-grade opioid agonists, like methadone and buprenorphine, which aren't addictive but help reduce withdrawal symptoms. After the patient has stabilized on these alternatives and has been abstinent from heroin for a period of time, the opioid agonist medications can be gradually tapered.

What are the symptoms of heroin withdrawal?

Heroin is a short-acting opioid, and withdrawal symptoms usually begin within eight to 24 hours of the last use. They typically last four to 10 days.

Early symptoms of withdrawal include these:

  • Anxiety
  • Agitation
  • Muscle aches
  • Insomnia
  • Runny nose
  • Watery eyes
  • Sweating
  • Yawning

Later symptoms include these:

  • Abdominal cramping
  • Diarrhea
  • Nausea
  • Vomiting
  • Dilated pupils
  • Gooseflesh

Quitting heroin cold turkey isn’t just unpleasant. In some cases, the vomiting and diarrhea are so severe, they can cause severe dehydration, which may lead to electrolyte abnormalities (like sodium, potassium, chloride, calcium, and magnesium)l and even heart failure. That’s why people should seek medical help when quitting heroin, and it is also why many rehab facilities are equipped for medical detox, where patients’ vital signs can be monitored and medication and fluids can be administered.

How does opioid tapering work?

Opioid tapering is the slow reduction of a dose in order to minimize withdrawal symptoms.

Tapering is commonly done among patients who have taken prescription opioids for chronic pain for a long time and have developed physical dependencies. In patients who have chronic pain and have taken opioids for more than a year, the CDC recommends doses of the prescription drug be reduced by 10% per month. For those who have taken opioids for a shorter time (weeks to months), a decrease of 10% per week may work.

Slow reductions in doses aren’t usually done with patients with substance use disorder, who are less likely to comply with tapering regimens and who shouldn’t take an addictive drug for longer than necessary.

Rather, they are tapered using medication-assisted treatment (MAT). MAT is the use of opioid agonists, like methadone or buprenorphine (Suboxone), which also bind to opioid receptors, but they do so more slowly or less completely so they don’t produce rewarding effects, all the while still preventing withdrawal symptoms. On these substitute medications, the patient’s addictive behaviors around the drug may fluctuate, and the dose can slowly be tapered, reducing their physical dependence over time. Patients are also often stabilized on the MAT first, sometimes for a year or more, before a taper is begun.

In the United States, guidelines call for a 10% reduction in doses of methadone every one to two weeks.

However, methadone and buprenorphine can’t be tapered too quickly or patients will develop withdrawal symptoms, which they may treat with the continued use of illicit, addictive opioids. One study of heroin-addicted patients taking methadone found that those who started tapering after 52 weeks and had a taper ratio of less than 5% per week (but did so consistently) had the best odds of continued heroin abstinence.

The rate of tapering will depend on the person, the drug they abused, the amounts they were taking, the length of time they used, any co-occurring mental health conditions, (including other addictions), and other factors.

Some patients may continue to take methadone or buprenorphine for years if they struggle to taper down or if it’s judged they’re at risk of relapse.

Can heroin itself be tapered?

Heroin itself isn’t usually tapered. The drug is illegal and can only be procured on the black market, where doses and purity are difficult (if not impossible) to determine. Continued use of street heroin poses serious risks, including the risks of overdose and blood-borne infections, which outweigh the risks of a cold turkey withdrawal. Additionally, it’s short-acting, meaning dosing has to be regular to avoid heroin withdrawal symptoms, which complicates a tapering schedule.

Some people may try a self-guided tapering of heroin. But it can be difficult to hold yourself accountable and actually decrease your dose of this powerfully addictive substance, even if you could pinpoint the exact amount you're taking.

Can you quit heroin cold turkey?

The withdrawal symptoms of heroin are unpleasant and even dangerous, and they may push you to continue using. That’s why it’s often recommended that you undergo a medical detox.

During detox, you’ll be given medication to ease the symptoms of withdrawal, such as these:

  • Opioid agonists, such as methadone and buprenorphine
  • Clonidine, a medication that reduces sympathetic nervous system activity, helping prevent withdrawal symptoms, like an elevated heart rate, high blood pressure, excessive sweating, and temperature fluctuations
  • Antiemetics to lessen nausea and vomiting
  • Benzodiazepines to reduce anxiety, agitation, and insomnia

In medical detox, the team will closely monitor your vital signs. You may also be given fluids to prevent or treat dehydration, if necessary.

Resources:

  1. Bluthenthal, R. N., Simpson, K., Ceasar, R. C., Zhao, J., Wenger, L., & Kral, A. H. (2020). Opioid withdrawal symptoms, frequency, and pain characteristics as correlates of health risk among people who inject drugs. Drug and alcohol dependence, 211, 107932.
  2. Opiate and opioid withdrawal: MedlinePlus Medical Encyclopedia. (2016). Medlineplus.gov.
  3. Kugasia, I. R., & Shabarek, N. (2014). Opiate withdrawal complicated by tetany and cardiac arrest. Case reports in critical care, 2014, 295401.
  4. POCKET GUIDE: TAPERING OPIOIDS FOR CHRONIC PAIN *. (n.d.).
  5. Lu, Q., Zou, X., Liu, Y., Gong, C., & Ling, L. (2019). Dose Tapering Strategy for Heroin Abstinence among Methadone Maintenance Treatment Participants: Evidence from A Retrospective Study in Guangdong, China. International Journal of Environmental Research and Public Health, 16(15), 2800.
  6. Srivastava, A. B., Mariani, J. J., & Levin, F. R. (2020). New directions in the treatment of opioid withdrawal. Lancet (London, England), 395(10241), 1938–1948.

Activity History - Last updated: 15 November 2024, Published date:


Reviewer

Dr. Jennie Stanford

MD, FAAFP, DipABOM

Jennie Stanford, MD, FAAFP, DipABOM is a dual board-certified physician in both family medicine and obesity medicine. She has a wide range of clinical experiences, ranging from years of traditional clinic practice to hospitalist care to performing peer quality review to ensure optimal patient care.

Activity History - Medically Reviewed on 21 January 2023 and last checked on 15 November 2024

Medically reviewed by
Dr. Jennie Stanford

Dr. Jennie Stanford

MD, FAAFP, DipABOM

Reviewer

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