Xanax: 12 Things You Should Know
Medically reviewed by Leigh Ann Anderson, PharmD. Last updated on April 9, 2021.
Xanax Has Been Around for Over 30 Years
Xanax, commonly referred to by its generic name alprazolam, was originally developed by Upjohn Labs in the late 1960's. It was used a sleep aid with muscle relaxant properties, but researchers soon learned it had other properties, too.
Xanax, in the class known as benzodiazepines, works to suppress the overreaction of the central nervous system. It was found to be effective for anxiety and panic disorder, and the FDA approved these uses in 1981. Since then, new uses and forms of alprazolam have been approved.
Xanax has been one of the most successful, if not worrisome, blockbusters in years past due to a serious addiction potential. Patients also develop tolerance, requiring higher and higher doses. What other warnings should you be mindful of?
Xanax: A Boxed Warning
When you have anxiety don't you feel like everything is moving faster?
Benzodiazepines increase the neurotransmitter gamma-aminobutryic acid (GABA) in the brain to illicit a calming, sedative effect. Xanax is a benzodiazepine, and like all benzodiazepines, has action as a central nervous system (CNS) depressant.
- But beware: alprazolam can also cause drowsiness and affect your ability to react to situations. For these reasons, you should not combine alprazolam with alcohol, other CNS depressant medications like narcotic painkillers (opioids), other drugs that make you sleepy, or driving or doing harzardous tasks.
- Your inability to react quickly to an unexpected situation may lead to an accident and injury.
- Check for drug interactions for alprazolam.
Plus, the combination of sedatives like Xanax and narcotic (opioid) pain killers can be serious or fatal due to slowed or stopped breathing. Avoid the combination of any benzodiazepine with an opioid unless directed by your doctor. Ask your doctor or pharmacist if you are not sure if you are taking both. Go to an emergency room or call 911 if you have trouble breathing or other serious side effects such as seizures.
Be sure to tell your healthcare provider about all of the medicines you take. If you need to stop Xanax, it should be slowly discontinued in most cases; discuss this with your doctor. Weaning yourself off the benzodiazepines requires guidance from a physician. If your conditions worsens, or if you have withdrawal symptoms, contact your doctor immediately.
In Sept. 2020, the FDA further updated the Boxed Warning to alprazolam (Xanax), and other benzodiazepines, warning of an increased risk of abuse, misuse, addiction and dependence. A Boxed Warning is the most stringent safety advisory on the FDA's approved drug information for medicines.
I'm Afraid I Don't Know What Anxiety Is
We all worry. But when chronic, unwarranted worry lasts for over 6 months and disrupts our normal lifestyle, this may be diagnosed as Generalized Anxiety Disorder (GAD).
GAD affects about 5% of adults in the U.S. The occurrence of at least 3 symptoms below may constitute a diagnosis of GAD:
- Excess anxiety for at least 6 months, but not due to another condition or substance abuse
- Sleep disturbances, insomnia
- Difficulty concentrating
- Muscle tension
Understanding Panic Attacks
A panic attack is not just that dreaded feeling you get when you know you missed your credit card payment.
Panic disorder, or panic attacks, are repeated episodes of intense fear which may be expected or unexpected. Physical symptoms are similar to the body's normal response to danger - the fight or flight phenomenon.
Symptoms of a panic attack usually start very quickly and include:
- rapid heartbeat
- shortness of breath
Anxiety medication may be used short-term while other preferred medications, like SSRI antidepressants, kick in for longer-term treatment of panic disorder. Psychotherapy, often called talk therapy, may be used, too.
How is Xanax Dosed?
Doses of alprazolam for anxiety or panic should typically start low -- and go slow.
Doses range from 0.25 milligram (mg) to 0.5 mg tablets, usually given three times day, although your doctor may adjust this dose based on your individual symptoms. Higher doses, 1 and 2 mg tablets, are available, but are not usually used for the initial dose.
