Introduction
Alcohol and heroin use has continued to be a significant public health issue in many parts of the world. The financial and human costs of alcohol and drug abuse are staggering. Not to mention that both substances cause significant health and emotional issues for both the person who uses and the people who care about them. But one of the most serious problems involved in alcohol and heroin use is the withdrawal process. This not only applies to those wishing to get sober, but it also applies to those who chronically use and go through stops and starts during their use.
Few people understand what’s actually happening in the anatomy and nervous system of people undergoing withdrawal from alcohol and heroin. The process is harrowing and emotionally draining for both substances. Still, alcohol withdrawal has a reputation for being more physically dangerous than heroin. And with good reason.
Since most of us don’t understand what goes on in the body with these two withdrawal processes, it’s good to break them down in simple terms. Once we know the biological processes, we can make more sense of the outcomes.
First, let’s look at some alcohol and heroin abuse facts.
Alcohol and Heroin Abuse Facts
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According to the WHO and the CDC, alcohol use remained stable over the ’90s and early 2000s. Although the global average has remained stable between 2010 and 2016, alcohol use has slightly risen among women, young people, and those with more access to socioeconomic resources (1,2).
However, alcohol use seems to be rising quickly during this last tumultuous year. According to market trends, between January and March 2020, the sale of alcohol in the US has risen about 55%. And online sales of alcohol have seen a staggering 243% increase (3). Although the outcomes are unknown, it will undoubtedly require a renewed and more focused approach to mitigating the harmful effects.
Although, should we be that surprised? Even though alcohol is one of the most deadly and addictive substances on earth, it’s also the most widely used and accepted. But most importantly, alcohol is legal and marketed to almost all demographics in every part of the globe.
Heroin, of course, is still illegal. But unlike the stable statistics of alcohol, heroin use has had a surprising and dramatic increase in the last few decades. Before 2002, heroin use was thought to occur mostly in men with few socioeconomic resources. However, by 2011, heroin use rose sharply amongst females, young adults, and those with more socioeconomic resources. With heroin becoming more popular and widespread, we’ve also seen the rates of overdose nearly quadruple (4,5).
Let’s turn now to the ways in which both substances affect the body. How exactly do they make us “high.” We’ll need to know these things first if we want to understand the biological effects of withdrawing from alcohol and heroin.
What Alcohol Does to The Body
Alcohol is so widely used, promoted, and elevated in the western culture that we barely think of it as a drug. Most of us understand that alcohol is a depressant that mucks with your neurotransmitters. But, few know exactly why and how this happens. And until we know how alcohol affects the body, we won’t understand what happens during withdrawal.
Our entire neurological system operates using excitatory and inhibitory neurotransmitters. In simple terms, neurotransmitters carry messages from one neuron to the next. Excitatory neurotransmitters wake up the receiving neuron so it can actually receive the message. Whereas inhibitory neurotransmitters calm the receiving neuron. The whole system works on a tight balance. Without that balance, neurons would be either too excited or not excited enough (6,7).
Before we can understand how withdrawal works, we need to know that alcohol’s main action revolves around enhancing the inhibitory transmitters. When the receiving neurons’ activities are inhibited, the person drinking feels “high” or relaxed. At first, it seems like our nervous system calms down because, in a way, it does (6,7).
Over time though, the receiving neurons become less responsive to the inhibitory neurotransmitter. This means we need more alcohol to induce that “calming” effect. As well, during chronic alcohol use, excitatory receptors become increased (6,7).
Alcohol tolerance just means that the whole nervous system adapts in response to alcohol use. Inhibitory receptors remain less responsive, whereas excitatory receptors increase in numbers. Our nervous systems then become wired for excitation, and we need more and more alcohol to calm it down.
What Happens During Alcohol Withdrawal
Now that we understand how alcohol affects our nervous system, we can make better sense of the withdrawal process. Simply put, when alcohol is removed, we are still left with our re-wired and unbalanced nervous system that is wholly in favor of excitation.
