How should I taper a patient on Xanax (alprazolam) 1mg twice daily (bid) after long-term use?

Should You Taper This Patient Off Xanax?

Yes, you should taper this patient off alprazolam (Xanax) 1mg twice daily—long-term benzodiazepine use in a mid-50s patient carries significant risks including cognitive impairment, falls, and dependence, and the evidence strongly supports that gradual tapering is both feasible and beneficial in primary care. 1, 2

Why Tapering is Necessary

• Long-term benzodiazepine use is associated with serious adverse effects including cognitive impairment, reduced mobility, falls, fractures, loss of functional independence, and addiction 1
• Alprazolam specifically carries high dependence risk even at therapeutic doses (0.75-4 mg/day), and withdrawal symptoms including seizures have been reported after brief therapy within recommended ranges 3
• Discontinuation typically improves psychomotor and cognitive functioning, particularly making this intervention beneficial for your patient's age group 4
• Current consensus guidelines advise benzodiazepines solely for short-term use, not the years-long duration your patient has been taking them 1

Critical Safety Framework Before Starting

Never Taper Abruptly

• Abrupt discontinuation of benzodiazepines can cause seizures and death—this is as dangerous as suddenly stopping antihypertensives or antihyperglycemics 1, 3
• Benzodiazepine withdrawal carries greater risks than opioid withdrawal and must always be conducted gradually 1

Essential Pre-Taper Assessment

• Check your state's Prescription Drug Monitoring Program (PDMP) to identify all controlled substances the patient is receiving 1
• Screen for concurrent substance use disorders, psychiatric comorbidities, and any history of withdrawal seizures before initiating the taper 1
• If the patient is also taking opioids, taper the benzodiazepine first due to higher withdrawal risks 1

Recommended Tapering Protocol

Initial Approach and Patient Engagement

• Patient agreement and interest in tapering is a key component of success—use shared decision-making and explain the risks of continued use versus benefits of discontinuation 5
• Provide patient education about benzodiazepine risks and benefits of tapering, as this improves outcomes and engagement 1

Specific Tapering Schedule for Alprazolam 2mg/day

For patients on benzodiazepines for years, reduce by 10% of the current dose per month, not 10-25% every 1-2 weeks 1

• Month 1: Reduce from 2mg/day to 1.8mg/day (10% reduction)
• Month 2: Reduce to 1.6mg/day (10% of 1.8mg)
• Month 3: Reduce to 1.45mg/day (10% of 1.6mg)
• Continue this pattern, reducing by 10% of the current dose each month 1

The reduction should be a percentage of the current dose, not the original dose, to prevent disproportionately large final reductions 1

Alternative FDA-Recommended Approach

• The FDA label suggests decreasing by no more than 0.5mg every three days, though this may be too rapid for long-term users 3
• Some patients may benefit from an even slower dosage reduction than the FDA recommendation 3

Practical Dosing Considerations

• Alprazolam's short half-life makes tapering more challenging than longer-acting benzodiazepines 4
• Consider switching to diazepam (available in liquid formulation for precise dose adjustments), though this adds complexity 4
• For the final stages, once the smallest available dose is reached, extend the interval between doses before complete discontinuation 1

Realistic Timeline and Expectations

• Plan for a minimum of 6-12 months for the taper, and possibly longer—the goal is durability of the taper, not speed 1
• Some patients may need to extend their taper over many months to years to avoid debilitating withdrawal symptoms 6
• Research shows 62% of patients successfully discontinue with gradual tapering versus only 21% with usual care 7
• For every three interventions, one patient achieves complete withdrawal 2

Managing Withdrawal Symptoms

Common Withdrawal Symptoms to Monitor

• Anxiety, insomnia, tremor, sweating, tachycardia, headache, weakness, muscle aches, nausea, and confusion are typical withdrawal symptoms 6, 8
• Perceptual hypersensitivity (including tinnitus), dysphoria, and irritability may also occur 1, 6
• Withdrawal symptoms typically appear toward the end of taper or shortly after discontinuation and will decrease with time 3

