XANAX: Controlling, Reducing, Stopping

Xanax is the stand in for all benzodiazepines (BZDs), but it may be more grabbing/intense/problematic than others (Klonopin, Ativan, Valium, etc.)

They all work by attaching to the brain’s GABA-A receptors and increasing the amount of GABA (gamma amino butyric acid) in the brain, as well as increasing dopamine. GABA is the main substance in the brain for creating calm, quieting things down, relaxing muscles, enabling sleep, reducing fear and tension. These drugs work so well and so quickly (like alcohol, perhaps) that we may fail to notice or fear various downsides. Dopamine release is associated with pleasure. It is recommended not to use BZDs for more than two to four weeks, but many people become physically and mentally dependent very quickly.

Xanax is such a quick and beautiful apparent solution to life problems. But then many people need it constantly by their side and they fail to learn problem solving skills such as managing anxiety, tension, and sleep. They also don’t notice the insidious onset of

• Memory failures
• Unsteadiness (tendency to fall or lose driving skills)
• Particularly the tendency to increase amount and frequency (tolerance)

There are some people who benefit greatly from BZDs, permitting them to travel, interact socially, sleep, and lead a better quality of life- all without escalating doses. Some benefit by occasional or situational use, as when flying. Also, certain people with psychiatric illnesses may be better off continuing their BZD medication rather than trying to change. But a large percentage of people taking Xanax and related drugs become aware that they have lost control or that they are changed or harmed; or that others around them have noticed a problem (we are not the best judges of ourselves). Sometimes a person will become so preoccupied with having this substance that they violate their own principles to get it.

Those who wish to control, reduce, or stop medication are often successful. For others, it is a longer and difficult problem, and must be carefully individualized. Research results do not give fact based answers. There are numerous online resources (from which we psychiatrists also learn) including personal blogs, benzobuddies.org and other websites. Physicians such as Malcolm Lader and Heather Ashton have developed protocols; medical journals have published reviews (http://www.nejm.org/doi/full/10.1056/NEJMra1611832).

However there is no one approved procedure or medication which has outstanding results for withdrawal from benzodiazepines. It is generally agreed that you should not stop long term BZD use suddenly, and that slow taper of the one drug you are using over weeks and months is best, and that you should expect some symptoms and signs of withdrawal no matter how slowly you go. The famous Ashton protocol involves substituting longer lasting Valium for another drug and very slowly reducing as decided and tolerated by the patient. Paradoxes arise when severe symptoms occur despite very slow methods, or when going back to a higher dose does not work as well as you expect. Psychotherapy or cognitive behavior therapy (CBT) in its various forms including ACT, mindfulness, motivational enhancement, relaxation training, hypnosis, EMDR, etc. are very useful for many. Various adjunctive medications are useful, but no particular one is generally endorsed.

Individualization, in my experience, is best. Become aware of (and designate) one or more problems or targets for improvement as a baseline. Set a goal such as gaining control, reducing dosage, or stopping altogether. Decide whether another person can be involved for monitoring or support. Educate as to the range of discontinuation or withdrawal symptoms. Be aware of how strong is the fear of withdrawal. Develop habits such as looking at that bar or blue or orange pill and decide: How necessary is it to swallow it right now? What will happen if I take only half or defer to later? Can I solve this problem or relax in some other way?

Be careful and be aware of risk if someone is offering you a pill, or if you are thinking of asking your doctor “for something to help me through this.” Benefits can be immediate; risks are often somewhere down the line.

For more information on Xanax use (and other substances) please see the following posts.

Xanax: The Bad and The Beautiful

Dreaming About Xanax