Is it okay to take Xanax (alprazolam) in the short term?

Short-Term Xanax (Alprazolam) Use

Short-term use of Xanax (alprazolam) for up to 2-4 weeks is acceptable for acute anxiety or panic disorder, but carries significant risks of dependence even at therapeutic doses (0.75-4 mg/day), and should be prescribed at the lowest effective dose with clear discontinuation plans. 1

Evidence for Short-Term Efficacy

• Alprazolam demonstrates clear superiority over placebo for anxiety disorders and panic disorder in controlled trials lasting 4-10 weeks, with response rates of 37-83% achieving zero panic attacks 1
• The average effective dose in clinical trials was 5-6 mg/day for panic disorder, though lower doses (0.75-4 mg/day) are used for general anxiety 1
• Onset of action is rapid, which explains its widespread use despite guideline recommendations favoring SSRIs as first-line treatment 2

Critical Dependence and Withdrawal Risks

Even short-term use carries substantial risk of physical dependence:

• The FDA label explicitly warns that dependence can develop after "relatively short-term use" at recommended doses (0.75-4 mg/day) 1
• Risk of dependence increases significantly with doses above 4 mg/day and treatment duration exceeding 12 weeks 1
• Withdrawal symptoms can be life-threatening, including seizures, and occur more frequently with alprazolam compared to placebo in discontinuation studies 1
• Withdrawal symptoms include heightened sensory perception, impaired concentration, paresthesias, muscle cramps, diarrhea, blurred vision, and rebound anxiety 1

Recommended Duration and Dosing Strategy

For anxiety disorders:

• Limit prescriptions to very short courses (1-7 days) or short courses (2-4 weeks maximum) 3
• Consider single-dose, occasional, or intermittent use rather than continuous daily dosing 3
• Diazepam is generally preferred over alprazolam for anxiety due to lower abuse potential, though alprazolam is widely used in the US 3

For panic disorder:

• Treatment may require longer duration, but 71-93% of patients successfully tapered off alprazolam in 6-8 week trials 1
• Higher doses (>4 mg/day) make discontinuation more difficult 1

Specific Populations Requiring Caution

Elderly patients (>60 years):

• Reduce doses by 20% or more due to decreased clearance 4
• Higher risk of confusion, ataxia, falls, and prolonged sedation 4, 3
• The American Geriatrics Society recommends cautious use with thorough evaluation before prescribing 4

Patients with respiratory disease:

• Alprazolam causes respiratory depression, with increased risk when combined with opioids 5
• Consider prescribing naloxone for patients receiving ≥50 morphine milligram equivalents of opioids concurrently 5

Postoperative or delirious patients:

• Do not use benzodiazepines as first-line treatment for postoperative delirium except for alcohol or benzodiazepine withdrawal 5
• Benzodiazepines increase delirium duration and may precipitate delirium in ICU patients 5

Drug Interactions

• Reduce alprazolam dose by 50% when co-administered with nefazodone 5
• Exercise caution with fluvoxamine co-administration 5
• Synergistic respiratory depression occurs with opioids 5

Discontinuation Strategy

To minimize withdrawal symptoms:

• Taper gradually over 10-14 days minimum 5
• Patients on higher doses or longer duration require slower tapers 1
• Monitor for withdrawal symptoms including seizures, which can occur even with therapeutic doses 1
• Consider switching to longer-acting benzodiazepines (e.g., diazepam) to facilitate tapering 3

Alternatives to Consider

• SSRIs are recommended as first-line treatment for panic disorder due to lower dependence risk 2
• Benzodiazepines should generally be used in conjunction with psychological treatments or antidepressants for anxiety 3
• For insomnia, limit use to transient or short-term insomnia with courses not exceeding 2 weeks 3

Common Pitfalls to Avoid

• Do not prescribe alprazolam long-term without clear justification, as few cases of legitimate medical use lead to addiction, but dependence is common 6
• Avoid the misconception that physical dependence equals addiction—pharmacologic dependence is a predictable adaptation that can be managed through tapering 6
• Do not abruptly discontinue after even short-term use due to seizure risk 1
• Avoid combining with alcohol, which enhances sedative effects and increases adverse events 7