Withdrawal from alprazolam

Signs and symptoms of BZ withdrawal are similar to those of alcohol withdrawal, including muscle pain, anxiety, restlessness, confusion, irritability, hallucinations, delirium, seizures, and cardiovascular collapse. Withdrawal from short-acting BZs (e.g., oxazepam, lorazepani, alprazolam) has an onset within 12 to 24 hours of the last dose. Diazepam, chlordiazep-oxide, and clorazepate have elimination half-lives (or active metabolites with elimination half-lives) of 24 to greater than 100 hours. So, withdrawal may be delayed for several days after their discontinuation. 

The onset of withdrawal from long-acting BZs may be up to 7 days after discontinuation of the drug. Detoxification is approached by initiating treatment at usual doses and maintaining this dose for 5 days. The dose is then tapered over 5 days. Alprazolam withdrawal may require a more gradual taper. 

Substance-Induced Anxiety Disorder. Numerous medicines and drugs of abuse can produce panic attacks. Panic attacks can be triggered by central nervous system stimulants such as cocaine, methamphetamine, caffeine, over-the-counter herbal stimulants such as ephedra, or any of the medications commonly used to treat narcolepsy and ADHD, including psychostimulants and modafinil. Thyroid supplementation with thyroxine (Synthroid) or triiodothyronine (Cytomel) can rarely produce panic attacks. Abrupt withdrawal from central nervous system depressants such as alcohol, barbiturates, and benzodiazepines can cause panic attacks as well. This can be especially problematic with short-acting benzodiazepines such as alprazolam (Xanax), which is an effective treatment for panic disorder but which has been associated with between dose withdrawal symptoms. 

Naylor MW, Grunhaus L, Cameron O. Single case study myoclonic seizures after abrupt withdrawal from phenelzine and alprazolam. J Nerv Ment Dis 1987 175 111-114. 

Patterson JF. Withdrawal from alprazolam dependency using clonazepam clinical observations. J Clin Psychiatry 1990 5[Suppl 5] 47-49. 

Risk of seizure is greatest during the first 3 days after discontinuation of alprazolam, especially in those with prior seizures, head injuries, or withdrawal from drugs of abuse... 

Other clinical uses Tricyclic drugs are also used in the treatment of bipolar affective disorders, acute panic attacks, phobic disorders (compare with alprazolam Chapter 22), enuresis, and chronic pain states. Clomipramine and the selective serotonin reuptake inhibitors, including fiuvoxamine, are effective in obsessive-compulsive disorders. SSRls are also effective in patients who suffer from panic attacks, social phobias, bulimia, and premenstrual syndrome (PMS) and may also be useful in the treatment of alcohol dependence. Bupropion is used for management of patients attempting to withdraw from nicotine dependence. 

Alprazolam (Xanax), lorazepam (Ativan), and oxazepam (Serax) are metabolized and cleared from the body more quickly than the other members of this family, and are therefore more likely to produce withdrawal symptoms when they are discontinued. These three drugs, however, are less likely to produce side effects such as impaired coordination, concentration, and memory and muscular weakness or sedation. 

Severe withdrawal can occur after relatively short exposures to BZs. I have treated patients who suffered from severe withdrawal problems after only 2 weeks of low-dose exposure to prescribed alprazolam and clonazepam. Lader (1984) and the APA (1990a) task force confirmed that therapeutic doses commonly produce severe withdrawal symptoms. 

A placebo-controlled study in 12 healthy subjects found that nefazodone 200 mg twice daily caused an almost twofold increase in the plasma levels of alprazolam 1 mg twice daily taken for 7 days. Another study found that impairment of psychomotor performance and increased sedation occurred when nefazodone was given with alprazolam. A case report describes benzodiazepine withdrawal symptoms in a woman taking alprazolam after nefazodone was withdrawn following several years of concurrent use. She needed an alprazolam dosage increase from 500 micrograms to 4 mg daily to control her symptoms. ... 

---