Xanax: 12 Things You Should Know
Medically reviewed on Apr 4, 2018 by L. Anderson, PharmD.
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 as 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: How it Works and a Serious Warning
When you have anxiety don't you feel like everything is moving faster?
Xanax is a benzodiazepine, and like all benzodiazepines, has action as a central nervous system (CNS) depressant. Benzodiazepines increase the neurotransmitter gamma-aminobutryic acid (GABA) in the brain to illicit a calming, sedative effect.
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. Check drug interactions for alprazolam here.
Plus, as reported in a 2017 study published in BMJ, the combination of sedatives like Xanax and narcotic pain killers can be serious or fatal due to a lowered, or absent, breathing.
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 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 with severe liver disease. Slowly stop this medication, too, tapering by no more than 0.5 mg every 3 days. Follow your doctor's directions on stopping this drug.
Alprazolam also comes as:
- Xanax XR, an extended-release form for panic disorder (with or without agoraphobia)
- orally-disintegrating tablets (in generic only; the brand name product Niravam has been discontinued)
- an oral solution (generic only)
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.
Should Grandma Be Taking Xanax?
The elderly are very sensitive to the effects of benzodiazepines, and in general, they should be avoided those over 65 years of age.
The 2015 Beers Criteria, an expert opinion-developed guideline addressing safe drug use in the elderly, recommends against the use of this class in the elderly. Older adults have a lowered metabolism (liver break down and excretion) of this drug class, which may elevate dangerous side effects like dizziness or falls, excessive sedation, and confusion.
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.
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.
Warning: Don't Abruptly Stop a Benzodiazepine
The benzodiazepine class has addictive potential - this is a well-known fact.
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 a withdrawal.
You may end up with side effects such as:
- trouble sleeping
- worsened (rebound) anxiety
- blurred vision
- panic attacks
In general, benzodiazepines should be discontinued slowly to minimize symptoms. In certain cases, this may take many months. Talk to your doctor how to slowly stop a benzodiazepine like Xanax.
Why the Bad Rap for Grapefruit Juice?
You might think that grapefruit juice interactions with medicines aren't really that important, but you are wrong.
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; but 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
As was mentioned before, liver enzymes are a source of drug interactions for many medicines when used in combination with alprazolam (Xanax and others).
Two interactions are very important to know about:
- Xanax should not be used with oral ketoconazole or itraconazole, two 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 and you can check them here, too.
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."
A review of benzodiazepine overprescribing was published in the February 2018 issue of the New England Journal of Medicine (NEJM). Overdose deaths are on the rise with benzodiazepines and have increased exponentially over the past decade, as has prescribing for these medications.
- 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 with opioids has 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.
How to Handle Other More Common Xanax Side Effects
Overall, alprazolam can be a useful drug with low toxicity if used properly, short-term, and with proper monitoring.
Addiction, overdose, and CNS sedation can all be severe effects of Xanax, but alprazolam also has other more common side effects, too, such as:
- 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 -- alprazolam -- is found on many lower cost drug lists at pharmacies; be sure to ask your pharmacist specifically about this. In some pharmacies, 30 tablets of alprazolam can be purchased for $5 or less.
Anxiety is often a component of depression, and 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 to help with those anxious feelings and your sleep.
But short-term use -- about 2 to 4 weeks -- of alprazolam treatment is preferred due to its addictive potential.
Finished: Xanax: 12 Things You Should Know
- Xanax, Valium Looking Like America's Next Drug Crisis. Drugs.com. Feb. 22, 2018. Accessed April 3, 2018 at https://www.drugs.com/news/xanax-valium-looking-like-america-s-next-crisis-68786.html
- American Geriatrics Society 2015 Updated Beers Criteria for Potentially Inappropriate Medication Use in Older Adults. J Am Geriatr Soc 63:2227–2246, 2015. Accessed April 3, 2018 at http://onlinelibrary.wiley.com/doi/10.1111/jgs.13702/full
- Opioid Painkillers and Xanax or Valium a Deadly Mix: Study. Drugs.com. Accessed April 3, 2018 at https://www.drugs.com/news/opioid-painkillers-xanax-valium-deadly-mix-study-64838.html
- Xanax Product Labeling. Pfizer January 2017. Accessed April 3, 2018 at http://labeling.pfizer.com/ShowLabeling.aspx?id=547