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Xanax (alprazolam) is an excellent drug for the short-term management of anxiety and panic disorder. It works quickly and effectively and the drowsiness that it sometimes induces usually wears off quickly as one becomes accustomed to taking it. The drug is intended for use only on a short-term basis to assist in the temporary management of anxiety such as grief reactions and emotional emergencies. It is not a good drug for long-term use (See the Benzodiazepines). The main reason that Xanax is problematic with long-term use is the physical dependence that quickly develops with Xanax.
How Xanax Perpetuates its Own Need
What makes the dependence on Xanax so problematic is that the major withdrawal symptom of Xanax is anxiety. Xanax withdrawal actually creates anxiety, the very condition that it treats. Xanax is short-acting, meaning it is metabolized very quickly causing blood levels to drop significantly in a matter of hours. As blood levels drop, withdrawal symptoms of Xanax can appear within hours of taking the last dose, even before the next dose is due. As it comes on slowly, this withdrawal anxiety may be indistinguisahable from one’ s underlyng anxiety and will be perceived as such, tricking one into believing they are having recurrent anxiety. This recurrent anxiety triggers the patient to take more Xanax – when in fact the anxiety is a result of Xanax withdrawal.
As one can see, Xanax becomes self-perpetuating by creating it’s own need and tricking you into thinking that withdrawal anxiety belongs to you rather than simply being a withdrawal symptom from the drug. It becomes difficult to distinguish between when one needs Xanax for personal anxiety and when one needs Xanax to avoid Xanax withdrawal. Unfortunately, the latter case is often true although it masquerades as the former case. This is particularly true for individuals who have taken Xanax 2-3 times a day for more than 3-4 months. The result of this sustained pattern is that many people end up taking Xanax for years due to their perceived “need,” when truthfully they can be successfully tapered off by treating and eliminating their physical dependence.
Managing Anxiety: The Primary Goal
Clearly, the primary goal is to live without being overwhelmed by anxiety, not to eliminate anxiety. When Xanax is determined to be the best choice for managing anxiety when needed, it is best when that need is not based on a dependence – withdrawal cycle. Ideally, treatment is directed at avoiding or eliminating physical dependence on Xanax and breaking the cycle of taking Xanax in response to the anxiety generated by dropping blood levels of the medication. To avoid the development of physical dependence on Xanax, it is important to maintain intermittent use only with the lowest dose needed, preferably limiting use to no more than 2 days/week. The methods of reducing and eliminating physical dependence on Xanax are reviewed below.
It is important to emphasize that the tapering process should be tailored to the needs of the patient to avoid anxiety, insomnia or other problems. When reducing reliance on Xanax as a means of coping with anxiety, it is important to replace this means with other means. An integrative, behavioral approach with emphasis on self-reliant skills is preferred. That being said, however, the use of other anxiolytic medications may be prescribed for anxiety, as well as medications to facilitate sleep and reduce the presence of withdrawal symptoms (See below). Our psychotherapist at Accurate Clinic is available for instruction on learning how to deal with anxiety and avoid the need for relying on medications. Our psychotherapist is also available to provide individual, couples and family counselling.
See: Anxiety and Stress
Reducing or Discontinuing Xanax
When the decision is made to reduce dosing or taper off Xanax, the pace at which is done should be guided by patience and the individual’s ability to tolerate the process. It may takes months, even up to a year to successully wean off Xanax, especially if one has been taking Xanax for years. There are alternativs to simply weaning Xanax down slowly.
While it is beyond the intent and capacity of this web page to provide complete and thorough instructions for all of the ins and outs of discontinuing Xanax, a brief review of treatment options follows. Please discuss any plans to wean off Xanax or other benzodiazepines with your physician before starting to do so.
