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Heroin Relapse Rates: Why Does It Happen?

Elena Hill, MD, MPH profile image
Medically Reviewed By Elena Hill, MD, MPH • Updated Aug 21, 2023 • 5 cited sources

Heroin use disorders (HUD) do not develop overnight, nor can they be cured overnight. The road to recovery can be long. Along the way, it is relatively common for people who are trying to stop using heroin to relapse.[1]

This happens in part because there is a physical dependence at play that causes withdrawal symptoms and significant cravings for the substance. Without Medication for Addiction Treatment (MAT) to reduce withdrawal symptoms and manage cravings, relapse to heroin use is highly likely. 

Additionally, issues at home or out in the world can trigger uncomfortable emotions, which causes people who do not yet have strong coping mechanisms under their belt to return to substance use. 

Other factors such as poor social support, or concurrent mental health conditions have been associated with increased risk of relapse. 

Avoiding heroin relapse begins with laying the foundation for success in recovery and starting MAT. To learn more about the medication that has been proven effective in helping people to avoid relapse, contact Bicycle Health today

Why Are Relapse Rates for Heroin So High?

Relapse rates for heroin use disorder vary, but it is estimated that between 40% and 60% of individuals in recovery from substance use disorder (SUD) will relapse at some point in their recoveries.[2]

Though the changes in heroin relapse rates over the years is not well documented, it may be that rates of heroin relapse have increased due to the rise of even more potent opioids such as fentanyl. 

Even though 40% to 60% sounds like a high rate, it is important to remember that addiction is a complex and chronic disease. Relapse can occur with recovery from any substance, not just heroin. These rates are not unlike the “relapse” rates of patients managing other chronic illnesses like diabetes. With the right support and treatment in place, relapses can be prevented. 

What Factors Impact Heroin Relapse?

There are a number of factors that can have an impact on relapse. Here are just a few: 

Physical Dependence

Continuous use of heroin can lead to physical dependence, leading to withdrawal symptoms when use stops. The addition of synthetic opioids like Fentanyl has made heroin even more addictive, and withdrawal symptoms even more severe than in the past. [3] The more physically addictive a substance, the higher the risk of relapse.

Psychological Dependence

Heroin can create strong psychological cravings, leading to continued use despite negative consequences. Even when people utilize medications like Suboxone to help them manage physical withdrawal symptoms, psychological symptoms can persist. This is why behavioral therapies are so effective and important in addiction recovery, along with medications. 


Environmental or emotional triggers, such as stress, can prompt a return to use. For people whose sole coping mechanism has been substances in the past, it can be very difficult to learn new, more productive coping mechanisms when a trigger does occur. This is again why behavioral therapies are so important in addiction recovery – to help individuals address cravings with more healthy coping mechanisms other than substance use. 

Lack of Social Support

Social support is key to recovery. Many people are isolated from others when they are actively using. When they transition into recovery, they may feel that they have no solid, healthy relationships to turn to for support, especially if those relationships have been damaged during their time of heroin use. Rebuilding a support system either through friends/family, or through a community of similarly recovering individuals (peer support, group therapy, etc) can be essential. 

Undiagnosed or Untreated Mental Health Issues

Co-occurring mental health disorders can increase the likelihood of OUD, and they can increase the likelihood of relapse as well. The most effective addiction recovery plan will not forget to address any co-occurring mental health conditions. Treatment of anxiety and depression will help to stabilize the individual in their mental health prior to any attempts to sustain recovery. 


Time itself “heals all wounds”, including addiction disorders. One study that followed people in recovery from heroin use disorder over the course of 33 years found that relapse was exceptionally common. But they also noted that if people were able to abstain from heroin use for five years, they were at a much lower risk of relapsing. But they also saw that even after 15 years of abstinence, about a quarter of the study participants still relapsed.[4] The results of this study add up to an important truth: OUD is often a lifelong condition, and it requires ongoing vigilance to manage it.

Why Are Rates of Overdose High Due to Heroin Relapse?

Overdose can happen at any time, but when someone relapses after a period of abstinence, overdose is more likely for a few reasons: 

When a person is frequently using a substance, they build up a tolerance to that substance. This means they can often tolerate a high dose. 

After a period of abstinence, the body recalibrates, and the old dose of heroin that was once considered “normal” the body is no longer used to. [5] 

When this happens, an individual may consume the quantity of a drug they are used to without realizing their tolerance has decreased, leading to an overdose. 

This is a phenomenon that all users should be aware of, and proceed with extreme caution if they do return to use after a period of abstinence. 

What Are the Signs of Heroin Relapse? 

Signs of an impending heroin relapse may include the following:

  • Increased cravings for the drug
  • Isolation from loved ones 
  • Avoiding responsibilities or previous interests
  • A return to old behaviors and habits associated with drug use
  • Increased secretive or dishonest behavior
  • Financial problems or increased borrowing or stealing
  • Unexplained mood swings or changes in attitude
  • Contemplating using heroin again and justifying that once wouldn’t be a big deal

What Can Prevent Heroin Relapse? 

Though relapses do happen, strategies exist to prevent them. Here are some good strategies for relapse prevention: 

Creating New Environments

Returning to the same physical locations where use occurred can be a strong trigger. Choosing new environments can mean working somewhere new, finding a new housing environment, or spending time with new friends in different locations from where use used to occur. 


Speaking to a professional about some of the emotional issues, trauma and thought processes that contributed to the development of OUD in the first place can help the individual develop new coping mechanisms other than substance use to handle stressful triggers. 

Treatment for Co-Occurring Disorders 

If co-occurring disorders such as anxiety or depression are an issue, getting treatment is critical. Attempting to treat an addiction disorder without addressing or treating concurrent mental health disorders makes sustained recovery much more difficult. The good news is there are many pharmacological and behavioral therapies for most common mental health conditions – including anxiety, depression, PTSD, schizophrenia, bipolar disorder, etc. These conditions should be addressed along with the substance use disorder itself.

Medication for Addiction Treatment 

MAT is considered a cornerstone of treatment for OUD. There are 3 medications that are FDA approved for MAT at this time: Methadone, Suboxone, and Naltrexone. 

For more information on the medications that can help you or your loved one to heal from OUD related to heroin, contact Bicycle Health now.

Medically Reviewed By Elena Hill, MD, MPH

Elena Hill, MD; MPH received her MD and Masters of Public Health degrees at Tufts Medical School and completed her family medicine residency at Boston Medical Center. She is currently an attending physician at Bronxcare Health Systems in the Bronx, NY where ... Read More

  1. Understanding and Managing the Relapse Process. United Nations Office on Drugs and Crime. Accessed January 2023.
  2. Treatment and Recovery. National Institute on Drug Addiction. July 2020. Accessed January 2023.
  3. Notorious Mexican Drug Lord — Known as the "Boss of Bosses" — Leaves Prison After 33 Years. CBS News. September 2022. Accessed January 2023.
  4. A 33-Year Follow-up of Narcotics Addicts. JAMA Psychiatry. May 2001. Accessed January 2023.
  5. Loss of Tolerance and Overdose Mortality After Inpatient Opiate Detoxification: Follow Up Study. BMJ. May 2003. Accessed January 2023.

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