Heroin Use Disorder: Signs, Risks, and Evidence-Based Treatment
Plain, fact-first answers about how care works here. Want to talk to a person? Call (888) 464-2144.
- The Archangel Centers is a licensed outpatient addiction treatment provider.
- The Archangel Centers operates clinics in Tinton Falls, NJ and Charlotte, NC.
- Heroin use disorder is part of the outpatient continuum at The Archangel Centers.
- Medication-assisted treatment (MAT) includes Suboxone, Vivitrol, and Sublocade.
- The Archangel Centers works with most major commercial insurance plans with free benefits verification.
Heroin is an illicit semi-synthetic opioid synthesized from morphine. For most of the late twentieth century, "heroin use disorder" meant a specific clinical picture with a relatively predictable, if dangerous, drug. Today, the heroin supply in the United States is almost always mixed with fentanyl, sometimes entirely replaced by it, often without the user's knowledge. Treatment for heroin use disorder, in the practical sense, has become treatment for opioid use disorder in a fentanyl-contaminated supply.
This page covers the clinical specifics of heroin use disorder, the realities of the current supply, and the evidence-based treatment that works.
What heroin is, pharmacologically
Heroin (diacetylmorphine) is a fast-acting mu-opioid receptor agonist. Compared to morphine, it crosses the blood-brain barrier more quickly, producing the rapid onset that defines its abuse potential. Once in the brain, heroin is metabolized to morphine; it is morphine that produces most of the sustained opioid effects.
Heroin can be injected, snorted, or smoked. Injection is the highest-risk route for both overdose and infection.
The current supply is fentanyl-contaminated
For more than a decade, the illicit opioid supply has shifted from "heroin" to "heroin and fentanyl mixtures" to, in many U.S. markets, "fentanyl sold as heroin." If you use what is sold as heroin, assume fentanyl is in it. Three implications follow:
- Tolerance to heroin alone does not predict tolerance to today's supply. A person using what is sold as heroin today is usually using fentanyl, often in unpredictable doses.
- Naloxone reverses both heroin and fentanyl overdoses, but fentanyl overdoses frequently require multiple doses and a longer monitoring window, because fentanyl outlasts a single naloxone dose.
- **Treatment planning is the same as for fentanyl use disorder**, with attention to the buprenorphine induction considerations specific to fentanyl users.
What are the signs of heroin use disorder?
Common signs:
Physical signs that may be noticeable to family members:
- Persistent strong craving for heroin
- Use larger amounts or longer than intended
- Failed attempts to cut down or stop
- Significant time spent obtaining, using, or recovering
- Withdrawal symptoms when not using
- Tolerance
- Continued use despite known harms
- Work, family, or legal consequences
- Use of physically hazardous routes (sharing needles, using alone)
- Isolation from people not involved in use
- Constricted (pinpoint) pupils during use; dilated during withdrawal
- Track marks (needle injection sites), often along veins of the arms, legs, hands, neck, or groin
- Wearing long sleeves in hot weather to hide injection sites
- Nodding off mid-conversation
- Significant weight loss
- Hygiene changes
- New or worsening dental problems
What does heroin withdrawal look like?
Heroin withdrawal is unpleasant but rarely life-threatening on its own (in contrast to alcohol or benzodiazepine withdrawal). Symptoms typically begin 8 to 24 hours after the last use and peak at 36 to 72 hours, with most acute symptoms resolving by 5 to 10 days. Symptoms include:
Post-acute withdrawal symptoms (sleep disturbance, low mood, anhedonia, intermittent craving) can linger for weeks or months. This is one of the most common reasons people return to use without comprehensive treatment.
Medical detox can dramatically reduce the misery of withdrawal and stabilize the person for the start of buprenorphine-based MAT. See medical detox in Tinton Falls or medical detox in Charlotte.
- Generalized muscle and bone aches
- Strong craving
- Anxiety, irritability, restlessness
- Runny nose, tearing eyes
- Sweating, chills, goosebumps
- Nausea, vomiting, diarrhea, abdominal cramps
- Dilated pupils
- Insomnia
- Yawning
Overdose
Overdose risk is high with any heroin use today, because fentanyl contamination is unpredictable. Recognition and response:
Call 911. Administer naloxone (multiple doses may be needed for fentanyl-contaminated heroin). Begin rescue breathing if trained. Place the person on their side. Stay until help arrives. Good Samaritan laws protect callers.
- Slow, shallow, or stopped breathing
- Blue or grey lips, nails, skin
- Pinpoint pupils
- Unresponsive
- Gurgling or choking sounds
What are the medical risks of heroin use?
Beyond overdose, ongoing heroin use, particularly injection use, carries serious health risks:
These risks are not deterrents in the traditional sense; people in active addiction know about them and continue. What matters clinically is treating the underlying disorder, which simultaneously reduces the exposure that drives these risks.
- HIV and hepatitis C from shared injection equipment
- Bacterial infections including abscesses, cellulitis, and endocarditis (heart valve infection)
- Collapsed veins and chronic injection-site damage
- Tuberculosis in some populations
- Liver and kidney disease, often compounded by hepatitis C
- Reproductive and pregnancy complications
How is heroin use disorder treated?
Treatment follows the opioid use disorder continuum, with the fentanyl-aware adjustments noted above.
Detox
Medical detox at an accredited partner facility is often the right starting point. We coordinate placement and step-down into our outpatient continuum.
Medication-assisted treatment
The Archangel Centers MAT formulary for heroin (and fentanyl-contaminated heroin) use disorder:
Methadone is not in our formulary; clients who need methadone are referred to a federally licensed opioid treatment program.
- Suboxone (buprenorphine/naloxone) Primary option. Used for daily oral or sublingual dosing.
- Sublocade Monthly injectable buprenorphine. Removes the daily medication ritual and supports long-term retention.
- Vivitrol (extended-release naltrexone) Monthly injectable opioid antagonist for clients who choose an antagonist approach after a sufficient opioid-free period.
What is the outpatient continuum?
- PHP at Tinton Falls or PHP at Charlotte for the initial post-detox phase
- IOP and OP for ongoing care and MAT management
Therapy
- Cognitive behavioral therapy for trigger work and coping
- Trauma-informed care for the trauma that often underlies long-term heroin use
- Relapse prevention with concrete coping plans
- Family therapy for repair
- Group therapy with structured peer work
What co-occurring conditions does Archangel treat?
Depression, anxiety, PTSD, and ADHD are common co-occurring conditions in heroin use disorder. See depression and addiction, anxiety and addiction, and PTSD and addiction.
Frequently Asked Questions
Is heroin still even on the market?
Will MAT keep me high?
How long should I stay on MAT?
Can I do outpatient treatment without detox first?
What if I have hepatitis C from prior injection use?
Will I be able to keep my job?
What does the first week of heroin treatment look like at The Archangel Centers?
Can my partner or parents be involved in my heroin treatment?
Related Pages
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