Phenobarbitol Replacement of Xanax (or other benzodiazepines)
For a more rapid discontinuation of benzodiazepines than a slow taper, one can stop the benzodiazepine and start phenobarbitol and proceed with a tapering regimen off the phenobarbitol. Because the initial dosing of phenobarbitol in this situation requires close monitoring and adjustment, it is usually recommended that a patient be admitted to the hospital or a detox unit for the first days. This is a common technique for discontinuing Xanax that is generally well-tolerated and successful.
Tapering Off Xanax (or other benzodiazepines)
Because Xanax is short acting, tapering off Xanax directly may create significant withdrawal symptoms including anxiety, restlessness and insomnia as well as other symptoms including seizures in some people. For this reason, it is generally easier and more successful to taper off Xanax by first converting Xanax to an alternative long-acting benzodiazepines such as Valium (diazepam) or Klonopin (clonazepam). By using a long-acting benzodiazepines, the tapering process is associated with more gradual drops in blood levels leading to milder withdrawal symptoms that are much better tolerated.
Weaning of Xanax Directly
Because of the significant potential for severe withdrawal symptoms including seizures when tapering Xanax directly, it is important to reduce dosing slowly, no more than 0.5 mg every 3 days.
When tapering Xanax, it is important to first establish a daily routine of taking Xanax that is both consistent and distributed throughout the day. Twice daily dosing tends to create withdrawal anxiety between doses. If you experience between-dose anxiety while on twice daily dosing, you should first spread your Xanax over three doses a day instead of two. For example, if you are currently taking one Xanax tablet twice a day, begin by splitting your daytime dose into two: take a half-tablet in the morning, the other half-tablet in the afternoon and continue taking a full tablet at night. Spreading your dosing to three times a day will create less withdrawal anxiety and will make the tapering easier. If you are comfortable with twice daily dosing and it is not creating any breakthrough anxiety, than the tapering process can continue with twice daily dosing.
If you are taking your Xanax “as needed” and your daily pattern is inconsistent, start by taking the Xanax in three, or no more than four, doses/day. The doses don’t always have to be the same each time, but each day should be consistent. Examples of appropriate schedules might include one full tablet three times a day, or 1⁄2 tablet in the morning, 1⁄2 tablet in the afternoon and 1 tablet at night. Just try and maintain consistency.
When your Xanax dose is consistent and effective, the tapering process can begin. Start by reducing the morning dose by a small fraction of your daily dose, such as by 10% or less. For example, if you are taking 3 tablets/day, reduce the morning dose by 1/4 tablet which represents 1/12 or 8% of the total dose. Maintain this dose reduction for 3-7 days to establish that the reduction is well tolerated before proceeding with the taper. When proceeding, reduce the evening dose next by 1/4 tablet for 3-7 days then reduce the night time dose by 1/4 tablet. Do not progress with the taper until you are certain that you are tolerating your current dose, including maintaining adequate sleep.
Weaning of Xanax by Converting Xanax to Valium (or Klonopin)
Generally the best method of tapering Xanax is to slowly substitute Valium (or Klonopin) for Xanax on a dose-by-dose schedule. Then the Valium is slowly tapered off at a pace defined by the patient, a process that may take many months.
The Conversion Process
To begin the tapering process, a fraction of the Xanax dose is converted to Valium (diazepam) or sometimes Klonopin (clonazepam). The conversion will be done on a dose-by-dose basis and the conversion is based on 0.5mg of Xanax being equivalent to 5-10mg of Valium (or 0.5mg Klonopin). In the conversion process, usually no more than 0.5mg of Xanax is converted at a time.
Example: Xanax is taken 0.5 mg twice a day
If your current Xanax dose is 0.5 mg twice a day, the night dose is first converted to 5-10 mg of Valium. So the first step is to take Xanax 0.5 mg in the day and 5-10 mg Valium at night. If the 5 mg dose of Valium is inadequate to allow good sleep, the 10 mg dose is used. If the 10 mg dose of Valium is too sedating, the 5 mg dose is used – all based on your experience. This initial conversion regimen will be continued for 2-4 weeks when the next step is to convert the day dose of Xanax to Valium with the dose of Valium determined by the initial conversion ratio that proved best. Once the Xanax has been completely converted to Valium, the Valium is slowly tapered down at a rate of about 10% every 2-4 weeks. If there is uncontrolled anxiety complicating the tapering process, the tapering is held until the patient is ready to continue. If insomnia becomes a problem, alternative medications are provided to facilitate sleep.
