Alprazolam

Alprazolam

Welcome to a brand new blog, people! Last week we talked about mindfulness, so I hope everyone has been trying to practice that in at least some small ways everyday, especially when stressed. If not, the topic of the new series I’m introducing today may be a bit of foreshadowing, as you might need it. Trust me when I tell you that it’s far easier, not to mention more rewarding, just to live a more mindful life. The new topic is alprazolam, which you might better recognize as Xanax, a drug used nearly solely for anxiety, at least when used as intended, but we’ll get to that. 

Today as an introduction, I’ll give you an overview on what you should know about alprazolam if you’re thinking about taking it. But my advice? Don’t, because while it works, it can be so sneakily addictive, in a way that seems almost sinister. Insidious. It took me a second to get there, people. My point is, it will creep in and take over anyone’s life if given the smallest opportunity to do so. We’ll talk more about that later. For now, suffice it to say that it’s so abused by so many people, it’s literally become a threat to public health. I hear stories everyday about how it ruins the lives of good people with only the best of intentions. For that reason, plus more that I’ll get into, everyone should really know the basics about alprazolam. 

Alprazolam belongs to a group of medications called benzodiazepines, aka benzos. Other meds in this group include Valium, Klonopin, and Librium.  You may have seen my YouTube video on benzodiazepines, barbiturates, and alcohol. If not, I’ll put the link at the bottom so you can check it out. Alprazolam, aka Xanax, has a lot of slang names as well, mostly referring to its shape and color. Bricks, zanny bars, blue footballs, and z-bars are the ones that come to mind right now, but there are others used on the street. Speaking of, alprazolam is pretty cheap in the pharmacy. On the street, it’s pretty damn expensive when you consider it can easily cost you your life, but it usually goes for around $3 to $5 per bar or pill, depending on strength. What a bargain. 

Alprazolam, like other benzos, is most commonly prescribed for people with anxiety disorders or panic disorder. Sometimes it’s also used short term for treating severe insomnia, alcohol withdrawal, and prolonged seizures. I myself prescribe it for these indications- very short term and as low dose as possible- because it works well and it’s so fast acting. For anxiety and panic attacks, I almost universally try other meds and methods first, because of its aforementioned insidiousness, but occasionally I might use it as a bridge while the other meds and methods start to work. 

How Alprazolam Works

Like all other benzodiazepines, alprazolam works by binding to specific receptors in the CNS called GABA (gamma-aminobutyric acid) receptors. GABA is an inhibitory neurotransmitter, meaning it works to decrease nerve activity. The simplified pharmacological mechanism looks like this: when alprazolam binds to the GABA receptors, it enhances GABA’s inhibitory activity. This pumps up the GABA, which greatly reduces neural stimulation. This decreased neural activity produces general CNS depression, and elicits the anti-anxiety and sedative-hypnotic effect that’s felt by the person ingesting it. It’s important to note that alprazolam doesn’t affect everyone in the same way. There can be other factors involved, including the person’s mental state at the time the drug is taken, the dose taken, the person’s age, weight, and individual variances in the metabolism of the drug. 

How Alprazolam Feels

Captain Obvious says that this depends on the dose, which I’ll get into next, but when taken as prescribed for anxiety or panic disorders, the idea is that you should feel “normal” after your first dose. The sedative effect should help alleviate the symptoms of anxiety, and calm your body’s response to the anxiety or the stressor. If you take it recreationally, aka without a prescription, the effects you feel would still be dose dependent, and if you take a small dose, in theory you would have the same effects. I say in theory because that would depend greatly on where you get it. If you buy it on the street, you’re probably not taking actual alprazolam. Fake alprazolam is a huge, lethal problem, and I’ll be dedicating an entire blog to that topic in this series. You’ll be shocked. Hint: if you want to live, don’t buy Xanax on the streets! Unlike stimulant drugs like cocaine, which produce a euphoric “high” feeling, recreational alprazolam users describe feeling more relaxed, quiet, and tired, often to the point of passing out for several hours at a time. Some people have memory lapses or amnesia or black out periods, where they can’t remember anything that happened for several hours, even if they’re awake at the time. Equally important is what you should not feel when you take alprazolam, and I’ll cover that below, when I talk about side effects.

Alprazolam Dosing

Alprazolam is available in multiple milligram strengths, 0.25 mg, 0.5 mg, 1 mg, and 2 mg. 

The effects become more significant as the dose increases, so first-time alprazolam users should absolutely start with the lowest possible dose and let your prescribing physician know exactly how it affects you to determine if the dose needs to be adjusted. You don’t ever get to play doctor here, people. Don’t increase the dose on your own, even if you’re an experienced user. This is because higher doses can be fatal for everyone- from first-time users all the way up to people who’ve used it as prescribed for many months or years. Again… don’t take a higher dose than what’s prescribed by your doctor. 

