Are you familiar with interdose withdrawal symptoms? Can the Ashton Manual help to avoid Xanax interdose withdrawal?
In short: yes, the Ashton Manual’s approach can help. Xanax (alprazolam) is short-acting, with a half-life of 6 to 12 hours in the Manual’s Table 1, so its level in the blood rises and falls through the day and withdrawal symptoms can appear between doses. That is interdose withdrawal, and it is one of the main reasons a Xanax taper is harder than a taper off a longer-acting benzodiazepine. The Manual’s answer is a gradual switch to diazepam (Valium), whose half-life is 20 to 100 hours, followed by a slow taper. A liquid formulation allows the small steps a slow taper needs.
Xanax, also known as alprazolam, is one of the most commonly prescribed benzodiazepines.
Benzodiazepines are medications prescribed for anxiety and panic disorder. Ativan, Klonopin, and Valium are some well-known examples of benzos, in addition to Xanax.
When a person has been taking Xanax for a long time, and they stop suddenly, they will be at risk for severe withdrawal symptoms. Xanax withdrawal symptoms may be life-threatening. A seizure or any other medical emergency during withdrawal means calling 911.
After the acute phase of Xanax detox, a person may experience protracted withdrawal, which is a form of post-acute withdrawal syndrome. Protracted withdrawal is a period that can last for months or years, in which the person experiences insomnia, anxiety, gastrointestinal symptoms, and many other possible symptoms.
Benzodiazepine withdrawal is a serious issue, so to prevent it, going forward, doctors are now recommending only short-term use of drugs such as Xanax. For people who have already been taking Xanax long-term, a gradual taper is the safe way off, and quitting Xanax cold turkey is not.
Unfortunately, when tapering off of Xanax, interdose withdrawal can be an issue. During the time between each Xanax dose, the person may experience benzo withdrawal symptoms.
Xanax works fast, and wears off fast.
Some benzodiazepines take a long time to start working. Others start working quickly.
Likewise, some benzos wear off fast, only lasting for a few hours at most. Other benzos last much longer. Diazepam (Valium), for example, has a half-life of 20 to 100 hours in the Ashton Manual’s Table 1, against 6 to 12 hours for Xanax.
A favorite benzo tranquilizer among psychiatrists is Klonopin, also known as clonazepam. Klonopin starts working fast, but it lasts for a long time. Because of this, they feel it is less addicting.
Xanax, on the other hand, wears off fast, so the patient may feel rebound anxiety between doses. The doctor may interpret the patient’s desire to take another Xanax as soon as possible as the beginning of Xanax addiction.
The knowledgeable psychiatrist will switch the patient to a longer-acting benzo. A less knowledgeable doctor may commit the patient to the psych ward, or ship them off to rehab for substance abuse treatment.
Is Xanax addictive? Does Xanax dependence mean Xanax addiction?
It is true that Xanax is used by people who misuse other drugs. Some people buy Xanax bars from a dealer to come down from a stimulant high.
Likewise, some heavy drinkers take Xanax to make their alcohol buzz more intense. Mixing Xanax with alcohol or other sedating drugs is dangerous, because the combination can slow or stop a person’s breathing.
Yet, for most people who take Xanax as prescribed, the problem is physical dependence, not addiction. Physical dependence is common with long-term use, and the Ashton Manual itself separates therapeutic dose dependence from recreational misuse. Dependence is a medical condition that calls for a gradual taper, not addiction treatment.
When a patient complains that their Xanax is not working, and they are getting rebound anxiety, the problem is not addiction. The problem is physical dependence on a short-acting drug, not addiction, and a doctor who mistakes one for the other can do real harm.
How does interdose withdrawal make a Xanax taper difficult?
Imagine a person who takes Xanax 1 mg three times daily for an anxiety disorder. To start off the taper, the doctor may instruct them to reduce one of the three daily doses by a quarter milligram. That is a cut of less than a tenth of the daily total. Before the taper, the patient had adequate coverage, without the alprazolam levels dropping low enough to trigger withdrawal symptoms.
As the total dosage is reduced, the interdose levels, or the alprazolam blood levels between Xanax doses, drop low enough to cause interdose withdrawal. For example, if the patient takes Xanax at 8 am, 4 pm, and midnight, they may feel withdrawal symptoms around noon, 8 pm, and 4 am.
