Xanax (alprazolam) is a benzodiazepine and one of the most commonly prescribed sedative drugs in the United States.
As a class of drugs, benzodiazepines are used to treat several medical/mental health conditions, including:
- Anxiety disorder.
- Panic disorder.
- Certain seizure disorders.
- Skeletal muscle spasm.
- Acute alcohol withdrawal.
Of these, Xanax is specifically indicated for use in managing both panic and anxiety.
Benzodiazepines are controlled substances and are categorized by the United States Drug Enforcement Agency as Schedule IV drugs, meaning that they have a known potential for abuse and dependence— albeit relatively lower than those drugs in Schedules I, II, and III. Many prescription benzodiazepines are typically taken in oral tablet form, including Xanax.
How Xanax Works in the Brain
Xanax interacts with certain gamma-aminobutyric acid (GABA) receptors to increase the binding of and ultimately enhance the inhibitory effects of that neurotransmitter. GABA is the most common inhibitory neurotransmitter throughout the central nervous system. The inhibitory effects of GABA lead to a reduction in the excitability of other neurons in the brain when the neurotransmitter is active.3
Because of these inhibitory properties, Xanax can be an effective pharmacotherapeutic option for managing panic disorder and anxiety. It is generally indicated for short-term use.1 Some people who use the drug consistently for long periods of time, use it in quantities that exceed recommended dosing, or otherwise misuse the drug for nonmedical reasons (e.g., to “medicate” other conditions without a prescription, to elicit a euphoric high, to enhance or change the acute intoxication or after-effects of other simultaneously used substances) may be at higher risk of experiencing adverse drug effects including significant physiological dependence, withdrawal, and addiction.4
Other Pharmacologic Effects and Side Effects of Xanax
Xanax and other benzodiazepines are central nervous system (CNS) depressant drugs. Their inhibitory effects have a range of potential clinical uses, including procedural sedation, anxiety reduction, and seizure management. The same pharmacologic mechanisms that underlie Xanax’s therapeutic uses are associated with additional effects, including:4,5,6
- Drowsiness or over-sedation.
- Ataxia or problems with gait, posture, movement.
- Slurred speech.
- Blurred vision.
- Memory impairment.
- Respiratory depression.
Similar to many other substances of abuse, Xanax and other benzodiazepine use may also be associated with a dopamine-mediated reinforcement of continued use.7 Especially when consistently misused in larger-than-recommended doses, such an artificially produced neurochemical reward can lay the groundwork for developing patterns of compulsive use and addiction.
Signs of Abuse and Addiction
Abuse, or nonmedical misuse, of Xanax occurs any time someone uses the medication in a way other than prescribed or for illegitimate reasons such as getting high. Using someone else’s prescription, shopping around to obtain additional prescriptions of your own, or purchasing illicit/diverted sources of Xanax may also be indicative of problematic use.8
Addiction to Xanax is diagnosed as a Sedative, Hypnotic, or Anxiolytic Use Disorder. Consistent, compulsive patterns of Xanax use may lead to significant adverse repercussions in multiple areas of an individual’s life. Such problematic use may be exemplified by the following:9
- Xanax is used in greater amounts or for longer periods of time than initially intended.
- There are strong cravings or urges to continue use.
- Increasing amounts of time and attention are dedicated to obtaining and using Xanax.
- There is a persistent desire and, potentially, repeated efforts to slow or quit using Xanax.
- Xanax use has started to result in a failure to fulfill work, school, or domestic obligations.
- Use of the drug continues despite marked social or interpersonal problems related to such drug use.
- Participation in once important social, recreational, or work activities slows or stops as a result of Xanax use.
- Xanax begins to be used in hazardous situations, such as operating a vehicle.
- Use continues despite persistent or recurring mental or medical health issues related to such use.
- Xanax tolerance has developed.
- Xanax withdrawal is experienced when use slows or stops.
Treatment professionals may make a diagnosis of a Xanax use disorder should two or more of the above criteria be met within a 12-month period.
Mixing Xanax and Alcohol
Xanax misuse sometimes occurs in a setting of concurrent substance use, such as drinking alcohol. Such a combination of CNS depressant substances can be synergistically dangerous, and can more easily result in profound sedation, loss of consciousness, and increase the risk of respiratory depression-related fatalities.1 Additionally, should such a combination of substances be misused regularly, it increases the chances of developing considerable physical dependence to both substances, an additionally complicated withdrawal syndrome, and polysubstance addiction.
Xanax overdose is possible. Overdose fatalities have been reported on alprazolam alone, though they may be more common when the drug is used in combination with alcohol or other substances.1,8 Overdose death may occur as a result of respiratory arrest and a resulting lack of oxygen being delivered to the brain.8
Other signs of Xanax overdose include:1,8
- Markedly impaired coordination.
- Pronounced confusion.
- Profound somnolence and/or loss of consciousness.
Sedative overdoses can be life-threatening and should be treated as an emergency. If you suspect that you or someone nearby is experiencing an Xanax overdose, call 911 immediately.
Though Xanax is commonly indicated for short-term therapeutic use, some people become chronic users of the drug and face some additional health risks. For instance, people who use it in higher than recommended doses and/or in a setting of additional drug or alcohol use may be at increased cumulative risk of experience an overdose. On the topic of overdose, should someone have sustained hypoxic injury (a lack of adequate oxygen delivery to the brain and or other tissues/organs), the health consequences—including persistent neurologic deficits—can become issues that require long-term management.8
In addition to cumulative overdose risks, an important long-term consideration with Xanax use/misuse is the likelihood of considerable physical dependence development and an associated risk of significantly severe withdrawal at the point that a person slows or quits use.1,8,10
Discontinuation / Withdrawal Syndrome
Symptoms of acute Xanax withdrawal may include:6,8,9
- Disturbances in sleep (e.g., insomnia, nightmares).