Lower doses are needed in the elderly and in those with severe liver disease. Your doctor will slowly stop this medication by tapering by no more than 0.5 mg every 3 days. You may need to stop it even more slowly. Follow your doctor's directions on taking this drug and on how to stop it.
Alprazolam also comes as:
- Xanax XR, an extended-release form for panic disorder (with or without agoraphobia)
- orally-disintegrating tablets (generic only)
- an oral solution (generic only)
Extended-release tablets (Xanax XR) can also be used once-daily for the treatment of panic attack.
Generics are available for all forms and can save you money at the pharmacy. Ask your pharmacist about this option. Alprazolam is a schedule IV controlled substance due to abuse potential.
Should Grandma Be Taking Xanax?
The elderly are very sensitive to the effects of benzodiazepines, and in general, they should be avoided in those over 65 years of age.
The Beers Criteria, an expert opinion-developed guideline addressing safe drug use in the elderly, recommends against the use of this class in this population.
- Older adults have a lowered metabolism (how the drug is removed from the body) of benzodiazepines, which may elevate dangerous side effects like dizziness or falls, excessive sedation, and confusion.
- In addition, the combined use of opioid painkillers (for example: hydrocodone, oxycodone, fentanyl) and benzodiazepines should be avoided due to an increased risk of an overdose and severe sedation-related side effects such as depressed breathing and death.
Combining benzodiazpines like alprazolam with opioids like hydrocodone or oxycodone can have serious consequences. As reported in the February 2018 issue of the New England Journal of Medicine (NEJM), experts note that many overdose deaths involve people taking a benzodiazepine with another substance, such as opioids or alcohol.
If there is a documented need, physician-monitored low doses and drugs with shorter durations (half-lives) will help to minimize side effects like dizziness, weakness, and falls that may lead to hip fractures.
Warning: Don't Abruptly Stop a Benzodiazepine
The benzodiazepine class has addictive potential - this is a well-known fact.
In general, benzodiazepines should be discontinued slowly (as directed by your doctor) to minimize symptoms. In certain cases, this may take many months. Talk to your doctor how to slowly stop a benzodiazepine like Xanax.
Abruptly stopping Xanax, or any benzodiazepine, after you have been regularly taking it, even if only for a short while, can lead to troublesome side effects, often due to withdrawal symptoms.
You may end up with side effects such as:
- trouble sleeping, restlessness, irritability
- worsened (rebound) anxiety
- weakness, tremors
- blurred vision, headache
- panic attacks
- psychosis, hallucinations.
Xanax and Grapefruit Juice
You might think that grapefruit juice interactions with medicines aren't really that important, but think twice.
- Grapefruit and grapefruit juice can affect liver enzymes that are needed to break down (metabolize) Xanax.
- When you take Xanax with grapefruit or grapefruit juice, the amount of alprazolam in your blood may increase and boost side effects like drowsiness, dizziness and confusion.
- It may be best if you avoid grapefruit juice while you take alprazolam. Do not increase or decrease the amount of grapefruit products in your diet without first talking to your doctor.
Luckily, orange juice does not interact with benzodiazepines so you can still get your daily dose of vitamin C.
Avoid These Xanax Drug Interactions
Enzymes that live in our liver or gut or are a source of drug interactions for many medicines when used in combination with alprazolam (Xanax, Xanax XR).
Two interactions are very important to know about:
- Xanax should not be used with oral ketoconazole or itraconazole, both antifungal medicines, because these drugs inhibit (block) the 3A4 liver enzymes needed to break down alprazolam for elimination from your body.
- Using either of these drugs together with Xanax can cause drowsiness, slowed breathing and possible confusion. These reactions can be especially serious in older patients.
Always have your pharmacist check for drug interactions with Xanax; you can check them here, too. Ask your doctor or pharmacist to explain any possible concerns you have.
Many drugs can interact with alprazolam (Xanax). This includes prescription and over-the-counter medicines, vitamins, and herbal products. Not all possible interactions are listed here, and there are many others. Tell your doctor about all your medicines and any new medicines you start or stop using.