The process of withdrawal can be compared to a rubber band that has been stretched out. The rubber band is our nervous system, and alcohol is what keeps it in the same taut position. We barely notice that our nervous systems are out of balance until we remove the alcohol. When that happens, it’s as if we let the rubber band go, and it snaps back with excessive excitation.
As the alcohol has favored excitatory receptors, we now have an influx of excited neurotransmission. All the neurons in our body are like thousands of rubber bands snapping all over the place. This process is responsible for all the troubling and dangerous withdrawal symptoms. And unfortunately, most alcoholics undergo withdrawal symptoms several times in their life, even when they never intend to quit drinking (6,7,8).
Studies show that the extent and severity of withdrawal symptoms are positively correlated with the amount of alcohol consumed over time. The larger the dose, the more severe the rubber band of excited neurotransmission snaps back (6).
Mild symptoms include:
- Tremors
- Craving
- Vivid dreams
- Anxiety, irritability, hypervigilance
- Loss of appetite, nausea, vomiting
- Headaches
- Sweating
However, with more severe alcohol withdrawal, symptoms can progress to hallucinations, seizures and delirium tremens. This is where alcohol withdrawal can be dangerous and life-threatening without treatment. The condition called delirium tremens (DT) is different than the typical “shakes,” anxiety and insomnia that many people experience after a night of heavy drinking (6,8,9).
Symptoms involved in DT include:
- Hallucinations
- Seizures
- Extreme confusion
- Rapid heart rate
- High blood pressure
- High body temperature
- Agitation
- Sweating
Death is often a result of heart arrhythmias, muscle breakdown, aspiration pneumonia, and respiratory failure. Also, the risk of DT igniting other comorbid conditions is high, enhancing the dangers of severe alcohol withdrawal. Changes in electrolytes, heart rate, blood sugar, and blood gases can wreak havoc on pre-existing conditions like diabetes or cardiovascular disease. Severe alcohol withdrawal and DT can cause previous liver, pancreas, or lung issues to worsen (8,9).
More factors may predict the severity of the alcohol withdrawal process. Still, most researchers agree that the dose and duration of alcohol intake are the most important (9).
What Heroin Does to The Body
Heroin, like alcohol, induces a sedating and relaxing effect, but for very different reasons. Heroin attaches to receptors in the brain that are specific to opioids. Once that happens, heroin causes two events in the brain. The first is that it triggers the same biochemical processes that produce reward and pleasure. The second is that heroin inhibits the production of noradrenaline. And since noradrenaline has a waking and activating effect on the body, the suppression of this chemical causes sedation, low blood pressure, and slow respiration. The result is a feeling of intense relaxation and pleasure (10).
Moreover, the brain’s exposure to heroin, and the resulting pleasure, etches a memory of the drug in the person’s mind. The memory creates a positive association between the drug and the pleasant memory. This association is often at the heart of continued drug use for many people (10).
Like alcohol, repeated heroin use causes a tolerance to the drug in the brain. Over time, the neurons affected by heroin increase their activity, which means more heroin is required to get pleasant and sedating effects. Now that we know how heroin induces a “high” in people who use it, we can better understand what’s happening in withdrawal.
What Happens During Heroin Withdrawal
Once heroin is removed, the overactive neurons no longer have the substance that was suppressing them. This results in an excessive amount of noradrenaline being released by those neurons, causing much of the withdrawal symptoms (8,10).
Heroin withdrawal symptoms include:
- Feeling very jittery and nervous
- Anxiety
- Diarrhea
- Muscle cramps
- Sweating and goosebumps
- Nausea and vomiting
- Fast heart rate
- Runny nose and watery eyes
- Muscle and joint pain
The other important feature of heroin withdrawal is an intense craving for the drug. This craving is connected to the reward system that was stimulated by the drug. Over time, chronic use of heroin and other opioids can reset the pleasure-reward system. This means that regular pleasurable activities no longer feel rewarding. So the craving for heroin often feels like an intense search for pleasure that can never be fulfilled. Research has shown that this pleasure-reward system underpins the drive for continued drug use (8,10).
Why is Alcohol Withdrawal More Dangerous?