- Increased feelings of tension and anxiety.
- Rebound panic attacks.
- Increased irritability.
- Elevated blood pressure.
- Tachycardia (elevated heart rate).
- Hand tremor.
- Psychomotor agitation.
In some people, symptom development can progress to severe levels, and include potential life-threatening complications such as seizures and delirium.
The withdrawal syndrome associated with Xanax discontinuation may be particularly severe in comparison with other benzodiazepines.13 Avoidance of unpleasant, if not severe withdrawal, may drive continued use—making recovery more difficult. Similarly, the return of once-managed symptoms, such as panic or anxiety, might prompt an individual to simply take more Xanax.
To keep people as safe and comfortable as possible during withdrawal, some form of medical detox—including a considerable time period allotted for gradual benzodiazepine tapering—is commonly sought early on in treatment for benzodiazepine addiction.4,11
Treatment for Xanax Addiction
Because of the potential for significant withdrawal when one attempts to quit using Xanax, a period of medical detoxification may be indicated, as mentioned above.
As part of a medical detox protocol, a team of healthcare professionals will provide supervision, regular progress evaluations and, when needed, medical intervention to manage withdrawal during the early stages of recovery. Depending on individual withdrawal risks, detoxification for benzodiazepine withdrawal may be successfully carried out in either an inpatient or outpatient program.11
Though both settings may be helpful given different individual needs and the corresponding appropriate level of care, often, the choice of beginning an inpatient or outpatient program will be suggested by a treatment professional. It is also important to note that completion of a medical detox program is rarely sufficient treatment intervention to sustain recovery from significant addiction to Xanax or any drug. In most cases, further therapeutic treatment in the form of longer-term rehabilitation will be beneficial.
Professional treatment program lengths are commonly 30-90 days although, depending on the needs of the individual, treatment can be extended much longer.
No matter the setting, many professional rehabilitation programs will be built around a combination of behavioral therapies administered in both group and individual sessions. In addition to therapeutic techniques such as cognitive-behavioral therapy, which facilitates the examination of and changing of previously maladaptive patterns of thoughts and behaviors regarding substance use, many programs incorporate and encourage participation with 12-step programs, such as Narcotics Anonymous. Individuals in structured treatment programs who start attending 12-step meetings as part of the larger program structure may, as part of an aftercare routine, continue with these meetings after their formal treatment has ended.13
Choosing the Right Treatment Program
Though they share many commonalities, different treatment programs may make efforts to tailor their therapeutic offerings to the needs of the individual.14 For example, many programs will encourage supportive visits from family members and loved ones whenever possible and might additionally host family therapy sessions.
Other factors to consider when choosing a treatment program for recovery from Xanax addiction include:
- Is there a need for medical detox and withdrawal management?
- Is the program affordable? Will the facility work with the insurance provider in question?
- What evidence-based treatment interventions are utilized?
- Are any complementary or alternative treatments used to augment recovery?
- Is location a factor—would staying close to home or traveling for treatment be more conducive to recovery?
- Since social support can be an important factor in recovery, can family members or loved ones be part of the recovery process?
- U.S. Department of Health and Human Services—Food & Drug Administration. (2016). Labeling-Medication Guide: Xanax.
- United States Drug Enforcement Administration. (n.d.). Drug Scheduling.
- Griffin, C. E., 3rd, Kaye, A. M., Bueno, F. R., & Kaye, A. D. (2013). Benzodiazepine pharmacology and central nervous system-mediated effects. The Ochsner journal, 13(2), 214–223.
- Verster, J. C., Volkerts, E. R. (2004). Clinical pharmacology, clinical efficacy, and behavioral toxicity of alprazolam: a review of the literature. CNS drug reviews, 10(1), 45–76.
- Hamilton, RJ. (2017). Tarascon Pocket Pharmacopoeia, 2017 Professional Desk Reference Edition. Jones & Bartlett Learning.
- U.S. National Library of Medicine—MedlinePlus. (2017). Alprazolam Drug Info.
- National Institute on Drug Abuse. (2012). Well-Known Mechanism Underlies Benzodiazepines’ Addictive Properties.
- National Institute on Drug Abuse. (2018). Prescription CNS Depressants.
- Diagnostic and statistical manual of mental disorders: DSM-5.(5th ed.). (2013). Washington, D.C.: American Psychiatric Association.
- Miller, S. C., Fiellin, D. A., Rosenthal, R. N., & Saitz, R. (2019). The ASAM Principles of Addiction Medicine, Sixth Edition. Philadelphia: Wolters Kluwer.
- Substance Abuse and Mental Health Services Administration. (2015). TIP 45: Detoxification and Substance Abuse Treatment.
- Ait-Daoud, N., Hamby, A. S., Sharma, S., & Blevins, D. (2018). A Review of Alprazolam Use, Misuse, and Withdrawal. Journal of addiction medicine, 12(1), 4–10.
- National Institute on Drug Abuse. (2018). Principles of Drug Addiction Treatment: A Research-Based Guide (Third Edition)—12-Step Facilitation Therapy.
- National Institute on Drug Abuse. (2018). Principles of Drug Addiction Treatment: A Research-Based Guide (Third Edition).