Signs and Symptoms of Heroin Use

No matter what substance a person may be using, there are signs which, if detected early, would alert family members, teachers, dentists and physicians to a problem before it results in death or incarceration. Recreational drug use, or prescriptions for pain can end in a devastating life-threatening condition, and heroin addiction in particular is a very serious situation. The unfortunate reality is that the majority of individuals entering the Narconon Program had used drugs and alcohol for a period before it was discovered.

Drug users are seldom able to honestly talk about their drug use and will go to extreme lengths to deny using in order to continue their drug use. Educating yourself about what to look for is the critical first step to get someone help and to safeguard your friends and family from individuals who are in the middle of an active addiction. One of the tragedies of addiction is the change in behavior that accompanies drug use. Individuals who were once happy and trusted members of their families and communities must now lie, cheat and steal to feed their ever-growing habit.

Noticing the signs of heroin addiction does not require you to be a detective, and you should never put yourself or anyone else at risk in order to investigate a loved one you suspect of using. Simply by being aware and watching the behavior of the individual and those who are around them is usually all it takes to begin to notice the signs and symptoms of drug use.

Heroin Use: Items and Paraphernalia

Heroin Paraphernalia

Some of the first signs that individuals are using heroin are the items that are used to inject, snort or smoke it. These items, known as drug paraphernalia, can provide an insight not only into what drug is being used, but how it is being used. Items to be on the lookout for include:

  • Burnt spoons
  • Tiny baggies (may have white or tan powdery residue in them)
  • Small white paper wrappers (may have an image or words stamped on them)
  • Tan or whitish powdery residue
  • Dark, sticky residue (black, dark brown or dark grey)
  • Small glass pipes
  • Syringes
  • Rubber tubing
  • Aluminum foil with burn marks
  • Cut aluminum cans
  • Straws or empty pens

Burnt spoons, syringes and rubber tubing all indicate that an individual is injecting heroin. Other items can include cut-apart coke cans, small tea candles or other small metal containers that can be heated. In order to inject heroin it must first be dissolved with heat in water. So any small makeshift metal container can be used to cook heroin prior to injection. The other things to look for if you suspect someone is injecting heroin are of course syringes and syringe tops. Less obvious items are cotton balls, cotton swabs, tampons or cigarette filters which can be used as a filter when the dissolved heroin is drawn into a syringe.

Aluminum foil and small glass pipes indicate that someone is smoking heroin. Heroin is smoked by vaporizing the drug and inhaling the fumes created by the drug. Heroin is not actually burned in this process, but rather creates a gummy substance similar to burnt oil. One difference between smoking methamphetamine and smoking heroin is the large about of residue left in the pipe or on the foil when heroin is smoked.

Cut straws, empty or hollow pens, or rolled-up Post-it notes or bills can be used for snorting heroin.

Immediate Signs of Current Heroin Use

Dilated and smaller eye pupils.

Heroin is a fast-acting opiate. When it’s injected, there is a surge of euphoria that arrives within seconds. Those using the drug other ways may not feel this surge as sharply. This rush of euphoria is accompanied by a dry mouth and flushed skin. Dilated or smaller-than-normal pupils are also an indication of current heroin intoxication. Other than the rush of euphoria, the symptoms of heroin use are the same for all methods of use. The difference is in the degree a user will feel the effects.

Users will often appear drowsy and move slowly. With heroin injection in particular, users will often exhibit a particular behavior. The individual will momentarily pass out, only waking up when their chin hits the chest. Since this looks a lot like someone nodding, heroin users are sometimes known as “being on the nod” and the behavior is known as “nodding out.” This in particular is an almost certain sign that heroin is being used. This effect is what depresses breathing and results in death if no intervention is made.

When the user is awake, the person’s thinking will be unclear. They will tend to lose some of their memory. Their decision-making and self-control are likely to deteriorate. As heroin is a powerful opiate, the user’s pain response will be limited.

Other signs of heroin use are itching, nausea and vomiting. Another sign of heroin use is the constipation often suffered by opiate abusers. The regular user of this drug may look for laxatives. They may experience skin infections, or other kinds of infections, and a lowered immunity to illness.

Physical Signs of Heroin Use and Addiction

Carefully noticing the physical appearance of someone you suspect of heroin use is as effective as identifying behaviors, smells, and sounds. There are a number of physical symptoms caused by the drug itself which include:

  • Tiny, pinpoint pupils
  • Sleepiness, a tendency to nod off
  • Slow breathing
  • Flushed skin
  • Runny nose or itchy nose
  • Vomiting
  • Scratching
  • Slurred speech
  • Sweating
  • Lack of appetite and weight loss

Indications of changes in behavior are also associated with heroin use. These may occur only when the individual is under the influence, or they may result from longer-term issues with self care or even from self harm.

