Alprazolam, marketed under the name Xanax, is one of the most popular benzodiazepines available. Initially touted as a safe alternative to diazepam (Valium), this drug has recently came under fire for its potential for addiction and dependence as well as claims of widespread abuse.
Consider the following case example. A 33-year-old married woman, recently hospitalized for major depression, suffers from brief periods of moderate anxiety that fail to meet criteria for either generalized anxiety disorder or panic attacks. She conveys this anxiety to her primary nurse, who suggests that she try various measures (warm bath, staff talk, relaxation exercises) to alleviate the anxiety. When these suggestions fail, she requests half of her standing (0.25 mg) p.r.n. dose of alprazolam. Her request is met with, "don't you know Xanax is very addictive and hard to discontinue. . . . Let's figure out other ways you can deal with your anxiety." The patient, misunderstood and unsure about what else to try, is left feeling confused about why the 0.25 mg of alprazolam that she took infrequently prior to admission is now a problem.
Although oversimplified, this scenario is not atypical from what patients experience regarding benzodiazepine use. Given this controversy, a discussion about the effectiveness and indications of alprazolam, contraindications to treatment, and some of the potential pitfalls is useful.
Indicated for the treatment of certain forms of anxiety, alprazolam has been demonstrated to be effective for anxiety associated with generalized anxiety disorder, panic disorder, adjustment disorders, and milder forms of depression (Cole, 1 988). Anxiety is a normal reaction to unpredictable stressors that arise; when taking a test, socializing with new people, or beginning a new task, many of us will feel some degree of nervousness or anxiety. Mild to moderate anxiety can be useful and motivating, such as the performance anxiety associated with test-taking.
Not unlike the distinction between occasional depressed feelings and major depressive disorder, everyday feelings of anxiety are very different from anxiety disorders. At severe levels, anxiety can be one of the most crippling and debilitating illnesses, leading to an inability to function and possibly suicide attempts. Although controversial, individuals diagnosed with panic disorder are thought to be at high risk for suicide, perhaps even higher than those with major depression (Weissman, 1989).
Anxiety attacks as part of panic disorder recur spontaneously, sometimes daily, leading to phobic avoidance and agoraphobia (American Psychiatric Association, 1 987). Individuals with generalized anxiety disorder often have daily, lifelong anxiety that interferes with relationships and performance. Severe anxiety that remains untreated exerts its toll on physiology with increased stress on the body in the form of compromised cardiac status, tachycardia, and heightened arousal. Benzodiazepines, with known efficacy in the treatment of these disorders, can offer substantial relief, improve daily functioning, and lead to healthier adaptation. In combination with traditional psychotherapy and behavioral/cognitive therapy, individuals who suffer from these disorders can use a variety of alternatives to manage their symptoms and enjoy a more satisfying life. Thus, pharmacotherapy is one treatment available to individuals with generalized anxiety or panic disorder, and alprazolam is one pharmacologic option.
Alprazolam has been targeted as a highly addictive, abusable medication that may lead to severely adverse consequences. Any of the benzodiazepines possess the potential for addiction, physical dependence, and abuse (Cole, 1988). Thus, diazepam (Valium), clonazepam (Klonopin), lorazepam (Ativan), triazolam (Halcion), and other benzodiazepines carry these risks. Is there any evidence to suggest that alprazolam is any more likely to cause addiction than these other medications? Although news reports suggest that it does, a review of the literature revealed no controlled studies that compare alprazolam's addiction potential with that of the other medications.
Some reports do suggest that because of its relatively short half-life, patients may experience breakthrough symptoms of anxiety. Sometimes referred to as "clock watching," a patient on alprazolam (on a q.i.d. schedule for panic attacks, for example) begins to notice the onset of anxiety, palpitations, and shortness of breath an hour or so before the next dose. In response to the symptoms, the patient becomes more anxious, impatiently waiting for the time to pass until the next dose can be taken. Thus begins a vicious cycle of checking the time, very conscious of when the medication can be taken. At times, these episodes may lead individuals to take earlier or extra doses of medication, hence increasing their dose without supervision. Or dosage escalation may be prescribed by the physician to treat the interdose symptoms. This untoward reaction is usually treated by switching the dose to a longer acting benzodiazepine equally effective in treating the disorder; eg, a switch from alprazolam to clonazepam (Tesar, 1991 ).
Other reports exist on the difficulty of discontinuing benzodiazepines, including alprazolam. Preventive efforts to discourage continual escalation to high dosages is ideal. When patients do receive large ongoing dosages, very gradual tapering, support, and behavioral measures may be necessary to cope with withdrawal symptoms. Switching to longer acting preparations and then decreasing dosages of the substituted benzodiazepine are another option. In extreme cases, hospitalization or concomitant administration of other medications, including anti-convulsants such as carbamazepine (Tegretol), has been necessary to successfully taper some patients on high doses of alprazolam.
