For the layperson ---
Dr. Steve's Guidelines for Discontinuing Xanax (alprazolam)
Stephen Cox MD, Asst Clinical Professor of Psychiatry, UKMC

This article is written in lay terminology and with analogies to make complicated medical science understandable.

You've no doubt heard negative things about Xanax. We have all read stories of some negative aspect of the use of Xanax. These stories are surprising. I, personally, have seldom experienced difficulty in tapering Xanax in patients with panic disorder. This may be a surprise to those who are not experienced in prescribing psychoactive medicants for anxiety disorders.
     The fact is that Xanax works very well indeed in treating panic disorder. Tolerance develops to the initial dose. Dose increases are necessary in the first weeks of therapy. Why the tolerance? This is a very good question and should be answered before you start taking Xanax. You can't possibly know how to go off Xanax unless you understand what happens to your body as you are going on it.
     There is a neurotransmitter in your brain called GABA. It stands for gamma amino butyric acid. GABA is your natural God-given tranquilizer. It is present at 80% of the nerve connections in your brain. When you are too nervous your brain cells release GABA which causes negatively charged chlorine atoms to stream into your nerve cells. That's good because it makes it harder for other stimulating neurotransmitters to trigger the firing of that nerve. If your brain were a car, anxiety might be like the car speeding down a hill toward a sharp curve. As it comes to a curve it must slow down. The car brakes are applied so that the car can negotiate the curve and not burst through the guard rail. The GABA molecules of your brain are like the brakes in your car. If you don't have enough GABA, your brain is going to be like the car speeding toward a curve with worn out brakes!  Xanax acts by making what little GABA you do have work more strongly. This is sort of like applying stronger pressure on worn out brakes so that your car will negotiate a curve safely.
     When you take Xanax for a couple of weeks it usually works great for panic disorder but then it does not seem to work as well as time goes on.  This is to be expected.  Why?  This could be for two reasons. One possibility is that your brain cuts back on the release of GABA.  It is sort of like your brain says, "Gosh, things are a lot calmer in here.  I don't think I need to make as much GABA as I used to."  Well, you likely didn't have enough GABA to begin with.  And now your brain makes even less than it did before you started taking Xanax.  Naturally, the Xanax wouldn't work as well once GABA is reduced.
     A second reason for tolerance may be down in your liver. Your liver gets rid of Xanax ultimately by making enzymes which destroy Xanax. After you are on Xanax for awhile it is as if your liver says, "Hey we sure are getting a lot of Xanax these days. Let's make more Xanax-destoying enzymes." And so it does. Let's say your dose that you started out on was giving you a blood level of, say, 100 units. But after your liver makes more of this destroying enzyme you have a level of, say, 55 units of Xanax. No wonder you feel like the Xanax isn't working as well. It isn't! Even though you're taking the same dose, your blood level dropped. Remember, it does not really make any difference how many milligrams you swallow. What really matters is how much is running around in your bloodstream.
     So, tolerance normally develops to Xanax and it may be due to either or both of the above reasons. If you didn't understand those two things, go back and read it again because what follows won't make much sense unless you understand those two ideas.
     Now, let's say we have a 26 year old woman, Monica, who has been on 6 mg of Xanax for panic disorder for 3 years.  She's doing great.  She can drive anywhere she wants and no panic attacks have occurred for 2 years.  She even flew from Cincinnati to Cancun Mexico without a problem.  She asked her psychiatrist if it would OK if she went off the Xanax now to see if she still needed it.  The psychiatrist said yes, 'but you must not do it faster than I order'.  The patient was relieved to hear her psychiatrist was urging a gradual decline.  You see, the patient's roommate,  Suzy, had taken herself off Xanax from 6 mg per day to 3mg a day suddenly.  And after only a week she stopped it completely. She thought she would die, she felt so bad; and, she blamed it on 'the addictive nature of Xanax'.  Fortunately, Monica was told by her psychiatrist to cut her daily dose from 6.0 mg per day to 5.75 mg per day and to stay on that dose for two weeks.  Then she was told to cut to 5.5 mg a day for another 2 weeks, and so on by 0.25 mg off her daily dose every 2 weeks.  Monica's psychaitrist explained that there was no way to tell if she still had panic disorder or not and by going down that slowly, if Monica should experience any anxiety symptoms, it would be due to the reappearance of panic disorder symptoms that were inadequately treated by her lower dose of medicine.  This would mean that Monica still was afflicted with panic disorder and needed continued treatment, at least for the time being.  If, on the other hand, she gradually tapered the Xanax down to zero and had no panic attacks, she would officially be either well or in remission.
     So, if you want to go off Xanax, ask your doctor how to do it.  If there is a rush, it can be done faster than the above method. But usually there is no rush. And it is usually best to go slowly.
     Now, let's review.  Why didn't our patient Monica have any withdrawal when she tapered off Xanax, whereas her roommate, Suzy had severe withdrawal?  The answer is that both women had a very, very low level of GABA production and a very high level of liver Xanax-destroying enzymes. When Suzy cut herself off over a week's time, she thought she was tapering off but it was actually much too fast. It takes a long time for the brain to figure out that it needs to make more GABA and to do so. It also takes a long time for the liver to quit making so much Xanax-destroying enzymes.  Monica's psychiatrist wisely told her to make these tiny cuts in the Xanax dose that were barely perceptible to her as far as the way she felt. And equally wisely she had her go 2 weeks on that dose to let her brain GABA increase and liver enzymes decrease before cutting the dose further.
     Dr. David Sheehan of the University of South Florida suggested this method to me at a meeting in Tampa years ago. I cannot recall any of my patients experiencing any bothersome withdrawal discomfort in going off Xanax by the above method.  Any difficulties I witnessed were relapses of a clinically silent panic disorder that was previously adequately treated by the Xanax at the pre-taper dose.
     You should never, never, never decide to go off Xanax on your own without your physician's counsel and guidance.  Xanax is a remarkably safe medicine except for two things: overdosing on it can be extremely hazardous to driving safety.  Sudden or rapid stopping Xanax at daily doses of 4 mg or more can cause moderate to severe withdrawal and, in very rare instances, a convulsion could occur.
     You should carefully weigh the decision to go off Xanax with medical counsel.  Is this a good time to go off it?  Is this a stressful time?  If so, you should wait until a calmer time.  Are you being pressured into going off Xanax prematurely by well-meaning, but uninformed family or friends who value more your 'being off medicine' than they do the relief of your suffering with panic attacks and avoidance behavior.  Panic disorder is not a trivial thing.  It, untreated, is associated with the highest suicide attempt rate of all medical disorders.  It, untreated, also has a higher mortality risk from cardiovascular cause than non-panic disorder persons.  The general principles we have discussed with Xanax also holds true for other high potency benzodiazepines like lorazepam (Ativan) and clonazepam (Klonopin). The dosages however are all different and the mg reductions do not apply to these other medicants.
     Despite popular beleif, it is my opinion that Xanax is under-utilized by clinicians in their patients.  Such medicines are remarkably safe.  Panic disorder patients seem rarely to abuse such medicine.  Compliance problems (patients not following doctors orders) with panic disorder patients on Xanax are rare;  and, when seen are most often a matter of the patient not taking as much medicine as is prescribed rather than taking too much.
Stephen Cox, MD
President - NAF
Medical Director

Linda Vernon Blair

C. Todd Strecker

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Georgann Chenault
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