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                                         Volumen 22| Año 2025 | Publicación continua 
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Sección de adicciones 
______________________________________ 
Original 
Symptomatic Profile of Ecuadorian Patients with       
Withdrawal Syndrome due to Inhaled Heroin Use 
 
Perfil sintomático de pacientes ecuatorianos con  
síndrome de abstinencia por consumo de heroína inhalada 
 
José Alejandro Valdevila Figueira1,2,3     
Andrés Ramírez Coronel3,4   
 Indira Dayana Carvajal Parra1,3    
Jimmy Martin-Delgado5,6    
José María Durán Pérez5     
Rocío Valdevila Santiesteban3    
 
1Institute of Neurosciences, Guayaquil Charity Board, Guayaquil, Ecuador 
2Ecotec University, Ecuador 
3Psychology and Psychiatry Research Group (GIPSI), Ecuador 
4 Salesian Polytechnic University, Cuenca, Ecuador 
5 Alfredo Paulson Specialty Hospital, Guayaquil Charity Board, Ecuador 
6 Faculty of Health Sciences, Catholic University of Santiago de Guayaquil, Ecuador    
Recibido: 02/03/2025 
Aceptado: 26/05/2025 
 
 
 
Editores: 
Reinaldo Fabelo Roche 
Arturo Chi Maimó  
Magdalena Sosa Martínez 
 

Symptomatic Profile of Ecuadorian Patients with Withdrawal Syndrome due to Inhaled Heroin Use

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Abstract

Introduction: The symptoms of opioid withdrawal syndrome vary depending on the specific

drug used, adulterants, and route of administration. This study analyzed the symptom profile

of withdrawal syndrome due to inhaled heroin use in Ecuadorian patients, and its relationship

with sex and age.

Objective: Describe the symptom profile of withdrawal syndrome due to inhaled heroin use

and its relationship with sex and age in Ecuadorian patients.

Methods: A descriptive cross-sectional study was conducted in a specialized care unit in

Ecuador from 2018 to 2022. Patients with withdrawal syndrome due to inhaled heroin use

were included. Symptoms were categorized into general, neuropsychiatric, gastrointestinal,

and cardiorespiratory. Associations with sex, age, and year of care were analyzed using the

Chi-square test (p < 0.05).

Results: A total of 983 patients were evaluated, 82 % were male, with a predominance of the

11–18 age group (n = 597). General symptoms predominated in all age groups except those

over 35 years. The most common symptoms were rhinorrhea, anxiety, myalgia, arthralgia,

nausea, vomiting, insomnia, diarrhea, chills, and headache.

Conclusions: The symptom profile of withdrawal syndrome in Ecuadorian inhaled heroin

users was consistent with established clinical patterns, without significant variations among

groups.

Keywords: substance withdrawal syndrome, opioid-related disorders, heroin dependence,

withdrawal symptoms, heroin

Resumen

Introducción: los síntomas del síndrome de abstinencia a opioides varían según la droga

consumida, los adulterantes y las vías de administración. Este estudio analizó el perfil

sintomático del síndrome de abstinencia por consumo de heroína inhalada en pacientes

ecuatorianos, y su relación con el sexo y la edad.

Objetivo: describir el perfil sintomático del síndrome de abstinencia por consumo de heroína

inhalada y su relación con el sexo y la edad en pacientes ecuatorianos.

Métodos: se realizó un estudio descriptivo de corte transversal en una unidad de atención

especializada de Ecuador, entre 2018 y 2022. Se incluyeron pacientes con síndrome de

abstinencia por consumo de heroína inhalada. Los síntomas se categorizaron en generales,

neuropsiquiátricos, gastrointestinales y cardiorrespiratorios. Se analizaron asociaciones con

sexo, edad y año de atención mediante la prueba de ji cuadrado (p < 0.05).

Resultados: se evaluaron 983 pacientes, de los cuales el 82 % eran hombres, con

predominancia del grupo etario entre 11 y 18 años (n = 597). Los síntomas generales

predominaron en todos los grupos, excepto en mayores de 35 años. Los síntomas más

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frecuentes fueron rinorrea, ansiedad, mialgia, artralgia, náuseas, vómitos, insomnio, diarrea,

escalofríos y cefalea.

Conclusiones: el perfil sintomático del síndrome de abstinencia en consumidores

ecuatorianos de heroína inhalada se correspondió con los patrones clínicos reconocidos, sin

variaciones significativas entre grupos.

