Heroin detox is a level of care. It is not a single service, and it is not a cure. SAMHSA’s own protocol calls it a set of steps aimed at managing acute intoxication and withdrawal [1]. It quotes a second, plainer definition too: a medical step that takes a person safely through acute withdrawal [1].
The key sentence is the one people are least often told. Detox is not substance abuse treatment and rehabilitation [1]. It is how somebody gets to the start line safely. It is not the race.
So this page is about the level of care. What a detox program does. The five settings federal guidance names. What supervision involves. Which medications are used, in general terms. What happens at the end. And what a health plan has to do with any of it. The duration question belongs to our page on heroin withdrawal, which sets out the course.
What Detox Actually Means, and What It Is Not
SAMHSA builds detox from three parts. They may happen at the same time, or as a series of steps [1].
Evaluation. Testing for substances in the blood. Measuring how much is there. Screening for mental and physical conditions that sit alongside the drug use [1]. It also covers a full look at the person’s medical state, their mental state and their situation at home. The point of that is to decide the right level of treatment after detox. SAMHSA calls it the basis of the first treatment plan [1].
Stabilization. The medical and social work of getting somebody through acute intoxication and withdrawal [1]. The goal is a state that is medically stable, fully supported and free of the drug. SAMHSA says this is often done with the help of medications. It also says that in some approaches to detox, no medication is used [1]. This stage covers two other things. Telling a person what to expect and what their own role will be. And bringing in family, employers and other people who matter, where that fits and where the person agrees to it [1].
Fostering entry into treatment. Getting somebody ready for what comes next [1]. SAMHSA describes a written treatment contract for people who have a pattern of finishing detox and then not going on to treatment. It is careful about what that is. The contract is not legally binding. It is signed by choice, when a person is well enough to do so. In it, the person agrees to a continuing care plan. The details and the contacts are set up before detox finishes [1].
SAMHSA adds one thing about all three, and it is not decoration. People going through detox need to know that someone cares about them, respects them, and has hope for their future [1].
The Five Levels of Detox, and Who Decides Which One
Detox is not one place. SAMHSA sets out five levels of care [2]. Naming them is the most useful thing this page can do. A reader who knows the ladder can ask a real question on the admissions call.
- Level I-D, ambulatory detox without extended onsite monitoring. For example a doctor’s office, or a home health care agency. SAMHSA calls it an organized outpatient service, monitored at set intervals [2].
- Level II-D, ambulatory detox with extended onsite monitoring. For example a day hospital service. What marks it out is the nurses. Credentialed, licensed nurses monitor people over several hours on each day of service [2].
- Level III.2-D, clinically managed residential detox. A non-medical or social detox setting. SAMHSA says it emphasizes peer and social support. It is meant for people whose intoxication or withdrawal is enough to warrant 24-hour support [2].
- Level III.7-D, medically monitored inpatient detox. For example a freestanding detox center. Unlike the level above it, this one provides 24-hour medically supervised detox services [2].
- Level IV-D, medically managed intensive inpatient detox. For example a psychiatric hospital inpatient center. This level provides 24-hour care in an acute care inpatient setting [2].
Who decides. SAMHSA describes the aim as matching a person’s clinical needs to the right setting, in the least restrictive and most cost-effective way [2]. Then it names what gets in the way. Gaps in the range of settings and levels on offer. Limits set by third-party payors, such as strict use of standard admission criteria. Clinicians who lack the authority, and sometimes the knowledge, to decide the right setting. Insurance with no substance use disorder benefit. And no health insurance at all [2].
Read that list twice. Three of the five obstacles are about money rather than medicine. Our guide to the levels of care covers the treatment ladder above detox. Our general page on medical detox covers what the rung itself involves.
Where the Timeline Lives, and the One Figure This Page Carries
A withdrawal course and a detox stay are two different lengths. Running them together is how a page ends up carrying durations that do not agree with each other.
