Alprazolam (Xanax): a short-term benzodiazepine for severe anxiety

Alprazolam is a short-acting benzodiazepine. Benzodiazepines depress the nervous system and slow the brain and body down, according to FRANK, the UK government drug information service. Xanax is the original brand and is the name used on Xanax tablets of 250 and 500 micrograms listed on the electronic medicines compendium. In the UK, alprazolam is a prescription-only, controlled Class C drug.

The licensed indication in the UK is narrower than many people assume. The product information says Xanax is indicated for short-term symptomatic treatment of anxiety in adults, only when the disorder is severe, disabling or subjecting the individual to extreme distress. It is not licensed for children and adolescents under 18, and safety and efficacy have not been established.

Alprazolam is not a treatment for depression on its own: the product information says benzodiazepines should not be prescribed alone to treat depression as they may precipitate or increase the risk of suicide.

The product information is explicit. Prior to starting, a discussion should be held to put in place a strategy for ending treatment in order to minimise the risk of dependence, addiction and drug withdrawal syndrome. The medicine should be used at the lowest possible effective dose, for the shortest possible time and for a maximum of 2 to 4 weeks, with frequent reassessment. Long-term treatment is not recommended, and if longer-term treatment is necessary, intermittent treatment may be considered to minimise dependence.

The labelled dosing for anxiety is 250 to 500 micrograms three times daily, increased if required to a total of 3 mg daily, with lower doses in the elderly or those with debilitating disease. If side effects occur, the dose should be lowered. These figures are for understanding the label; dosing is a matter for the prescriber.

The practical message is that a prescription for alprazolam should come with a plan: how long it will be used, how it will be reduced and who will review it. If you have been taking it for longer than a few weeks, do not stop suddenly; speak to your GP about a gradual reduction.

The product information says that for all patients prolonged use may lead to drug dependence and addiction, but that this can occur with short-term use at recommended doses. Risks are increased in people with a current or past history of substance misuse, including alcohol, or mental health disorders such as major depression. Tolerance can develop, with people needing more to get the same effect or supplementing with other medicines, which are signs to tell the prescriber. Overuse or misuse may result in overdose and death.

Once physical dependence has developed, abrupt termination will bring withdrawal symptoms. FRANK describes bad withdrawal symptoms including tremors, nausea, vomiting, headaches, anxiety, panic attacks and depression, and says people going through withdrawal might experience fits. Some people report withdrawal symptoms after using benzodiazepines for a relatively short time, such as a few weeks. FRANK advises talking to your GP for help and support if you want to stop.

The product information adds that withdrawal symptoms may occur within the dosage interval with short-acting benzodiazepines, especially at high doses, and that people should not switch between benzodiazepines without advice.

The product information lists contraindications including hypersensitivity, myasthenia gravis, severe respiratory insufficiency, sleep apnoea syndrome and severe hepatic insufficiency. It advises caution in older people because of the risk of sedation and muscle weakness that can promote falls, in people with impaired kidney or liver function, in chronic respiratory insufficiency, and in those with a history of alcohol or drug abuse.

Concomitant use with opioids may result in sedation, respiratory depression, coma and death, and the prescribing of both should be reserved for patients for whom alternatives are not possible. FRANK says that alcohol and other drugs that depress the central nervous system, including benzodiazepines, heroin and other opioids, pregabalin and gabapentin, increase the risk of overdose and death. The product information also reports overdose-related deaths when alprazolam is abused with other depressants.

Benzodiazepines can affect driving. FRANK notes that driving while under the influence is dangerous and illegal, and the product information explains that treatment should be reviewed regularly. Do not give your medicine to anyone else and store it safely, because the product information notes that alprazolam may be subject to diversion.

FRANK warns that benzodiazepines can be prescribed medicines that have been transferred away from the person they were prescribed for, or illicit or fake products. It says tablets sold as diazepam or alprazolam often do not contain the drug they are sold as, and may instead contain other dangerous benzodiazepines, their analogues or other chemicals, so people may be taking a much more potent drug than they think. It adds that some drugs are increasingly cut with dangerous synthetic opioids, and that you cannot normally be sure of purity unless you have been prescribed the drug.

Anyone who has taken tablets from an unknown source and feels very drowsy, has slow or shallow breathing or cannot be woken needs emergency help: call 999.

For generalised anxiety disorder the NHS says the main treatments a GP may offer are talking therapies, usually cognitive behavioural therapy, medicines that can help to treat anxiety, usually a type of antidepressant called an SSRI, and referral to a community mental health team. A GP will usually advise trying talking therapies before prescribing medicine or referring to a specialist, and adults can refer themselves to NHS talking therapies without a GP referral.

Self-help steps include talking about your feelings, self-help therapies, calming breathing, regular exercise, enough sleep, a healthy diet, and avoiding too much caffeine, alcohol, cigarettes or drugs to relieve anxiety, as the NHS suggests.

If anxiety is severe, a benzodiazepine may be considered for a short period, which is exactly what the licensed indication describes. Ask the prescriber what the plan is for ending it.

Benzodiazepines are prescribed in NHS and private practice alike under the same controlled-drug rules. Be wary of any online source that supplies them without a proper assessment. If you are worried about dependence, your GP can help with a gradual reduction plan and with support services.