Palabras clave: síndrome de abstinencia a sustancias; trastornos relacionados con opioides;

dependencia de heroína; síntomas de abstinencia; heroína.

Introduction

Opioid Use Disorder (OUD) is a chronic and relapsing condition marked by compulsive

opioid consumption, tolerance, and withdrawal symptoms upon cessation. It affects over 16

million individuals worldwide and is responsible for approximately 120,000 deaths each

year, making opioids the leading cause of mortality among people with substance use

disorders. (1–3)

According to the latest global data, drug use reached 292 million people in 2022, reflecting

a 20 % increase over the last decade. Opioids are now the second most commonly consumed

illicit substance globally, with over 60 million users. In 2019 alone, they were implicated in

80 % of the 600,000 drug-related deaths. Despite the severity of the crisis, only one in ten

individuals with substance use disorders receives treatment, with women facing

disproportionate barriers to access. (2,4,5)

Heroin, a semi-synthetic opioid, is frequently used due to its low cost and potent psychoactive

effects. The method of administration—whether injection, inhalation, or snorting—along

with unknown adulterants, significantly affects both the intensity and variability of

withdrawal symptoms. (6–8) These symptoms can range from mild (e.g., muscle aches, nausea,

irritability) to severe (e.g., respiratory distress, cardiovascular complications), depending on

individual, pharmacological, and contextual factors. (9,10)

In Ecuador, opioids rank among the top three most consumed illicit drugs and are closely

associated with rising rates of violence, HIV transmission, and premature death. The

emergence of inhaled heroin, commonly referred to as “H-hache,” has worsened the

addiction landscape, particularly among adolescents, due to its low price, widespread

availability, and poorly understood chemical composition. (11–13) This study aims to

characterize the symptom profile of withdrawal syndrome in Ecuadorian patients who use

inhaled heroin and to examine the influence of demographic variables such as age and sex

on these clinical manifestations.

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Methods

An observational, cross-sectional, and analytical study was conducted from January 1, 2014,

to December 31, 2017. The target population consisted of patients aged 11 to 61 years who

presented to the emergency department of the Guayaquil Institute of Neurosciences (INC)

for suspected opioid abuse.

The study universe included all patients admitted during the study period with a clinical

suspicion of opioid use (ICD-10 code F11). From this group, the sample comprised 983

patients who received a confirmed diagnosis of opioid withdrawal syndrome (ICD-10 code

F11.3).

A simple random sampling method was applied using a random number sequence to ensure

representativeness. Inclusion criteria were: patients with complete medical records, a

diagnosis of opioid withdrawal syndrome, and a reported route of heroin administration via

nasal inhalation. Exclusion criteria included incomplete sociodemographic or clinical data

and evidence of polydrug use during the withdrawal episode. Sociodemographic variables

(age and sex) were collected, and clinical symptoms were classified into four categories:

general (malaise, chills, headache, and weight loss), cardiorespiratory (dyspnea, cough, and

tachycardia), gastrointestinal (nausea, vomiting, and abdominal pain), and neuropsychiatric

(anxiety, insomnia, hallucinations, and suicidal ideation).

Procedure

Data were retrieved from the MIS system, which contains the electronic medical records

supported by the Ecuadorian Ministry of Public Health (models 003 and 008). (14) Eligible

cases were selected using a computer-generated random number sequence. Each record was

reviewed by the research team to ensure compliance with inclusion and exclusion criteria.

Ethical Statement

This study was approved by the Department of Teaching and Research at the Guayaquil

Institute of Neurosciences (INC), Ecuador. In accordance with national regulations, written

informed consent was not required due to the retrospective design of the study. All data were

anonymized, and patient confidentiality was maintained throughout the research process. The

study complied with the ethical principles outlined in the Declaration of Helsinki (2024

version), which governs research involving human subjects.

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Statistical Analysis

Quantitative variables were described using medians and interquartile ranges due to non-

parametric distribution. Qualitative variables were reported as absolute and relative

frequencies. Associations between categorical variables were examined using the Chi-square

test, with statistical significance defined as p < 0.05. Statistical analyses were performed

using R software, version 4.4.2. (15)

Results

Descriptive

A total of 983 patients diagnosed with withdrawal syndrome due to inhaled heroin use (ICD-

10 code F11.3) were included in the study. These patients were selected from an initial

universe of 1,517 individuals admitted to the emergency department of the Guayaquil

Institute of Neurosciences (INC) between 2014 and 2017 for suspected opioid abuse. The

final sample included 809 men and 174 women, with ages ranging from 11 to 61 years (mean

= 18). The most affected age group was 11–18 years (n = 597), and the highest number of

cases occurred in 2014 and 2015, followed by a notable decline in 2016 and 2017.

