How to wean someone off Xanax (alprazolam) with a non-benzodiazepine?

Weaning Patients Off Alprazolam Using Non-Benzodiazepine Alternatives

For patients requiring discontinuation of alprazolam (Xanax), the most effective approach is to substitute with a non-benzodiazepine medication such as buspirone, starting at 5 mg twice daily and gradually increasing to 20 mg three times daily while simultaneously tapering the alprazolam dose by 10-20% every 1-3 days. 1

Assessment Phase

Before initiating the weaning process, determine:

• Duration of alprazolam use
• Total daily dose
• Presence of comorbid conditions (anxiety, depression, insomnia)
• History of previous withdrawal attempts

Non-Benzodiazepine Substitution Options

First-Line Options:

1. Buspirone

   • Start 2 weeks before completing alprazolam taper
   • Initial dose: 5 mg twice daily
   • Titrate up to maximum 20 mg three times daily as needed
   • Takes 2-4 weeks to become fully effective
   • Best for mild to moderate anxiety symptoms 1

2. SSRIs for comorbid anxiety/depression

   • Fluoxetine, paroxetine, sertraline, or citalopram
   • Particularly useful when anxiety co-occurs with depression
   • Begin SSRI at least 2 weeks before completing alprazolam taper 1

3. Carbamazepine as adjunctive therapy

   • Dosage: 200-800 mg/day
   • Has shown promise in helping patients remain benzodiazepine-free after taper
   • Most beneficial for patients on higher doses (≥20 mg/day diazepam equivalent) 2

For Sleep Disturbances During Withdrawal:

• Mirtazapine: 7.5 mg at bedtime, can increase to 30 mg as needed
• Trazodone: Low doses for sleep and anxiety during withdrawal 1

Alprazolam Tapering Protocol

1. For patients on alprazolam >14 days:

   • Consider substituting with chlordiazepoxide using a 50:1 ratio (50 mg chlordiazepoxide = 1 mg alprazolam)
   • Begin non-benzodiazepine medication (buspirone or SSRI) concurrently
   • Taper chlordiazepoxide by 10% every 1-3 days 1, 3

2. For patients on alprazolam 7-14 days:

   • Use a faster taper schedule of 10-20% reduction every 1-2 days
   • Monitor closely for withdrawal symptoms 1

3. For patients on alprazolam <7 days:

   • May discontinue quickly with minimal risk of significant withdrawal 1

Monitoring During Tapering

• Assess for withdrawal symptoms at each dose reduction
• Common withdrawal symptoms include:
  • Anxiety, tremor, insomnia, nausea, sweating, tachycardia, headache
  • Seizures (rare but serious)
• If withdrawal symptoms emerge:
  • Temporarily hold at current dose
  • Consider slowing the taper rate to 5-10% reductions
  • Increase adjunctive non-benzodiazepine medication 4

Common Pitfalls to Avoid

1. Abrupt discontinuation - can lead to severe withdrawal including seizures
2. Substituting with another short-acting benzodiazepine - perpetuates dependence
3. Tapering too quickly - aim for withdrawal in <6 months to prevent the process from becoming the focus of the patient's existence 5
4. Neglecting reassessment after interventions - crucial to evaluate effectiveness 6
5. Ignoring psychological support - cognitive-behavioral therapy can be particularly effective in preventing relapse 5

Special Considerations

• Elderly patients may require a more gradual taper (5% reduction) and lower substitution ratios (25:1 for chlordiazepoxide) 3
• Long-term users (>8 months) may benefit from inpatient monitoring during initial substitution 7
• Patients with comorbid substance use disorders require closer monitoring and specialized addiction services

By following this structured approach with non-benzodiazepine substitution and gradual tapering, most patients can successfully discontinue alprazolam with minimal withdrawal symptoms and improved long-term outcomes.