What Is Xanax/Alprazolam?

Xanax (Alprazolam) is a commonly prescribed drug to help alleviate symptoms of anxiety and panic. It's manufactured by Pfizer Inc.

Xanax belongs to a class of drugs called benzodiazepines, which are central nervous system depressants that work by enhancing the effect of the neurotransmitter "gamma-aminobutyric acid" (GABA).

GABA is essentially the brain's tranquilizing neurotransmitter. Xanax binds to certain sites on the GABAA gamma-amino-butyric acid receptor, slowing down activity in the brain, producing a calming effect.

Xanax is a benzodiazepine with a very fast onset of action. Most people feel its effects kick-in within 20 minutes of ingestion - peak effects of the drug are normally achieved within an hour.

Initially approved by the US FDA in 1981 for the treatment of anxiety, Xanax became the first FDA-approved drug for panic disorder therapy in 1990.

Since its approval the drug has become one of the most prescribed, yet also one of the most misused benzodiazepines available - because of its high potential for abuse and dependence.

Medical uses of Xanax

Xanax is one of America's most popular anti-anxiety medications.

Xanax is primarily used to treat panic and anxiety disorders, such as social anxiety disorder (SAD) and generalized anxiety disorder (GAD). Xanax is also used to alleviate nausea after chemotherapy.

According to the FDA, "Demonstrations of the effectiveness of XANAX by systematic clinical study are limited to 4 months duration for anxiety disorder and 4 to 10 weeks duration for panic disorder."

Managing anxiety

The FDA has approved Xanax for short-term treatment of anxiety and for the management of certain anxiety disorders. Several high quality studies have demonstrated its efficacy in reducing anxiety.

A large-scale double blind study found that Xanax was effective in improving symptoms of anxiety in 151 anxious outpatients; the results of the study, published in the American Journal of Psychiatry, revealed that "alprazolam and diazepam produced similar clinical improvement, which was significantly larger than improvement produced by placebo and was clearly evident after only 1 week of treatment."

Panic disorder

Xanax is considered to be an effective medication for panic attacks. However, due to its potential for abuse it is not a first line treatment option. One study, published in the Journal of Clinical Psychopharmacology, concluded that "evidence fails to demonstrate alprazolam as superior to other benzodiazepines for the treatment of panic disorder."

A report in the Primary Care Companion Journal of Clinical Psychiatry noted that for treatment of panic disorder "four drug classes have similar efficacy (tricyclic antidepressants, selective serotonin reuptake inhibitors [SSRIs], benzodiazepines, and monoamine oxidase inhibitors)."

The World Federation of Societies of Biological Psychiatry (WFSBP) only recommends the use of Xanax for the treatment of panic disorder when the patient shows no history of tolerance or dependence.

Precautions

Pregnant women should not take Xanax as it can cross the placenta and affect the fetus, increasing the risk of congenital abnormalities. In addition, taking Xanax during the last trimester of pregnancy can result in fetal drug dependence.

Doctors should be especially careful with patients who have a history of drug dependence when considering Xanax therapy.

Side effects of Xanax may include:

- Dry mouth
- Slurred speech
- Drowsiness
- Disinhibition
- Skin rash
- Constipation
- Hallucinations (very rare)

Dependence and withdrawal

Xanax - like all other benzodiazepines - binds to certain GABA receptors (called benzodiazepine receptors), prolonged use of the drug can eventually cause adaptive changes in these receptors, making them less sensitive to the drug's effect. When this occurs a higher dosage of Xanax is required for the same initial effect to be felt, increasing the risk of physical dependence and tolerance.

According to a paper published in the journal Addiction:

"Physiological dependence on benzodiazepines can occur following prolonged treatment with therapeutic doses, but it is not clear what proportion of patients are likely to experience a withdrawal syndrome."

"Withdrawal from normal dosage benzodiazepine treatment can result in a number of symptomatic patterns. The most common is a short-lived "rebound" anxiety and insomnia, coming on within 1-4 days of discontinuation, depending on the half-life of the particular drug. The second pattern is the full-blown withdrawal syndrome, usually lasting 10-14 days; finally, a third pattern may represent the return of anxiety symptoms which then persist until some form of treatment is instituted."

