by Stuart Shipko, M.D.
Power Surge Anxiety-Panic Expert
Read The Side Effects Of Alprazolam (Xanax)
In the 80’s I saw a lot of people with panic disorder through the Workers’’ Compensation system. Many of them had episodes at work where they were taken out by ambulance. My first choice of a pharmacological agent was imipramine. I wanted to spare the patients the risks of Xanax dependency so I went with the antidepressant. What I found with imipramine was an unacceptable level of tachycardia and agitation. Patients would return to the office worse than before treatment. And these people had no room to deteriorate.
Xanax seemed to work quickly and with mostly sedation as an initial side effect. Of course, the person who has not slept for a few weeks usually welcomes the sedation. It was obvious that Xanax worked and antidepressants did not. This goes double for the SSRIs.
Diagnosis: The person who is subjectively overstressed to the point where they are sick tends to have panic attacks and GERD. The best treatment for this is Xanax. Xanax not only slows the nervous system via GABA enhancement, but it slows the system through its antagonism of CCK (cholecystokinin), which peps up the nervous system. It treats GERD by antagonism of the CCK mediated secretion of bile release and flow.
The first consideration in the use of Xanax is the condition for which it is being prescribed. It is not a good drug for people who have personality disorders as these people are more at risk for ““disinhibition”” or atypical reactions where the person feels intoxicated and often acts intoxicated or aggressive. It is not a good drug as a sleeping agent. Tolerance to sleep inducing effects occurs after three nights and after that dosage escalation and dependency become problems. As an agent to reduce worry it is not particularly effective although it does calm a person down through its sedative properties.
It is good for the person with panic attacks, clusters of panic attacks, or severe anxiety with a lot of somatic symptoms. Usually this is found with reflux and Xanax is even better if the clinical picture includes reflux.
The Dosage: In general I try to figure out how sensitive a person is going to be to drugs of all kinds. One index of this is how much alcohol a person is consuming. A lot of patients are self-medicating with alcohol when they present for consultation. The amount of alcohol they are consuming gives some indication of Xanax tolerance. For example, a non-drinker who cannot tolerate most medications might do best with .125 mg two or three times a day. A person who is drinking a bottle of wine each night will probably do better on a starting dose of .5 mg TID. Xanax needs to be taken at the same time each day. It is prescribed to prevent attacks not to be taken once an attack has started, usually three times daily.
It is not necessary to take Xanax indefinitely. The original treatment requires a dosage sufficient to stop all panic attacks. In some people this will be a single dose or an irregular PRN schedule and in others it will be a regular dosage two or three times a day (if it is needed more than three times a day I switch to Klonopin or stop it entirely as this suggests that a BDZ might be counterproductive). Despite the literature, I find that above 4 mg/24 hours I do not get further improvement.
The goal is zero spontaneous panic attacks. At one week the symptoms and dosages are reevaluated. Some people may need dose reductions and some people may need dosage increased. Sedation should not be present after three days at a given dosage.
Tapering: Knowing how to stop Xanax is as important as knowing how to prescribe it. The Stephen Cox protocol was pretty much the only thing written on this subject and was the guideline I initially followed. He proposes a gradual but rigid tapering schedule. What I found when I tried to follow this was that the initial reduction seemed to work pretty well. However as people moved towards the lower doses they became very uncomfortable. The concept was to stay at a dose and wait for the discomfort to recede before lowering the dose further. Unfortunately it seems that at the doses of 0.5 mg or less per 24 hours patients remain very uncomfortable and waiting longer only seems to prolong the agony. Adaptation did not seem to happen and originally we assumed that lowering the dose further or stopping would result in intolerable discomfort. This was not the case. At the lower dosage one does not wait to become comfortable before stopping the dose. It is only after stopping completely that the discomfort goes away (counterintuitive).
As far as the speed of the tapering, I have found it to be so highly variable that I have no one schedule. I usually suggest cutting the dose in half over a month and then dropping by either .25 mg or .125 mg a week after that (see sample schedule). Almost all drug-tapering schedules are designed for addicts. With an addict, it seems that taking any extra drug during the weaning process results in a return of the full addiction. For example, if an alcoholic gets even a single shot glass of liquor during withdrawal it is almost a foregone conclusion that they will return to prior full tilt drinking habits. In patients who are taking Xanax as I prescribe it, at fixed doses at regular times of day, taking an extra .25mg or .125 mg to reduce withdrawal symptoms (usually for irritability, insomnia, muscle aches or shakiness) does not interfere with the weaning process. So, if in the tapering schedule, a person needs an extra dose to relieve excessive discomfort, this is not a problem. After taking the extra dose one resumes the schedule. If this is a persistent problem the schedule is revised. As part of the tapering process (which is very fluid) it is important not only to reduce the quantity of medication at the fixed dosage, but also to stretch out the time between dosages. For example, if the dosage is .25 mg three times a day, one might wait as long as possible before taking the midday dosage. Eventually the midday dosage will be moved back so close to the last dose that it can be dropped out entirely.
Critical to the weaning process is the patient. I have never forced anyone to wean, as that is doomed to failure. Placebo expectations are very powerful in the withdrawal experience. When I prescribe I discuss weaning from the drug at the time of the first prescription. Relapse of the original condition has not yet happened in my practice. I suspect that the concept of withdrawal relapse was merely the drug company’’s way of distracting attention from withdrawal (much the way Paxil is marketed –– I guess GlaxoSKB learned from Upjohn). Most patients feel sure that they will relapse if they stop Xanax. This seems to be a part of the collective unconscious in PNE and needs to be discussed in detail. I mention it frequently, but I wait until the patient feels good enough that they express an interest in stopping medication.
For a person on 0.5 mg three times a day a typical suggested tapering would be:
- 0.50 mg 0.50 mg 0.50 mg to start
- 0.50 mg 0.25mg 0.50 mg at first drop and revisit in a week:
- 0.25 mg 0.25 mg 0.50 mg (assumes sx worse at night) for a week stretch mid dose until it drops off at night dose
- 0.25 mg 0.50mg one week at comfort
- 0.25mg 0.25 mg (beyond comfort) one or two weeks
- 0.125 mg 0.25 mg (one week –– some stop here)
- 0.125 mg 0.125 mg (one week –– more stop here)
- 0.125 mg (a few days)
I am reluctant to say that there is a curative effect of taking Xanax because that is what they say about the SSRIs (although nobody with a positive response seems to go off a SSRI until they are in poop out which is usually called relapse). Still, the patients who have gone off of Xanax are doing as well or better than they did when still on Xanax.
A BDZ (benzodiazepam) is not a life sentence (although some people are better off taking them indefinitely). Still, those who withdraw from regular use of Xanax often continue to use it sporadically (once a week or less) when insomnia, tension and irritability are building. Most people have a sense of when they are building towards panic attacks and can prevent them entirely. As a chronic and relapsing problem, people may need to return to regular dosing from time to time.
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