Xanax (alprazolam) belongs to the benzodiazepines, a class of drugs that has numerous medicinal uses and features some of the most commonly used medications around the world.
- Benzodiazepines reduce the subjective feelings of anxiety or stress.
- They produce sedation and relaxation.
- They are central nervous system depressant drugs (slow down the functioning of the central nervous system).
- Their continued use results in the rapid development of tolerance and physical dependence.
Different benzodiazepines are used for different purposes, but all the benzodiazepines have their primary uses as treatments for anxiety, as anticonvulsants, as sleep enhancers, and as muscle relaxants. In addition, some benzodiazepines may be useful as pre-anesthetic drugs, to treat withdrawal symptoms from alcohol or other benzodiazepines, to treat specific neurological disorders such as restless leg syndrome, and to treat anxiety that occurs with certain mental health disorders (other than anxiety disorders).
What Is Xanax
Xanax is a potent benzodiazepine with an intermediate onset of action and a relatively brief half-life. Very small doses of the drug produce powerful effects that often wear off quickly. Thus, Xanax is primarily used for the treatment of anxiety, to initiate sleep, and as a muscle relaxant as opposed to being a medication that is commonly used to treat seizures, withdrawal symptoms from alcohol, or other conditions that require a longer-acting drug.
Xanax was originally conceived to be a replacement for the benzodiazepine Valium (diazepam), which was a drug of significant abuse. It was believed that Xanax provided the potency to deal with anxiety, and because its effects were relatively short-lived, it would not be a significant drug of abuse; however, Xanax abuse does occur. The United States Drug Enforcement Administration(DEA) recognizes the abuse potential of Xanax and classifies it as a Schedule IV controlled substance. This classification is associated with drugs that have a fair potential to be abused.
According to the Substance Administration Abuse and Mental Health Services (SAMHSA), Xanax is the most widely prescribed benzodiazepine. Per data released in 2017, SAMHSA estimated that about 18.4 million individuals used some form of alprazolam in 2016; of these individuals, it was estimated that 4.3 million misused the drug at least once that year.
SAMHSA and other professional sources, including the National Institute on Drug Abuse (NIDA), have stated numerous times that benzodiazepines like Xanax are most often not primary drugs of abuse. Instead, these drugs are taken in conjunction with other drugs that are being abused, particularly alcohol, narcotic pain medications, other benzodiazepines, and other drugs. Therefore, chronic Xanax abuse would also be associated with chronic abuse of some other drug, most likely alcohol.
A person who develops a substance use disorder due the misuse or abuse of Xanax would formally be diagnosed with a sedative, hypnotic, or anxiolytic use disorder. Because Xanax is often a second drug of abuse, it is highly likely that such a person would have a substance use disorder as well as a potential co-occurring mental health disorder that is not related to substance abuse, such as depression, an anxiety disorder, eating disorder, etc. This can make it difficult to recognize Xanax abuse because individuals may present with more salient indicators of these other potential disorders. Nonetheless, some of the signs that an individual is abusing Xanax include:
- Getting Xanax without a prescription
- Having a prescription for Xanax but using the drug in a manner that is in contrast with its prescribed uses, such as using it with alcohol or other drugs, using more of it than prescribed, doctor shopping to get more prescriptions, etc.
- Using Xanax to cope with everyday stressors
- Continuing to use Xanax even though its use is affecting performance at work, schoolwork, personal relationships, or other important areas of life
- Having numerous empty prescription drug containers around
- Problems controlling use of Xanax, such as using it more often intended, using more of it than intended, spending more time using the drug than intended, spending significant amounts of time trying to get the drug, having cravings to use the drug, etc.
- Giving up important activities or personal commitments as a result of Xanax use
- Becoming isolated from others
- Demonstrating tolerance to Xanax
- Numerous unsuccessful attempts to quit using or cut down on Xanax use
- Becoming very defensive when others question one’s use of Xanax
- Using Xanax when alone or hiding use from others
- Developing withdrawal symptoms when stopping Xanax use
Consequences of Abuse
There are numerous potential effects associated with Xanax abuse. Because benzodiazepines are central nervous system depressants, their action slows down the functioning of numerous organ systems. Chronic abuse of Xanax can lead to issues with respiratory infections as a result of chronic shallow and slowed breathing, a lack of delivery of oxygen to organs as a result of respiratory suppression, a burden on the liver and kidneys due to the need to metabolize and eliminate benzodiazepines and other drugs, and cardiovascular effects due to constantly decreased and then increased blood pressure, irregular heart rate, etc. In addition, individuals who develop substance use disorders often neglect aspects of their hygiene and personal care. This can lead to numerous other problems, ranging from issues with dentition to major health issues, such as an increased potential to develop infectious diseases or cancer.
Other potential issues that can occur as a result of chronic abuse of Xanax include:
- Cognitive problems, such as issues with attention, problem-solving, and judgment (For most individuals, chronic use of benzodiazepines like Xanax results in an interference in their ability to encode information, which results in problems with learning and memory.)
- An increased susceptibility to developing some other mental health disorder as a result of increased vulnerabilities to stress, being a victim of abuse or a crime, getting involved in criminal activities, etc.
- Potential irreversible damage to personal relationships as a result of having a substance use disorder
- Loss of career due to the complications associated with Xanax abuse
- Increased potential to be involved in accidents, such as automobile accidents, being the victim of a fire, etc.