The course of heroin withdrawal is published, and it belongs to our page on heroin withdrawal. Here is the figure, once, in SAMHSA’s own words and with its own hedge. Heroin withdrawal typically begins 8 to 12 hours after the last heroin dose and subsides within a period of 3 to 5 days [3]. SAMHSA gives that per drug, not for opioids as a class. The same paragraph puts methadone’s start at 36 to 48 hours, with a course of 3 weeks or longer [3]. Keep “typically”. It is the source’s word, and it is doing work.
The length of a stay is a different question. No federal source read for this page answers it. What settles it is the evaluation, the level of care somebody is placed in, and what the plan authorizes. SAMHSA’s own framing helps here. The number and intensity of signs determine how severe opioid withdrawal is [3]. Repeated assessments should be made during detox, to see whether symptoms are improving or getting worse [3]. So a stay ends when the assessment says it should. Not on a published average.
If someone is having a seizure, is unresponsive or has trouble breathing, call 911. For a mental-health crisis call or text 988.
Heroin detox and treatment in Washington
The Recovery Village Ridgefield is our campus in Ridgefield, Washington, and its own page cards medical detox, inpatient treatment, partial hospitalization programming, intensive outpatient programming, dual diagnosis treatment and medically-assisted treatment. Its dual diagnosis card says co-occurring mental health conditions are common alongside addiction and that both are treated together, and admissions is where the question of which level of care fits is actually settled.
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The Recovery Village Ridgefield is part of our family of treatment centers. See the Recovery Village Ridgefield campus.
What Supervision Actually Involves
Three things. Each one is something a person on their own cannot do for themselves.
Being assessed properly. MedlinePlus describes what that looks like. A physical exam. Questions about medical history and medicine use. Urine or blood tests to confirm opioid use [4]. Then, depending on what the clinician is worried about, more. Blood chemistries and liver function tests. A complete blood count. A chest x-ray. An electrocardiogram. And tests for hepatitis C, HIV and tuberculosis, because many people who use opiates also have those diseases [4]. MedlinePlus adds one more. Anyone going through opioid detox should be checked for depression and other mental illnesses, and treating those can cut the risk of a return to use [4].
Being watched, over and over. SAMHSA says repeated assessments should be made during detox [3]. They check two things. Whether symptoms are improving or getting worse, and whether the medication being used is working [3]. MedlinePlus groups what they are watching for by when it tends to appear. Early: agitation, anxiety, muscle aches, increased tearing, insomnia, a runny nose, sweating and yawning. Late: abdominal cramping, diarrhea, dilated pupils, goosebumps, nausea and vomiting [4]. That is the difference between a plan and a guess. It is also what changes the plan at three in the morning rather than the following week.
Being caught if something goes wrong. SAMHSA notes that medical complications of opioid withdrawal can develop, and should be spotted and treated quickly [3]. MedlinePlus is direct about the alternative. Withdrawal from either opiates or opioids on your own can be very hard and may be dangerous [4]. It names three settings [4]. At home, with medicine and a strong support system, which it calls difficult and says should be done very slowly. In a facility set up to help people with detox. Or in a regular hospital, if symptoms are severe.
Our general guide to withdrawal symptoms covers what is being watched for across drugs.
Medications Used in Opioid Detox, in General Terms
What each medication is for, and nothing about amounts or timing. Those belong to a prescriber, and none appears anywhere on this page.
NIDA states the federal position first, and it is stronger than people expect. When treating addiction to opioids, including heroin, medication should be the first line of treatment. It is usually combined with some form of behavioral therapy or counseling [5]. NIDA lists four for opioids: methadone, buprenorphine, extended-release naltrexone and lofexidine [5].
MedlinePlus says what each of the main ones does [4].
Methadone relieves withdrawal symptoms and helps with detox. It is also used as a long-term maintenance medicine for opioid dependence [4].
Buprenorphine treats withdrawal from opioids and can shorten the length of detox [4]. It may also be used for long-term maintenance. It is often combined with naloxone, which helps prevent dependence and misuse [4].
