How to cross-taper from Xanax (alprazolam) to a long-acting benzodiazepine?

Cross-Tapering from Xanax to Long-Acting Benzodiazepines

For safe cross-tapering from alprazolam (Xanax) to a long-acting benzodiazepine, implement a gradual substitution approach with a 10% reduction per month, using a non-linear tapering schedule to minimize withdrawal symptoms and reduce mortality risk. 1

Initial Assessment and Conversion

• Convert alprazolam to equivalent dose of a long-acting benzodiazepine (typically clonazepam or diazepam)
• Conversion ratios:
  • 1 mg alprazolam ≈ 20 mg diazepam
  • 1 mg alprazolam ≈ 2 mg clonazepam

Cross-Tapering Protocol

Step 1: Initial Substitution (Week 1-2)

• Replace 25% of alprazolam dose with equivalent long-acting benzodiazepine
• Example: For 4 mg/day alprazolam
  • Continue 3 mg/day alprazolam
  • Add 20 mg/day diazepam (equivalent to 1 mg alprazolam)

Step 2: Progressive Substitution (Weeks 3-8)

• Every 1-2 weeks, substitute another 25% of original alprazolam dose
• Monitor for withdrawal symptoms between each reduction
• By week 8, patient should be completely switched to long-acting benzodiazepine

Step 3: Tapering Long-Acting Benzodiazepine

• Use non-linear reduction approach (each new dose is 90% of previous dose)
• For long-term users (≥1 year), aim for 10% reduction per month 1
• Make smaller reductions at beginning to build patient confidence
• Pause tapering if withdrawal symptoms become intolerable

Monitoring and Management

• Schedule frequent follow-ups (at least monthly)
• Assess for withdrawal symptoms: heightened sensory perception, impaired concentration, paresthesias, muscle cramps, anxiety, insomnia 2
• Be alert for seizure risk, which is greatest 24-72 hours after dose reduction, particularly with alprazolam 2

Special Considerations

• Avoid abrupt discontinuation of alprazolam, which carries high risk of withdrawal seizures 2
• For patients experiencing interdose symptoms (early morning anxiety), consider more frequent divided doses 2
• If withdrawal symptoms become severe, temporarily return to previous dose before attempting slower taper
• Consider adjunctive treatments:
  • Clonidine for autonomic symptoms
  • SSRIs for rebound anxiety
  • Cognitive behavioral therapy to increase tapering success 1

Warning Signs Requiring Immediate Attention

• Seizures
• Severe autonomic instability (significant BP changes, tachycardia)
• Confusion or delirium
• Psychosis

Practical Implementation Tips

• Educate patient about withdrawal symptoms and expected timeline
• Provide written tapering schedule
• Consider dispensing only enough medication until next follow-up
• Emphasize that successful tapering may take months to years for long-term users
• Implement non-pharmacological anxiety management strategies concurrently

This approach prioritizes patient safety while systematically transitioning from a short-acting to long-acting benzodiazepine, minimizing withdrawal risks and improving long-term outcomes.