In addition to instant death, high doses are associated with a counterintuitive complication known as the “Rambo effect.” This unusual side effect can happen out of the clear blue sky in anyone taking alprazolam, prescribed or not and experienced or not, and generally presents as the user beginning to display behaviors that are very unlike them. These might include aggression, theft, or promiscuity, but can really be any unusual legal or illegal behavior- the key is that it’s very atypical and seems to occur suddenly. It’s not clear why some people react this way, or how to predict who it will happen to, so it adds a very unwelcome guest to the alprazolam party. 

Alprazolam Metabolism

How alprazolam is broken down and affects you also depends on those aforementioned factors of age, weight, and individual variances in metabolism, but can also be impacted by the presence of other substances and/ or  medications you may be taking. When taken by mouth, alprazolam is absorbed quickly by the bloodstream, so it’s very fast acting. Some people can begin to feel its effects within 5 to 10 minutes of taking the pill, but almost everyone will feel the effects within an hour. One of the reasons why it’s so effective for treating panic attacks and anxiety is that the peak impact from the dose comes so quickly. But, fast acting meds wear off fast too, so the effects are brief. Most people will feel the strongest impacts from the drug for two to four hours, though lingering effects or “fuzzy feelings” may stretch out beyond that for several more hours. Some people even report a hangover type effect as well.

The length of time that alprazolam stays in the body before being excreted also varies person to person by those aforementioned factors. The half-life of alprazolam in a healthy adult averages about 11 hours, meaning that it takes the average healthy person 11 hours to eliminate half of the dose from the bloodstream. Typically speaking, that time would generally be a little shorter for younger people, and longer for older people. It’s important to recognize that you will stop feeling the effects of the alprazolam long before you reach half life.  

It is possible, even likely, to build up a tolerance to alprazolam, and this can happen very quickly. If that happens, you may begin to notice it takes longer to feel the sedative effects of the drug, and that feeling will wear off more quickly. As alprazolam wears off, most people will stop feeling the calm, relaxed, lethargic sensations that the drug is associated with. If you take this medication to relieve symptoms of anxiety, like a racing heart, those symptoms will begin to return long before it’s half-life. If you don’t have these symptoms, you’ll begin to return to feeling “normal.” However, some people who take alprazolam for reasons other than anxiety may find they actually begin to experience feelings of depression and/ or anxiety, even if they’ve never had an issue with these conditions, as the chemicals in their brain adjust to the lack of the drug. This rebound anxiety or depression is usually temporary, but will often happen each time it’s taken. I have a Huntington’s patient who never had any anxiety or depression until his specialist put him on alprazolam for severe muscle spasm, and now it’s a real problem. Sometimes it’s hard to tell what’s worse, the disease or the “cure.”

Alprazolam Side Effects

Captain Obvious says that being aware of potential side effects is very important when considering taking any drug. He also says that should you experience any of these, stop taking it and contact your prescribing physician immediately, or seek emergency medical attention if appropriate. Possible side effects of alprazolam include sleepiness, dizziness, headache, confusion, muscle cramps, decreased appetite, weight loss or weight gain, diarrhea, nausea or vomiting, manic symptoms, difficulty walking, dry mouth, irregular heartbeat, low blood pressure, and blurry vision.

How it Shouldn’t Feel 

When taken properly at prescribed doses, the effects of alprazolam should be mild, but detectable, and the symptoms for which it is prescribed should be decreased. If the drug appears to be having a significant negative impact, seek emergency medical attention and then contact the prescribing physician later. It should go without saying, but don’t take it again. Symptoms to watch for include extreme drowsiness, muscle weakness, confusion, fainting, loss of balance, and/ or feeling lightheaded. You should also seek emergency medical attention if you experience signs of an allergic reaction. Signs may include swelling of the face, lips, throat, and tongue, and difficulty breathing.

Alprazolam Special Considerations

Some people should avoid alprazolam entirely because they may be more sensitive to its side effects, or it could potentially harm them in some other way. This includes pregnant women, older patients, children and teenagers, people with a history of alcohol or drug abuse, and people with certain medical conditions such as respiratory illnesses.

Alprazolam Tolerance, Abuse, Dependence

I cannot overstate the potential for misuse, abuse, dependence, and addiction associated with alprazolam. And it doesn’t “just happen to junkies” people. Some folks without any reason take it recreationally just because they like the way it makes them feel. Others have undiagnosed anxiety disorder, so they start buying it or taking it. Others are prescribed it for anxiety, insomnia, seizures, or severe muscle spasm, but begin to need higher or more frequent doses of it to achieve the same effect; this is known as tolerance. 

Though the routes to get there vary widely, without any intervention, all of these situations usually lead to the same place: dependence and addiction. This happens when the body begins to rely on alprazolam to function normally. Over time, we’ve collected scientific data and anecdotal reports to determine that certain people/ groups are at greater risk for abuse, tolerance, and dependence on alprazolam. These include non-hispanic whites, young adults 18 to 35 years old, people with a current psychiatric disorder, and people with a personal or family history of substance abuse. For these people, taking alprazolam is like playing with fire. If you’re one of them, don’t risk getting burned. 