When to Slow or Pause the Taper

• The taper rate must be determined by the patient's tolerance to withdrawal symptoms, not by a rigid schedule 1, 6
• Pauses in the taper are acceptable and often necessary when withdrawal symptoms emerge 1
• Clinically significant withdrawal symptoms signal the need to further slow the taper rate 5
• If the patient struggles to tolerate the taper, slow it down or pause it until symptoms stabilize 5, 6

Pharmacological Adjuncts for Withdrawal Symptoms

Gabapentin (most evidence-based adjunct):

• Start with 100-300mg at bedtime or three times daily 1
• Increase by 100-300mg every 1-7 days as tolerated 1
• Adjust dosage in patients with renal insufficiency 1
• Gabapentin can mitigate withdrawal symptoms during benzodiazepine tapering 6

Other potential adjuncts (weaker evidence):

• Carbamazepine may assist discontinuation, though data are limited and it may affect alprazolam metabolism 1, 4
• Pregabalin has shown potential benefit in facilitating benzodiazepine tapering 1
• SSRIs (particularly paroxetine) may help manage underlying anxiety during tapering 1

Symptomatic management:

• For insomnia: trazodone for short-term management (not another benzodiazepine or Z-drug) 1
• For muscle aches: NSAIDs or acetaminophen 1

Non-Pharmacological Support (Critical for Success)

• Integrate cognitive-behavioral therapy (CBT) during the taper—this significantly increases success rates 1, 7, 8
• Additional supportive measures include mindfulness and relaxation techniques, sleep hygiene education, and exercise training 1
• Psychological support and patient education about the temporary nature of withdrawal symptoms improve outcomes 6

Monitoring Requirements

• Follow up at least monthly during the taper, with more frequent contact (weekly or biweekly) during difficult phases 5, 1, 2
• Monitor for withdrawal symptoms at each visit: anxiety, tremor, insomnia, sweating, tachycardia, perceptual changes 1, 6
• Screen for depression, anxiety, and substance use disorders that may emerge or be unmasked during tapering 5
• Monitor for suicidal ideation, as mood changes can occur during withdrawal 1
• Team members (nurses, pharmacists, behavioral health professionals) can support through telephone contact, telehealth, or face-to-face visits 5

When to Refer to a Specialist

Immediate specialist referral is indicated for 1:

• History of withdrawal seizures
• Unstable psychiatric comorbidities
• Co-occurring substance use disorders
• Previous unsuccessful office-based tapering attempts

Key Pitfalls to Avoid

• Never taper too quickly—research shows even a 10% reduction every 3 days resulted in only 24% of patients completing withdrawal successfully 1
• Never abandon the patient, even if tapering is unsuccessful—maintain the therapeutic relationship and consider maintenance therapy 1
• Do not substitute another benzodiazepine or Z-drug (zolpidem, zaleplon) as these carry similar risks 1
• Avoid prescribing additional CNS depressants during the tapering period 1
• Do not reverse a taper without carefully assessing and discussing benefits and risks of increasing dosage 5

If Patient Refuses to Taper

• When patients and clinicians cannot agree on whether tapering is necessary, acknowledge this discordance, express empathy, and seek to implement treatment changes in a patient-centered manner while avoiding patient abandonment 5
• Establish goals for continued benzodiazepine therapy and maximize non-pharmacologic treatments 5
• Continue close monitoring for adverse effects and reassess periodically 5

Expected Outcomes

• Improvement in PD symptoms and general well-being is typically maintained during both taper and follow-up phases 8
• Successful discontinuation leads to improved psychomotor and cognitive functioning 4
• Economic benefits also ensue from successful withdrawal 4
• The outcome of successful withdrawal is gratifying in terms of improved functioning and abstinence 4