- The development of physical dependence on benzodiazepines and other drugs
- The development of a substance use disorder
By definition, a person with a substance use disorder is experiencing significant distress and dysfunction in their life as a result of their substance use. A formal substance use disorder can only be diagnosed by a licensed and trained mental health clinician. However, many times, friends or family members recognize that the person may have a problem with drugs long before the person recognizes it. It is often up the family members and friends to convince the person to seek help. Because chronic use of Xanax can result in the development of physical dependence, the first step in the treatment of Xanax abuse is to address the withdrawal syndrome.
Timeline for Withdrawal from Xanax
An important consideration when dealing with any person who has chronically abused a benzodiazepine like Xanax is to determine if there is a potential abuse problem with alcohol or some other drug. The withdrawal syndrome associated with Xanax can be complicated by physical dependence on other drugs that have been chronically abused along with Xanax. Nonetheless, the withdrawal syndrome for benzodiazepines like Xanax has been well described. This withdrawal timeline typically consists of two phases: an acute stage and a protracted stage.
The acute phase begins within 1-2 days after the person has stopped using the benzodiazepine. The short half-life of Xanax may result in the experience of initial withdrawal symptoms within 24 hours after the person stops using the drug. Individuals who have developed very high tolerance to the drug and take large amounts of the drug may experience withdrawal symptoms after only a few hours.
The acute phase can be variable in length, depending on the severity of the person’s substance use disorder and may last from several days to 3-4 weeks. Symptoms that commonly occur during the acute phase include:
- Issues with anxiety, commonly referred to as rebound anxiety because the symptoms represent a return or appearance of symptoms that the drug is designed to control
- Cardiovascular effects that include increases in blood pressure and heart rate
- Significant issues with restlessness and insomnia
- Possible gastrointestinal issues, such as nausea, vomiting, stomach cramps, appetite loss, and weight loss
- Fever, sweating, and/or chills
- Neurological symptoms that can include headaches, tremors, shakiness, and seizures that can be fatal
- Psychological symptoms that include mood swings, depression, and cravings for the drug
The protracted phase begins after the acute symptoms have peaked and decreased in their intensity. Often, this peak occurs within 1-2 weeks as mentioned above, but for some individuals, the symptoms may remain intense for several weeks. Once their intensity begins to subside, the individual is entering the protracted stage of withdrawal.
The symptoms that occur during the protracted stage can include any of the above symptoms but they are less intense and continue to decrease in intensity. The potential to develop seizures remains during this stage. Many individuals will experience a sharp decline in the intensity of physical symptoms associated with withdrawal from Xanax, but they may experience an increase in feelings of anxiety (rebound anxiety) during this stage. For most individuals, the protracted phase will last several weeks.
After the drug has exited the system and the withdrawal period is over, some individuals continue to experience psychological issues, such as sensitivity to stress, problems with depression and motivation, and significant cravings to use Xanax again. These symptoms may linger for months or even longer. Some sources refer to this collection of symptoms as a post-acute withdrawal syndromethat represents an even longer phase of protracted withdrawal where the symptoms are primarily motivational and psychological in nature and increase the risk for relapse; however, research studies have not validated these symptoms as being related to the withdrawal process. They are probably more consistent with long-term psychological issues that occur in many individuals who have had substance use disorders.
The withdrawal syndrome from benzodiazepines has potentially fatal consequences due to the potential to develop seizures. Seizures can lead to significant brain damage and other complications that need to be controlled. It is strongly recommended that individuals who have abused benzodiazepines do not attempt to abruptly discontinue their use without first consulting with a physician. The approach to managing the withdrawal process associated with Xanax and other benzodiazepines is to place the person in a withdrawal management program to control withdrawal symptoms and avoid any potential serious complications. This is best accomplished on an inpatient basis.
The medical detox protocol for benzodiazepine withdrawal typically utilizes a long-acting benzodiazepine such as Valium (diazepam) on a tapering basis. An initial dosage is established that results in the person not experiencing any significant withdrawal symptoms. Over time, the dosage is reduced at specified times to wean the person off the benzodiazepine. This tapering strategy could conceivably be used with Xanax, but it is more common to use a long-acting benzodiazepine to better control withdrawal symptoms. Once the dosage has been tapered down to the minimal amount, the person can be taken off the benzodiazepine and the withdrawal process is complete. This tapering strategy typically takes a bit longer than withdrawing from the drug “cold turkey,” but it is obviously far safer.
Following completion of the withdrawal management program, the person should immediately become involved in a long-term care program to avoid relapse.
Treatment programs continue with medical management of co-occurring issues associated with one’s substance use disorder. They concentrate on the use of psychotherapy, participation in peer support groups, social support from friends and family, and other interventions as needed in the specific case.
Part of the recovery program is maintaining abstinence from Xanax and other benzodiazepines. For some individuals who have issues with anxiety disorders or who need a medication to control seizures or help them sleep, there are alternative approaches to addressing these issues. For the treatment of anxiety, drugs like BuSpar (buspirone) can be used, which has an entirely different mechanism of action than benzodiazepines and is not considered to be a drug without a significant potential for abuse. For the treatment of seizures, more conventional anticonvulsant medications can be used. For individuals who need treatment for insomnia, other sedative drugs with less potential for abuse can be prescribed.
In addition to these alternative medications, many of the issues that were previously treated with Xanax, such as anxiety, stress, insomnia, etc., can be the focus of behavioral interventions. Psychotherapy to treat anxiety disorders is extremely successful. Cognitive Behavioral Therapy (CBT) can be used to treat both anxiety disorders and insomnia. CBT can incorporate diaphragmatic breathing, relaxation training, and stress management techniques into treatment of the substance use disorder, and these techniques can also promote sleep.