  • Track marks on arms or top of hands or wrists
  • Scabs and sores from picking at skin
  • Covering arms with long sleeves
  • Not bathing
  • Rotting teeth
  • Eating large amounts of sweets

Behavioral Signs of Heroin Use and Addiction

In addition to physical signs of use, a number of behavioral and mood changes are associated with heroin use. These changes are most noticeable when living with the individual, but they can be noticed in other users. Unfortunately, many of the signs are usually written off or explained away by the addict. Individuals who are addicted to drugs and alcohol have become very good at lying to themselves and manipulation becomes a way of life. If something on this list occurs once or twice or then it might not be drug use or addiction. However, if multiple changes are present, drug use is the likely cause:

  • Mood swings, sudden and dramatic shifts in mood, up or down
  • Unexplained periods of euphoria and activity followed suddenly by severe fatigue
  • Changes in friends, falling out of touch with long-time friends
  • Lying
  • Theft, criminal activity, missing money
  • Spending longer than usual periods in the bathroom

As the addiction worsens, the behavioral changes will grow more and more extreme. It is a common myth that there is such a thing as a “functional” addict. The reality is that the functional addict is actually just an addict who has managed to avoid the consequences and has not seen the same effects—YET. The term “yet” is key because, given enough time, any substance use will eventually turn into an addiction. Some examples of issues which grow worse over time include:

  • Financial troubles
  • Missing school or work
  • Disappearing for unexplained periods of time
  • Letting personal hygiene go
  • Confusion, disorientation
  • Declining responsibility and declining work or study performance

The defining feature of any addiction is that it grows worse over time. If you know someone who has been gradually displaying more severe symptoms, heroin use is likely.

Heroin Tolerance, Addiction and Withdrawal

With regular heroin use, tolerance develops. This means the abuser must use more heroin to achieve the same intensity or effect. As higher doses are used over time, physical dependence and addiction develop. With physical dependence, the body has adapted to the presence of the drug and withdrawal symptoms may occur if use is reduced or stopped.

Withdrawal, which in regular abusers may occur as early as a few hours after the last administration, produces drug craving, restlessness, muscle and bone pain, insomnia, diarrhea and vomiting, cold sweats with goose bumps, kicking movements (“kicking”), and other symptoms. The cold, clammy skin, and goose bumps is where the term “cold turkey” is derived. This denotes someone who tried to stop using without any assistance. While the assistance needed does not likely include medication, individuals who receive support and further treatment for their heroin use are less likely to relapse. The term “kicking the habit” is also derived from the motion of a heroin user’s legs.

Major withdrawal symptoms peak between 48 and 72 hours after the last dose and subside after about a week. Sudden withdrawal by heavily dependent users who are in poor health is occasionally fatal, although heroin withdrawal is considered much less dangerous than alcohol or barbiturate withdrawal.

What Are the Symptoms of Heroin Withdrawal?

Regardless of dosage or means of consumption, these physical symptoms or reactions may appear during heroin withdrawal:

  • Fever and Chills
  • Muscle spasms and convulsions, especially in the legs
  • Deep bone pain, aches and cramps
  • Vomiting, diarrhea
  • Uncontrollable shaking, cold sweats or excessive sweating
  • Goosebumps, hot flashes
  • Increased or abnormal heart rate

In some cases heroin withdrawal may result in more serious symptoms. While this is nearly always the result of underlying medical issues, please seek medical advice for you or your loved one if you believe you are experiencing heroin withdrawal:

  • Heart attack
  • Sudden, sharp blood pressure increase
  • Stroke

In addition to these physical symptoms, behavioral changes occur with withdrawal as well as with use. These changes can at times be quite profound:

  • Insomnia
  • Depression
  • Anxiety
  • Suicidal thoughts and behavior

As withdrawal progresses, elevations in blood pressure, pulse, respiratory rate and temperature occur. One heroin user trying to dissuade a person from starting heroin use described his withdrawal this way: “Diarrhea, vomiting, uncontrollable shakes, cold sweats, goosebumps, hot flashes, aches and pains that will not go away, semi-permanent insomnia, anxiety, muscle spasms and suicidal thoughts.”

The severe symptoms that hit during a cold-turkey withdrawal are awful enough that, once a person goes through them, he (or she) may feel he can’t ever face them again. Sometimes a person must face a completely unassisted withdrawal in jail. While withdrawals vary from person to person, some people describe the muscle and bone pain as excruciating. Others may vomit repeatedly and experience continuous bouts of diarrhea as their bodies try to get rid of the drug toxins. Dehydration is a danger during withdrawal from heroin.

However, despite the discomfort that is typical during withdrawal, it is possible to give a person the support and help that makes withdrawal tolerable, and then to assist the person through the rest of the steps they need to take to live a truly drug-free life.

Heroin Overdose Symptoms

Heroin overdose occurs when too much of the drug is taken, or if the heroin has been mixed with strong substances, such as fentanyl. Overdoses can also occur when an individual has stopped using for some time, and then uses again. They use the same amount that they were used to taking before they stopped, but since they have not been using for some time, their tolerance has decreased and it is too much for their body to deal with.

Signs and symptoms of heroin overdose include:

  • Confusion
  • Slow and shallow breathing
  • Blue skin or lips
  • Small pupils
  • Decreased alertness
  • Unresponsiveness
  • Loss of consciousness

If you suspect someone is suffering from a heroin overdose, it is crucial to get medical help immediately. How fast the person is treated is a life-or=death matter. Contact emergency medical services (such as by calling 911) right away. If you or someone in the vicinity has naloxone this should be administered immediately. Ensure the person is breathing and their air passages are not obstructed. If there were other drugs used, ensure that the emergency medical personnel are aware as this could create other problems.

For More Information on Heroin:


Reviewed and Edited by Claire Pinelli, ICAADC, CCS, LADC, MCAP, RAS