Xanax and Opioids: A Potentially Fatal Mixture
Benzodiazepine prescribing information for drugs like Xanax contain a "boxed warning" -- the most stringent warning put in place by the FDA.
- The boxed warning states that benzodiazepines used in combination with opioids "may result in profound sedation, respiratory depression, coma, and death."
- Boxed warnings on all benzodiazepines were also updated in 2020 to include risks of abuse, misuse, and addiction for patients, which can lead to overdose or death.
- Warnings on dependence (addiction), withdrawal symptoms and the need to slowly discontinue the medicine were also updated.
Read the updated Xanax Boxed Warning here.
A review of benzodiazepine overprescribing was published in the February 2018 issue of the New England Journal of Medicine (NEJM). This review found:
- Overdoses involving benzodiazepines multiplied sevenfold between 1999 and 2015, increasing from 1,135 to 8,791 deaths.
- In addition, the researchers found the rates of prescribing benzodiazepine in combination with opioids had nearly doubled, increasing from 9% to 17%.
The combination of a benzodiazepine like Xanax with narcotic painkillers such as Oxycontin, Percocet, Vicodin is particularly dangerous because it can cause individuals to go to sleep and then stop breathing, leading to death.
More Common Xanax Side Effects
Overall, alprazolam can be a useful drug with low toxicity if used properly, short-term, and with adequate monitoring by your doctor.
Addiction, overdose, and sedation can all be severe effects of Xanax, but alprazolam also has other more common side effects:
- irritability and difficulty sleeping (especially when stopping the drug)
- memory impairment
- increased appetite
- loss of sexual desire
If you experience any side effects due to alprazolam, call your doctor who may adjust your dose to help lessen the side effect. Remember, it's best not to abruptly stop alprazolam, so check with your doctor first.
Generic Xanax is Affordable, But Short-Term Use Is Preferred
If you are prescribed Xanax, you can rest assured it shouldn't cost you too much.
- The generic for Xanax and Xanax XR, known as alprazolam, are both available in a generic now, so be sure to ask your pharmacist specifically about this.
- In most pharmacies, 30 tablets of alprazolam 0.25 mg can be purchased for about $10 or less.
- Be sure to look for online coupons, too, but not all pharmacies accept coupons for controlled substances like alprazolam, so it's best to call.
Related: Benzodiazepines: Overview and Use
Short-term use of alprazolam treatment is preferred due to its addictive potential.
Anxiety is often a component of depression. If you are prescribed an antidepressant, it may take up to 4 weeks for its full effect. In the mean time, you may be prescribed a quick-acting medication like alprazolam for a short period to help with those anxious feelings and your sleep.
Finished: Xanax: 12 Things You Should Know
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- FDA requiring Boxed Warning updated to improve safe use of benzodiazepine drug class. FDA Drug Safety Communication. Accessed April 9, 2021 at https://www.fda.gov/drugs/drug-safety-and-availability/fda-requiring-boxed-warning-updated-improve-safe-use-benzodiazepine-drug-class
- Holman C. Beers Criteria Updates: New Guidance for Geriatric Medication Safety. Wolters Kluwer CDI. March 19, 2019. Accessed April 9, 2021.
- A. Lembke, J. Papac and K. Humphreys. Our other prescription drug problem. New England Journal of Medicine. Vol. 378, February 22, 2018, p. 693. Accessed April 9, 2021 DOI: 10.1056/NEJMp1715050
- Xanax, Valium Looking Like America's Next Drug Crisis. Drugs.com. Feb. 22, 2018. Accessed April 9, 2021.
- American Geriatrics Society 2019 Updated AGS Beers Criteria for Potentially Inappropriate Medication Use in Older Adults. J Am Geriatr Soc. Apr;67(4):674-694. doi: 10.1111/jgs.15767. Accessed April 9, 2021.
- Opioid Painkillers and Xanax or Valium a Deadly Mix: Study. Drugs.com. Accessed April 9, 2021.
- Xanax Product Labeling. Pfizer Inc. Drugs.com. Accessed April 9, 2021 at https://www.drugs.com/pro/xanax.html
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