Clonidine reduces the anxiety, agitation, muscle aches, sweating, runny nose and cramping of withdrawal. MedlinePlus adds that it does not help reduce cravings [4]. SAMHSA fills in the background. Clonidine was first approved for high blood pressure. It is not FDA approved for opioid withdrawal. It is used off label for it, because the research literature supports its use in this condition [3].
Naltrexone helps prevent a return to use, and comes as a pill or as an injection [4]. It carries a warning that decides its timing. It can bring about a sudden and severe withdrawal if it is taken while opioids are still in the system [4].
One sentence from MedlinePlus is worth reading twice here. People who go through withdrawal over and over should be treated with long-term methadone or buprenorphine maintenance [4]. Our overview of medication-assisted treatment covers what that involves.
Is Heroin Detox Dangerous, and the Risk That Comes After It
Both halves, together.
The first half. SAMHSA states that unlike alcohol and sedative withdrawal, uncomplicated opioid withdrawal is not life-threatening [3]. MedlinePlus agrees: withdrawal from opiates is painful, but usually not life threatening [4]. “Usually” is the source’s own word.
The second half, from the same two pages. SAMHSA adds a caveat. Rarely, severe gut symptoms such as vomiting or diarrhea can lead to dehydration or electrolyte imbalance [3]. It also warns that existing heart illness can be made worse by the raised blood pressure, raised pulse and sweating that come with opioid withdrawal [3]. MedlinePlus names vomiting and breathing stomach contents into the lungs, which is called aspiration and can cause a lung infection. It lists dehydration and disturbed body chemistry too [4].
And the risk that is bigger than all of them. It arrives after the detox is over. MedlinePlus puts it in three sentences. The biggest complication is returning to using the drug. Most opioid overdose deaths occur in people who have just detoxed. Withdrawal reduces tolerance, so someone who has just been through it can overdose on a much smaller dose than they used to take [4]. NIDA states the same mechanism. If a person uses as much of the drug as they did before quitting, they can easily overdose, because their body is no longer adapted to that level of exposure [5].
That is the argument for detox being a level of care rather than an event. A detox that ends with a plan, a prescription and an appointment is a different thing from a detox that ends at the door.
If someone is having a seizure, is unresponsive or has trouble breathing, call 911. For a mental-health crisis call or text 988.
What Comes Next: The Treatment Detox Is For
NIDA puts the consequence of stopping here in one sentence. Detoxification alone without subsequent treatment generally leads to resumption of drug use [5].
What follows detox is medication plus behavioral work. NIDA describes the behavioral half in its own terms [5]. Cognitive-behavioral therapy helps people recognize, avoid and cope with the situations in which they are most likely to use drugs. Contingency management uses rewards or privileges for staying drug-free, for attending and taking part in counseling, or for taking treatment medications as prescribed. Motivational enhancement therapy uses strategies to make the most of somebody’s readiness to change and enter treatment. NIDA adds that these therapies can make medications work better, and can help people stay in treatment longer [5].
MedlinePlus lists the settings that work follows into. Outpatient counseling. Intensive outpatient treatment, which it describes as day hospitalization. And inpatient treatment [4]. It says most people need long-term treatment after detox [4]. Our pages on inpatient rehab and outpatient rehab describe both ends of that.
If somebody does return to use, NIDA says it does not mean treatment has failed [5]. It means speaking to a doctor about resuming treatment, changing it, or trying another one [5]. NIDA also names what usually sets it off. Stress cues linked to the drug use, such as people, places, things and moods. And contact with the drug itself [5].
Cost, Coverage and Getting a Date
The honest version of this section starts with SAMHSA’s own admission that money shapes placement. Three of the obstacles it lists are financial. Limits set by third-party payors, including strict use of standard admission criteria. Insurance with no substance use disorder benefit. And no insurance at all [2]. A health plan is part of the decision about where a detox happens, and pretending otherwise helps nobody.
Our own published ranges sit on our page about how much rehab costs. That page opens on price ranges by level of care, and it puts program length first among the things that change the total. Our guide to insurance coverage covers what a plan decides and what it does not.