Alprazolam: Synergistic Interactions

A synergistic interaction occurs when the combined effect of two drugs or substances is greater than the sum of the individual activity of each. As a CNS depressant, alprazolam has synergistic interactions with other CNS depressants, and there are lots of those out there. The biggest example is also the most commonly overlooked one: alcohol. Good ole EtOH. Other examples include: other benzos (duh), opioid analgesics ie OxyContin, Vicodin, morphine etc, barbiturates ie Seconal and Nembutal, hypnotic drugs ie Ambien, heroin, methadone, neuroactive steroids ie estrogen and testosterone, and intravenous and inhalational anesthetics. If you take alprazolam and any of these substances, the alprazolam intensifies the effects of that substance and vice versa, so when taken together, they literally become exponentially more potent than if you used either of them on their own. 

This is because all of these substances also increase neurotransmitter GABA activity in the CNS, slowing the activity of the nervous system, causing the sedative effect. When alprazolam is mixed with any of these substances, because the effects are synergistic and exponentially more potent than just the two combined, you’re at risk of excessive sedation, extreme confusion, prolonged memory loss, seizure, loss of consciousness, respiratory depression, cardiac problems, dangerous accidents from increased clumsiness and sedation, and unintentional death. Please note that these synergistic interactions occur whenever the substances are mixed- even if it is at prescribed doses. 

However, there are some drugs that cannot be combined with alprazolam that you wouldn’t even think about. This includes some oral contraceptives, antifungals, antidepressants, antibiotics, and heartburn drugs. These drugs can affect the pathway that’s responsible for eliminating alprazolam from the body, so that the alprazolam isn’t removed as quickly as it should be. Over time, this can lead to a toxic buildup of the drug, and eventually an overdose. Always speak with your doctor to review meds and discuss potential interactions. In addition, your pharmacist is an excellent resource for any questions about med interactions. Some specific meds that may interact with alprazolam include cimetidine (Tagamet), fluvoxamine (Luvox), fluoxetine (Prozac), paroxetine (Paxil), sertraline (Zoloft), carbamazepine (Tegretol), diltiazem (Cardizem), isoniazid (Laniazid, Rimifon, Hyzyd, Stanozide, Nydrazid), and cyclosporine (Sandimmune). 

Also, not a medication, but important to remember is… grapefruit juice! Grapefruit juice can block the action of CYP3A4, which is a critical enzyme in the body. Mainly found in the liver and the intestine, it oxidizes small foreign organic molecules, like toxins and drugs, so that they can be removed from the body. When CYP3A4 is blocked, instead of being metabolized, more of the drug enters the blood, and stays in the body longer. The result is too much drug in the body. I should add that there is some controversy surrounding this. The FDA says grapefruit juice does slow alprazolam metabolism, but some studies have published results that indicate it is “unlikely to affect the pharmacokinetics or pharmacodynamics of alprazolam, due to its high bioavailability.” Translating this geek speak to plain english, they’re saying their studies found that grapefruit juice had no effect on how alprazolam was metabolized and cleared from the body, because so much alprazolam is absorbed and available for biological activity in the cells and tissues where it’s metabolized. I say err on the side of caution and avoid alprazolam, or grapefruit juice if you just can’t. I should add that CYP3A4 is involved in the metabolism of other meds as well, so if you drink grapefruit juice, keep that in mind- tell your docs and pharmacist.  

Stopping Alprazolam

I touched on the dependence issue associated with alprazolam, but I’m going to discuss that and withdrawal in more detail in next week’s blog. Regardless, even if you have only taken alprazolam exactly as prescribed, and you’re sure you’re not dependent on it- if you want to stop using it, you must do so with the guidance of your prescribing physician or another healthcare provider, because stopping alprazolam abruptly can lead to serious, medically dangerous withdrawal symptoms and rebound anxiety. Don’t stop alprazolam on your own! Depending on how long you’ve been on it and how much you take, your physician will need to taper your dose, meaning step you down on the dosage until you stop it altogether. This is the only way to go. Withdrawal is no picnic, but stepping down makes it so much easier, and it eliminates the dangers associated with cold turkey. Rebound anxiety from abrupt alprazolam withdrawal is no joke- people who experience rebound anxiety report that their anxiety symptoms are at least at the same level, but usually worse, than they were before starting alprazolam- so not only are they not better, they’re worse. You want to avoid this if at all possible, so don’t stop alprazolam abruptly. 

Speaking of stopping abruptly, that’s it for this week. Next week I’ll talk in depth about alprazolam addiction and withdrawal. And we may have a guest blogger situation. We’ll see. 

I promised you a link to my YouTube video that covers a lot of this information, so here that is. Lots of other vids to check out there too. 

Benzodiazepines, Barbiturates, and Alcohol

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Thank you and be well people!

MGA