Signs and symptoms of Xanax dependence include:

- Being unable to cope without the medication
- Severe withdrawal symptoms in between doses
- Tolerance to the effects of the drug
- Unsuccessful attempts to stop taking the drug

Withdrawal symptoms include:

- Increased anxiety
- Depression
- Trouble sleeping
- Depersonalization
- Tremors
- Headache
- Muscle pains
- Hypersensitivity to touch
- Shakiness
- Twitching

It is important to taper off Xanax gradually, otherwise there is a risk of benzodiazepine withdrawal syndrome.

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Antipsychotics not meant for kids

Would you allow your child to be prescribed a powerful antipsychotic medication? If your first inclination is to say yes, would you still agree if you knew the drug was not tested or approved for children?

Researchers from British Columbia published a paper last week in the Canadian Journal of Psychiatry on what they described as an "alarming and exponential rise" of prescribing antipsychotic drugs to children. From 1996 to 2011, overall use of these medications among youth increased by 280 per cent, while the use of second-generation antipsychotic medications increased by 1,710 per cent.

The three most common reasons for treatment were depression, a group of disorders that includes attention deficit, hyperactivity disorder, and neurotic disorders that include anxiety.

How can this be? Antipsychotic medications were designed and approved originally to treat schizophrenia and bipolar disorder in adults. Over time, a few of the drugs have been approved for major depressive disorders in adults, and autism spectrum disorders. Only one drug, aripiprazole or Abilify, has been approved for use by children - to treat schizophrenia in youth aged 15 to 17.

It's because the vast majority of these powerful drugs has not been tested and approved for children, the side-effects are not fully known, although we do know that youth have more adverse events than adults.

An article in the International Review of Psychiatry found that antipsychotic use in children was associated with increased risk of significant weight gain, high blood sugar and cholesterol levels, cardiovascular disease and premature cardiovascular mortality. A review in the Journal of Clinical Psychiatry associated these drugs with an inability to initiate movement, an inability to remain motionless, sedation, prolactin elevation that disrupts menstrual periods, and various metabolic effects including increased risk of Type 2 diabetes.

A review in Drug Safety confirmed the results of the first two studies but added as side effects osteoporosis, spontaneous flow of milk from the breast, and sexual dysfunction.

In the B.C. study, psychiatrists were the major prescribers of antipsychotic medications to children for off-label or unapproved use, followed closely by family physicians. Pediatri-cians were much less willing to prescribe these powerful drugs to children.

Although the growth rate of prescriptions was largest for youth aged 13 to 17 years, children aged six to 12 still saw an increase of 280 per cent over the study period. The authors concluded that children are put on a wide range of potent drugs for a wide range of disorders without approval from Health Canada, and warned that we should be aware that these drugs have "potentially dangerous side effects."

In fact, Health Canada is now reviewing 17 suspected deaths among those serious side effects.So are drugs the only option? As mentioned, the main reason for prescribing them are disorders such as depression and attention deficit hyperactivity disorder. A Cochrane Collaboration review showed that behavioural and cognitive behavioural therapy significantly reduced child conduct problems, improved youth mental health, improved positive parenting skills, and reduced negative or harsh parenting practices. The programs also were found to be cost effective.

Another Cochrane review found that training for parents of children with hyperactivity disorder significantly reduced child withdrawal, anxiety, parent stress and child stress.

In Saskatchewan, the Ministry of Health reports that 2,520 children were prescribed antipsychotic medications in 2012, up from 464 in 1996. The number of children prescribed second generation antipsychotic medications grew to 2,410 in 2012, from just 146 in 1996.

The number of prescriptions filled for these drugs increased to 18,409 from 989 during the same time period. No information is available from the administrative claims database about the conditions for which the drugs were prescribed.

The claims numbers are underestimates because the data do not include prescriptions dispensed in hospitals and excludes those with federal benefits, such as First Nations children living on reserve. This last point is important because a number of publications have found that children from lower income families and minority groups are more likely to be prescribed antipsychotic medications.

An unpublished study from the Saskatoon Health Region found that children with mental health problems who live in affluent neighbourhoods were almost exclusively dispensed antidepressant medications.

In comparison, children with mental health problems who live in low-income neighbourhoods were almost exclusively dispensed antipsychotic medications.

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