When one is taking doses of Xanax that are greater than 0.5 mg, the conversion of Xanax to Valium is usually done in 0.5 mg increments every 2-4 weeks. So if one’s starting dose of Xanax is 2mg twice a day, the initial conversion step would be to take 2mg Xanax in the daytime and convert the night time dose to 1.5 mg Xanax along with 10mg Valium. In 2-4 weeks, the next step would be to convert the daytime dose to 1.5 mg Xanax along with 10mg Valium, meaning you would take 1.5 mg Xanax with 10mg Valium twice a day. Every 2-4 weeks additional 0.5 mg increments of Xanax are converted to Valium. Adjustments can always be made in the rate or amount of conversion based on your needs.
Medications to Facilitate Tapering of Benzodiazepines
Insomnia is the most common complaint associated with discontinuing benzodizepines. While emphasis is placed on sleep hygiene and behavioral methods for enhancing sleep, sometimes more specific aids to facilitate sleep are needed. The following non-habitforming medications have recent research evidence supporting their specific benefit for benzodiazepine-related insomnia:
- Gabapentin and possibly Lyrica
- Melatonin, up to a dose of 10 mg
- Valerian Root
Success Is Not Difficult
While this may appear complicated, it really isn’t. Your physician will work closely with you and after the first one or two conversion steps have been made, the subsequent process becomes easy to understand, easy to follow and well-tolerated.
Communicate with your Physician
It is important to remember that at any point in the process, if stressful situations develop in your life or the tapering is too fast, then the process can be adjusted to meet your needs. Everyone is different and will require different approaches – the above is simply a guideline for what to expect in the process. The physician will work closely with you to make the tapering process as comfortable as possible. There is no urgency to the taper and no need to be rigid with the adjustments. Communicate any concerns or difficulties you may have with the physician so that you can maintain comfort with the process – the physician will expect and depend on your feedback to make this work successfully for you.
When Daily Anxiolytic Medications Are Necessary
In some cases it is necessary to manage anxiety with daily medications. Under these circumstances, an assessment must also be made for other conditions including depression, PTSD and ADD. The truth is, there is no single medication available that is ideal for treating anxiety on a long-term daily basis. All of the medications currently available have potential problems regarding long-term use – including the SSRI’s (like Zoloft and Paxil) as well as the other benzodiazepines (like Ativan, Klonopin and Valium. The best answer for anxiety management lies in learning methods and techniques to minimize their impact. These techniques can be learned by anyone wishing to do so and a psychotherapist is available at Accurate Clinic to teach them.
See: Anxiety and Stress
This web site is an excellent resource for understanding the issues of benzodiazepine use with special attention to providing insights for discontinuing the use of Xanax and similar medications. Benzo.org.uk is the best resource to learn about discontinuing benzodiazepines.
This web page is written for physicians but provides in-depth discussion of the problems associated with long term use of benzodiazepine medications.
Benzodiazepines – Overviews
Emphasis on Education
Accurate Clinic promotes patient education as the foundation of it’s medical care. In Dr. Ehlenberger’s integrative approach to patient care, including conventional and complementary and alternative medical (CAM) treatments, he may encourage or provide advice about the use of supplements. However, the specifics of choice of supplement, dosing and duration of treatment should be individualized through discussion with Dr. Ehlenberger. The following information and reference articles are presented to provide the reader with some of the latest research to facilitate evidence-based, informed decisions regarding the use of conventional as well as CAM treatments.
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