As we can see, alcohol withdrawal carries more health risks than heroin withdrawal. In short, alcohol’s neurological effects cause more volatile outcomes when alcohol is removed. In particular, the increase in the number of glutamate receptors during alcohol use can cause serious issues when alcohol is removed. Glutamate is one of the neurotransmitters responsible for activating the nervous system. It must remain in the right balance so that the brain isn’t overwhelmed. Unfortunately, once alcohol is removed, the sudden influx of glutamate is often responsible for serious withdrawal issues like DT (6,8,9).
People need to understand that alcohol withdrawal complications don’t only apply to those wishing to stop drinking for good. Unfortunately, many alcoholics go through periods of withdrawal throughout their drinking lives. These kinds of “starts” and “stops” in one’s drinking pattern can cause severe withdrawal symptoms on their own. Research shows that the risk of experiencing DT is increased for alcoholics who undergo many withdrawal episodes throughout their life (6,8,9). The more alcoholics are educated about this, the better equipped they’ll be to buffer the risks.
Heroin withdrawal is not without its risks, but the withdrawal process doesn’t pose the same danger as alcohol. The most problematic issue in heroin withdrawal is dehydration due to vomiting and diarrhea. For some, these symptoms can be more severe and may require medical attention to mitigate the risks of electrolyte imbalance. Also, it depends on the health and comorbid conditions of the person experiencing heroin withdrawal. If he or she has other severe illnesses, then the withdrawal process may have more risks involved (11).
Lastly, if a person struggles with both alcohol and heroin dependence, then risks of withdrawal complications increase (11). Also, people who have multiple substance addictions often have comorbid health conditions that greatly impact the withdrawal process. Issues such as liver disease, malnutrition, and infectious diseases can increase mortality risk, especially for those who don’t receive medical withdrawal support (7,8).
Conclusion
As we now understand, alcohol impacts and changes the brain and nervous system. What that means in simple terms is that the brain becomes wired for excitation. When alcohol is removed, this excitation is what causes the withdrawal symptoms. Heroin has a similar process; however, it affects different neurotransmitters and receptors. Unfortunately, the neurobiological processes affected by alcohol have more severe outcomes.
Heroin withdrawal does require medical attention and support but usually doesn’t carry the same risk of mortality that alcohol withdrawal does. But we know that comorbid health problems, concurrent substance abuse, and severe dehydration can increase the health risks of heroin withdrawal.
For anyone wishing to withdraw from either alcohol or heroin, this process must be monitored by a medical professional. However, alcohol withdrawal needs to be taken more seriously, especially if there is long term abuse, and other substances are involved. It’s essential for alcoholics to understand this, even if they have no intention to stop drinking.
Many times, alcohol withdrawal requires inpatient admission due to severe risks, even for seemingly healthy people. And since alcohol is widely used, distributed, and marketed, it can be difficult for someone who wishes to stop drinking to actually ask for help.
However, the more that these facts get out there, the more these risks can be reduced. For anyone who struggles with alcohol dependence, it can be a lonely path. The best thing to do is to get educated about what’s involved in alcohol withdrawal and communicate about drinking patterns with a family doctor.
It’s crucial to find medical support for anyone who wishes to quit drinking. This is also important for people who tend to drink, then stop, and then go back to drinking. The more honest a person can be with medical professionals, the less impacted they will be by serious withdrawal complications.
References
1. https://www.who.int/substance_abuse/publications/global_alcohol_report/msbgsruprofiles.pdf
2. https://www.cdc.gov/alcohol/index.htm
3. https://www.marketwatch.com/story/us-alcohol-sales-spike-during-coronavirus-outbreak-2020-04-01
4. https://www.cdc.gov/vitalsigns/heroin/index.html
5. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5846593/
6. https://pubs.niaaa.nih.gov/publications/arh22-1/05-12.pdf
7. https://www.ncbi.nlm.nih.gov/books/NBK310652/
8. https://www.ncbi.nlm.nih.gov/books/NBK459239/
9. https://www.ncbi.nlm.nih.gov/books/NBK482134/
10. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2851054/
11. https://onlinelibrary.wiley.com/doi/full/10.1111/add.13512