Table 1. Frequencies by year

Year

11-18 (n = 597 1)

19-34 (n = 3681)

35 or more (n= 181)

Male

Female

Male

Female

Male

Female

2014

193 (19.6 %)

29 (3.0 %)

97 (9.9 %)

16 (1.6 %)

7 (0.71 %)

1 (0.1 %)

2015

215 (21.9 %)

59 (6.0 %)

120 (12.2 %)

25 (2.5 %)

4 (0.41 %)

0 (0.0 %)

2016

64 (6.5 %)

16 (1.6 %)

61 (6.2 %)

17 (1.7 %)

2 (0.20 %)

2 (0.2 %)

2017

18 (1.8 %)

3 (0.3 %)

26 (2.6 %)

6 (0.6 %)

2 (0.20 %)

0 (0.0 %)

Source: own elaboration

Note: Percentages were calculated by age group 1n (%)

Across all symptom categories—general, neuropsychiatric, gastrointestinal, and

cardiorespiratory—male patients aged 11–18 years consistently represented the largest

proportion of cases. Patients aged 35 and older, regardless of sex, were the least represented.

Notably, neuropsychiatric symptoms such as anxiety and insomnia were especially prevalent

among adolescents, while gastrointestinal complaints such as nausea, vomiting, and

abdominal pain also showed high frequencies in this group.

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Table 2. Distribution of symptoms grouped with respect to sex and age

Grouped symptoms

Age group

Sex

Neuropsychiatrists symtoms

11 – 18 (n=5791)

Female

8,5

Male

364

37,0

19 - 34 (n = 3681)

Female

4,9

Male

233

23,7

35 and over (n= 181)

Female

0,3

Male

1,3

General symtoms

11 - 18 (n = 5971)

Female

9,1

Male

437

44,5

19 - 34 (n = 3681)

Female

5,6

Male

252

25,6

35 and over (n= 181)

Female

0,2

Male

1,1

Gastrointestinal symtoms

11 - 18 (n = 5971)

Female

107

10,9

Male

490

49,8

19 - 34 (n = 3681)

Female

6,5

Male

304

30,9

35 and over (n= 181)

Female

0,3

Male

1,5

Cardiorespiratory symtoms

11 - 18 (n = 5971)

Female

7,3

Male

332

33,8

19 - 34 (n = 3681)

Female

4,0

Male

198

20,1

35 and over (n= 181)

Female

0,3

Male

1,2

Source: own elaboration

Note: 1n (%) 2 Chi-square test of independence

Anxiety was the most commonly reported symptom in both sexes, present in 56.7 % of men

and 61.5 % of women. Arthralgia, diarrhea, chills, and headache were also among the most

frequent manifestations. While men exhibited a wider range of symptoms—likely due to their

greater sample size—women showed slightly higher rates of anxiety. Less frequent

symptoms such as hallucinations, seizures, and chest pain appeared only sporadically.

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Figure 1. Frequenciy of symptons group by sex

Source: own elaboration

Note: Percentages are calculated relative to the total number of patients within each sex group.

Among male adolescents (11–18 years), the most frequent symptom combinations included

anxiety, insomnia, malaise, chills, arthralgia, myalgia, and rhinorrhea. As the number of

concurrent symptoms increased, the frequency of such cases decreased, with only a small

number of patients presenting more complex clusters that included abdominal pain,

tachycardia, and cough.

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Figure 2. Clinical manifestations in patients with withdrawal syndrome

Source: own elaboration

Note: Frequencies are calculated based on the total combination of symptoms for each patient

Over the four-year study period, the overall prevalence of symptoms declined. In 2014,

anxiety and arthralgia peaked at nearly 70 % and 50 %, respectively. However, by 2017, all

symptom proportions had decreased substantially, with anxiety and arthralgia remaining the

most common symptoms (around 40 %), while symptoms such as delusions and

hallucinations were virtually absent.

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Figure 3. Graph of symptom profile by years

Source: own elaboration

Note: The radar chart presents the top 10 most relevant symptoms for each year from 2014 to 2017, showing variations in

symptom prevalence across time

Discussion

This study analyzed 983 Ecuadorian patients diagnosed with withdrawal syndrome due to

inhaled heroin use, with a majority of cases occurring in adolescents aged 11–18 years and a

higher representation of males. The peak in cases observed in 2014 and 2015 may reflect

increased accessibility of heroin during those years, while the subsequent decline could be

associated with restricted service access at the Guayaquil Institute of Neurosciences (INC).