Several groups of patients may be at higher risk for benzodiazepine abuse and addiction. Patients with previous or active alcohol or drug abuse generally are not suitable candidates for any benzodiazepine, including alprazolam. As a result, these individuals carry a much higher risk for repeating their abusive behavior with this medication. Patients suffering from post-traumatic stress disorder (PTSD) also may be less than suitable candidates for alprazolam treatment. Individuals with PTSD may be more prone to abuse or may have suffered from alcohol or substance abuse to alleviate symptoms of hyperarousal, flashbacks, and insomnia (Bailey, 1991). In combination with alcohol or pain medications, the benzodiazepines (including alprazolam) intensify their effects, along with intensifying the effects of alprazolam. This synergistic effect becomes dangerous in driving, operating machinery, and in potential overdose. Thus, benzodiazepines carry substantial risks and patients are cautioned against the combination with alcohol or narcotics.
Reports of violent and aggressive behavior have also been associated with alprazolam use. Patients with borderline personality disorder have been reported to have severe episodes of behavioral dyscontrol during treatment (Cowdry, 1988). Patients in one study became self-destructive (cutting their wrists, overdosing) and violent (throwing objects) while receiving mean daily doses of 4.7 mg of alprazolam. Although known to be effective in some forms of depression, patients receiving treatment with alprazolam have developed both manic and hypomanic episodes (Feighner, 1983). The mood lability, dysphoria, and poor judgment characteristic of mania may lead to violent or aggressive behavior. Alprazolaminduced mania may thus have similar effects. As a result, patients with known bipolar disorder or borderline personality disorder may be at higher risk for violent, assaultive, or out of control behavior while receiving alprazolam.
In addition to behavioral dyscontrol and the development of manic episodes, other adverse reactions are possible. Alprazolam, like the other benzodiazepines, often causes sedation, especially with initial treatment or dosage increases. Tolerance to this effect usually occurs, and overall patients tolerate the medication quite well. With known uncomfortable and disruptive effects associated with other psychotropics (eg, dry mouth, constipation, impotence, tardive dyskinesia), the side effects of alprazolam are generally minimal. Other side effects include dizziness, weakness, decreased motor and cognitive performance, and nausea.
Overall, to promote the most effective treatment and minimize the risk of abuse, addiction, and adverse consequences, nurses as patient advocates need to be aware of the need for pharmacotherapy, possible alternatives, side effects, and potential pitfalls. Ideally, each patient will have several options available for appropriate treatment. As with most medications, alprazolam is neither a miracle cure nor a tortuous nightmare, but carries certain advantages and disadvantages. By promoting adequate informed consent and conveying important information about these emerging issues, promotion of the patient's optimal level of functioning is achievable. In returning to the earlier example, our role is not to bias or scare the patient with the latest news or research reports, but to honestly convey the most appropriate information. In this regard, alprazolam can be used most effectively, avoided in those with a high risk for developing untoward reactions, and the potential for abuse and addiction minimized.
- American Psychiatric Association. Diagnostic and statistical manual of mental disorders, 3rd ed, revised. Washington, DC; Author, 1987.
- Bailey, K., Glod, CA. Post-traumatic stress disorder: A role for psychopharmacology? / Psychosoc Nurs Ment Health Serv 1 99 1 ; 29 (9):4243.
- Cole, J.O. The drug treatment of anxiety and depression. Med Clin North Am 1988; 72:815830.
- Cowdry, R. W., Gardner, D.L. Pharmacotherapy of borderline personality disorder Alprazolam, carbamazepine, trifluoperazine, and tranylcypromine. Arch Gen Psychiatry 1988; 45: 1 1 1118.
- Feighner, J.P., Aden, G.C., Fabre, L.F., Rickers, K., Smith, W. T. Comparison of alprazolam, Imipramine, and placebo in the treatment of depression. JAMA 1983; 249:347-351.
- Tesar, G.E., Rosenbaum, J.F., Pollack, M.H., Otto, M., Sachs, G.S., Herman, J.B., Cohen, L.S. . Spier, S.A. Double-blind, placebocontrolled comparison of clonazepam and alprazolam for panic disorder. J Clin Psychiatry 1991; 52:69-76.
- Weissman. M.M., Klerman, G.L., Markowitz, J.S.. Ouellette, R. Suicidal ideation and suicide attempts in panic disorder and attacks. N Engl J Med 1989;321:1210-1214.