What are the dangers of mixing Xanax (alprazolam), alcohol, and marijuana?

Dangers of Mixing Xanax, Alcohol, and Marijuana

Combining Xanax (alprazolam) with alcohol and/or marijuana creates life-threatening risks including profound sedation, respiratory depression, coma, and death—this combination should be strictly avoided. 1, 2, 3

Critical Safety Warnings

Xanax and Alcohol Combination

The FDA has issued a black box warning specifically about combining benzodiazepines like Xanax with other CNS depressants, including alcohol, due to risks of slowed or difficult breathing and death. 1

• Death has been reported with overdoses combining a single benzodiazepine (including alprazolam) and alcohol, with alcohol levels sometimes lower than those typically associated with alcohol-induced fatality alone 3
• The combination produces additive and synergistic effects that dramatically increase overdose risk beyond what either substance causes alone 2, 4
• Even small quantities of alcohol (as little as 6.5-19.6 grams) combined with therapeutic benzodiazepine doses cause significant psychomotor impairment and paradoxically increase anxiety rather than relieve it 5
• Excessive sedation from this combination severely impairs driving ability, with both drugs affecting reaction time, coordination, and judgment 1

Adding Marijuana to the Mix

When marijuana is combined with alcohol, driving performance deteriorates dramatically with severe swerving and slowed reaction times—adding Xanax to this combination compounds the sedation and impairment exponentially. 1

• Cannabis users are more than twice as likely to be involved in motor vehicle crashes, and this risk increases substantially when combined with alcohol 1
• Fatal motor vehicle accidents involving both cannabis and alcohol increased from 4.8% in 2000 to 10.3% in 2018, demonstrating the deadly nature of this combination 1
• Higher blood levels of cannabis are associated with increased risk of fatal crashes when alcohol is also present 1
• The sedating effects of Xanax would add a third layer of CNS depression to the already dangerous cannabis-alcohol combination 1, 3

Specific Dangers by System

Respiratory System

• Profound respiratory depression leading to cardiopulmonary collapse and death 2, 3
• Animal studies show cardiopulmonary collapse occurs with massive benzodiazepine doses, requiring mechanical ventilation for resuscitation 3

Central Nervous System

• Somnolence, confusion, impaired coordination, diminished reflexes, and coma 3
• Severe cognitive impairment affecting memory, learning, and decision-making 5
• Paradoxical anxiety increase when benzodiazepines and alcohol are combined, despite both being anxiolytics individually 5

Psychomotor Function

• Dramatically impaired driving ability—a single 50mg dose of diphenhydramine (an antihistamine) has greater driving impairment than a 0.10% blood alcohol concentration, and benzodiazepines cause similar or worse impairment 1
• Patients taking opioids or benzodiazepines should be cautioned about operating vehicles or machinery, especially when combined with alcohol or cannabis 1

Overdose Manifestations

Clinical signs of alprazolam overdose, which are worsened by alcohol and potentially by cannabis, include: 3

• Somnolence and confusion
• Impaired coordination
• Diminished reflexes
• Coma
• Death (particularly when combined with alcohol)

Common Pitfalls to Avoid

• Do not assume "just a little" alcohol is safe—even small quantities (equivalent to 1/6 gill of vodka) combined with therapeutic benzodiazepine doses cause significant impairment and paradoxical anxiety 5
• Do not underestimate the duration of impairment—benzodiazepines have active metabolites that accumulate, and cannabis effects can last hours beyond the acute "high" 1, 2
• Do not drive or operate machinery for at least 24 hours after using this combination, as impairment persists well beyond subjective feelings of intoxication 1
• Avoid this combination entirely in elderly patients, who experience greater risks of sedation, falls, cognitive impairment, and prolonged drug effects 2

Cross-Dependence and Abuse Risk

• Benzodiazepine abuse occurs almost exclusively among individuals who also abuse alcohol, due to cross-dependence between the two drugs 4
• Both substances act on the GABA-benzodiazepine-chloride ionophore complex, creating additive interactions and shared withdrawal syndromes 6
• Cannabis use disorder develops in approximately 10% of chronic users, with higher rates (17% vs 9%) in those with medical cannabis cards 1

Emergency Management

If overdose occurs: 3

• Secure airway, ventilation, and intravenous access immediately
• Flumazenil (benzodiazepine antagonist) may reverse sedation but carries seizure risk, especially in chronic benzodiazepine users
• Monitor for re-sedation, respiratory depression, and residual effects
• Naloxone should be available if opioids are also involved 1