The medical professional may recommend breaking up the total daily intake into six divided doses, instead of three. Or, they may decide to transition the patient to a longer-acting benzo.
Transitioning to Diazepam, or Valium, is the recommended method in the Ashton Manual. The Ashton Manual was written by Professor C. Heather Ashton to document a safe and effective method for tapering off of many different types of benzodiazepines.
There are two reasons for switching to Valium. One reason is that Valium is much longer lasting compared to other benzos, so interdose withdrawal is much less likely. The other reason is that Valium is far less potent, which means that it can be broken down into smaller dose units for gradual tapering.
Why does Valium’s lower potency help with a Xanax taper?
Xanax is a very potent benzo. Xanax 0.5 mg is the same strength as Valium 10 mg. So, a person who takes Xanax 1 mg three times daily is taking the equivalent of Valium 60 mg daily.
Valium is available in 2 mg, 5 mg, and 10 mg tablets. Hence, each Xanax 1 mg tablet can be represented as 10 Valium 2 mg tablets. Instead of the messy and inaccurate method of cutting the Xanax tablet in halves and quarters, the patient can reduce slowly, using Valium 2 mg tablets.
If this seems confusing, think of how you would share a dollar with ten people. If you have four quarters, you can share with four people. But, with ten dimes, you have a much easier time, sharing with all ten individuals.
While tablets, unlike money, can be broken in half, and even into quarters, it is much better to have smaller dose units to facilitate the tapering process. Converting from Xanax to Valium, and then using the 2 mg tablets is sort of like converting currency and then switching from large bills to small coins.
Diazepam is also manufactured as a 1 mg per milliliter oral solution, which allows the small final steps of a taper without cutting tablets. For patients who cannot take diazepam at all, the preferred alternative is a crossover to clonazepam (Klonopin), which also lasts longer than Xanax. And, for patients who are concerned about the complexities of converting their Xanax to Valium, there are alternative drug taper methods. For example, a doctor may recommend using a liquid alprazolam preparation for gradual tapering.
How does compounded Xanax liquid help to taper off of Xanax slowly?
If a patient takes Xanax 1 mg tablets, the doctor can prescribe a liquid instead of a Xanax pill. Alprazolam is manufactured as an oral solution of 1 mg per milliliter, and a compounding pharmacy can also prepare a liquid at the concentration the taper calls for.
Now, the patient will take their Xanax with an oral syringe. The syringe will hold 1 mL, and it will have lines to divide it into tenths of a milliliter.
Instead of breaking Xanax tablets into pieces, or converting over to Valium, the patient is able to reduce their dosage gradually over time by filling the syringe to lesser quantities.
For example, they may fill the syringe to 0.9 mL instead of 1 mL, and then stay at that dose for some time. Later steps are smaller still, and a compounding pharmacy can prepare a weaker liquid so that each small step stays easy to measure.
Another method is known as a microtaper, where the dosage is reduced a tiny amount on a daily basis, rather than reducing and holding for a week or two. There are multiple methods for tapering, so each individual can use what works best for them, under the supervision of their doctor.
How does a liquid taper help to prevent Xanax interdose withdrawal?
Unfortunately, interdose withdrawal is still a risk when using alprazolam to taper, even with a compound solution. However, by reducing at a more gradual rate, using carefully measured liquid dosing, the patient may be able to better adjust during the taper.
By taking the taper slowly, as allowed by a careful liquid taper, there may be less of a risk of interdose withdrawal. Even though Xanax wears off quickly, the patient may be able to taper with a Xanax compound solution without having much of a problem with interdose symptoms.
Ideally, the patient should talk through their situation in detail with a doctor who knows benzodiazepine tapering. After careful consideration, doctor and patient can decide together on the best course of action.
Everyone is different, and every tapering situation is unique. Additionally, during the tapering process, the patient may discover that the plan is not working for them. So, the doctor will help to reassess and reformulate a new taper plan, minimizing the effects of the withdrawal process, reducing the risk of severe symptoms.
Coming off of Xanax is possible with a good, individualized tapering program. While a slow, flexible plan adjusted along the way with your doctor does not remove every uncomfortable symptom, it makes a Xanax taper far more manageable and lowers the risk of severe withdrawal. To talk through your own situation, contact the office today.
This article is educational. It is not medical advice, and reading it does not create a doctor-patient relationship. Decisions about starting, continuing, or tapering any medication should be made with your own physician.