Classifying symptoms into four categories (general, neuropsychiatric, gastrointestinal, and

cardiorespiratory) and analyzing trends by year and demographic variables allowed for a

deeper understanding of withdrawal manifestations and their consistency over time.

Opioid withdrawal is typically mild but distressing, with symptoms lasting between 3 to 10

days depending on the opioid’s half-life. Classical manifestations include sweating, tremors,

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restlessness, gastrointestinal disturbances, and anxiety, with severe cases potentially

progressing to delirium or cardiopulmonary compromise. (16) The most prevalent symptoms

in our sample—anxiety, arthralgia, diarrhea, chills, and headache—are in line with those

described in other studies on heroin withdrawal.(17-19) Interestingly, the frequency of

depressive symptoms, typically reported in 40–65 % of withdrawal cases (20), was low in our

cohort, possibly due to the acute nature of the observed episodes or underreporting in

emergency settings.

Anxiety was consistently the most reported symptom across all subgroups, with slightly

higher prevalence in females, which aligns with previous findings on sex differences in

withdrawal expression. (18) The broader range of symptoms reported by males may be

attributed to their numerical predominance in the sample rather than to true clinical

variability. The symptom patterns observed in this study were comparable to those described

in parenteral opioid withdrawal, (16) reinforcing the notion that the route of administration

does not fundamentally alter the core withdrawal profile, although it may affect symptom

onset and intensity.

The stability of symptom profiles over time suggests minimal variation in the chemical

composition of the heroin consumed in Ecuador during the study period. However, changes

in the proportions of cutting agents could still explain subtle shifts in the prevalence of certain

symptoms. (21) This reinforces the complexity of opioid withdrawal as a phenomenon

influenced by pharmacological, physiological, and psychosocial factors. (22)

Findings from this study are consistent with international reports from the European

Community (23) and the United States, (24) which may be due to the circulation of similar

adulterants in the global heroin market. This consistency underscores the global nature of the

opioid crisis and the need for harmonized treatment strategies that can be adapted to local

contexts.

This study has several limitations. First, it is based on retrospective data collected from

electronic health records, which may be incomplete or subject to reporting bias. Second, the

reliance on emergency department admissions may underrepresent patients with milder

symptoms or those who did not seek care. Third, the study focused exclusively on inhaled

heroin use, and its findings may not be generalizable to users of other opioids or

administration routes.

Despite these limitations, the study provides valuable insights into the clinical presentation

of withdrawal syndrome in a vulnerable population, with implications for early identification,

triage, and treatment. It also highlights the need for standardized symptom monitoring

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protocols and further research into demographic and psychosocial variables that influence

withdrawal severity and treatment response.

Conclusions

This study described the symptom profile of withdrawal syndrome in Ecuadorian patients

who use inhaled heroin and examined its association with age and sex. The most frequent

symptoms identified were anxiety, arthralgia, and diarrhea, aligning with clinical patterns

reported in international literature. No significant differences were observed in symptom

distribution across sex, age groups, or study years, suggesting a stable chemical composition

of the heroin consumed during the study period. These findings highlight the need for

standardized clinical approaches that prioritize the most prevalent symptoms and incorporate

demographic considerations into withdrawal management. Moreover, the results reinforce

the importance of ongoing public health strategies focused on prevention, early

identification, and expanded access to treatment for populations at higher risk of opioid use

disorder.

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Conflict of Interest Disclosure

The authors declare no conflict of interest.

Author Contributions

José Alejandro Valdevila Figueira: Conceptualization of the study, methodological design,

supervision of the research process, acquisition of funding, critical revision of the

manuscript, and correspondence with the journal during the submission and revision process.

Andrés Ramírez Coronel: Statistical analysis, interpretation of results, and drafting of the

methods and results sections.

Indira Dayana Carvajal Parra: Critical content review, drafting of the discussion section,

and ensuring compliance with the journal's editorial guidelines.

Jimmy Martin-Delgado: Data processing, preparation of tables and figures, and verification

of references.

José María Durán Pérez: Literature review, data collection, and initial drafting of the

manuscript.

Rocío Valdevila Santiesteban: Validation of the questionnaire design, final editing of the

manuscript and coordination among authors.

Funding Declaration

This research received no external funding.

Data availability statement

The datasets generated and analyzed during the current study are available from the

corresponding author upon reasonable request.