The admissions call settles the rest. How much medical cover the withdrawal needs. What the plan will authorize. And what is available at that level of care. Being accurate about how much heroin has been used, in what form and how recently is what makes the answer useful. Our guide to the admissions process sets out what a program needs before it can give someone a date. Our page on how long rehab takes covers length of stay. Our treatment center directory has a map you can browse by state, and our guide to heroin addiction covers the drug itself.
Frequently Asked Questions
What is the difference between heroin detox and heroin treatment? Detox manages acute intoxication and withdrawal; treatment addresses everything underneath it. SAMHSA is explicit that a detoxification program is not designed to resolve the longstanding psychological, social and behavioral problems associated with drug use, and that detoxification is not substance abuse treatment and rehabilitation. NIDA adds the consequence: detox alone without treatment afterwards generally leads to resumption of drug use.
Does heroin detox have to be inpatient? Not necessarily, and federal guidance describes five levels rather than two. They run from ambulatory detoxification monitored at set intervals, through ambulatory detoxification with nurses monitoring for several hours a day, to clinically managed residential, medically monitored inpatient and medically managed intensive inpatient care. Which one fits is a clinical decision made at assessment, and what a plan authorizes is part of it.
What happens on the first day of heroin detox? Evaluation. MedlinePlus describes a physical exam, questions about medical history and medicine use, and urine or blood tests, with further testing depending on the clinician’s concerns. SAMHSA describes the same stage as testing for substances, measuring their concentration and screening for co-occurring mental and physical conditions, plus an assessment of the person’s medical, psychological and social situation that sets the treatment plan.
What medications are used in heroin detox? NIDA lists methadone, buprenorphine, extended-release naltrexone and lofexidine for opioids, and says medication should be the first line of treatment. MedlinePlus adds clonidine, which eases anxiety, aches, sweating and cramping but not cravings, and warns that naltrexone can bring on sudden severe withdrawal if opioids are still in the system. How much of any of them is a prescriber’s decision.
How long does heroin detox take? Two different questions sit inside that one. SAMHSA puts the withdrawal course at typically beginning 8 to 12 hours after the last heroin dose and subsiding within 3 to 5 days. The length of a detox stay is decided by the assessment and by the level of care, and no federal source read for this page publishes an average for it. Our heroin withdrawal page covers the course.
Sources
- Center for Substance Abuse Treatment. (2006). Detoxification and Substance Abuse Treatment, Chapter 1: Overview, Essential Concepts, and Definitions in Detoxification. Substance Abuse and Mental Health Services Administration. https://www.ncbi.nlm.nih.gov/books/NBK64119/
- Center for Substance Abuse Treatment. (2006). Detoxification and Substance Abuse Treatment, Chapter 2: Settings, Levels of Care, and Patient Placement. Substance Abuse and Mental Health Services Administration. https://www.ncbi.nlm.nih.gov/books/NBK64109/
- Center for Substance Abuse Treatment. (2006). Detoxification and Substance Abuse Treatment, Chapter 4: Physical Detoxification Services for Withdrawal From Specific Substances — Opioids. Substance Abuse and Mental Health Services Administration. https://www.ncbi.nlm.nih.gov/books/NBK64116/
- U.S. National Library of Medicine. Opiate and Opioid Withdrawal. MedlinePlus Medical Encyclopedia. https://medlineplus.gov/ency/article/000949.htm
- National Institute on Drug Abuse. (2020). Drugs, Brains, and Behavior: The Science of Addiction — Treatment and Recovery. National Institute on Drug Abuse. https://nida.nih.gov/publications/drugs-brains-behavior-science-addiction/treatment-recovery
This page is for general information and is not medical advice. Only a licensed clinician who
knows your history can tell you what is right for you. If you or someone you know is in
immediate danger, call 911. For free, confidential support 24/7, call or text 988.
Author
Chief Medical Officer,
The Recovery Village
