What is the difference between alprazolam (Xanax) and temazepam for a patient with anxiety or insomnia?

Alprazolam vs. Temazepam: Key Differences

Alprazolam is FDA-approved for anxiety disorders and panic disorder, NOT for insomnia, while temazepam is specifically FDA-approved for short-term insomnia treatment (7-10 days). These are fundamentally different medications with distinct clinical indications that should not be used interchangeably 1, 2.

Primary Indications

Alprazolam:

• FDA-approved for generalized anxiety disorder characterized by unrealistic or excessive worry about multiple life circumstances for 6+ months 1
• FDA-approved for panic disorder with or without agoraphobia, effective for 4 months in anxiety and 4-10 weeks in panic disorder 1
• NOT approved or recommended for insomnia treatment 1

Temazepam:

• FDA-approved specifically for short-term insomnia treatment (7-10 days maximum) 2
• Recommended by the American Academy of Sleep Medicine as a first-line benzodiazepine receptor agonist for both sleep onset and sleep maintenance insomnia at 15 mg dose 3
• Effective for reducing nighttime awakenings and increasing total sleep duration, though less effective for sleep onset latency 4, 5

Pharmacokinetic Differences

Alprazolam:

• Intermediate-acting benzodiazepine with active metabolites that can accumulate with repeated dosing 6
• Higher potency benzodiazepine associated with greater risks of dependence and withdrawal 6
• Not recommended in UK guidelines for long-term use due to dependence concerns 6

Temazepam:

• Intermediate half-life of 10-15 hours with no long-acting metabolites 4, 5
• Peak plasma concentration occurs 2-3 hours after oral ingestion, which explains limited effect on sleep onset latency 4, 5
• More quickly metabolized than flurazepam, reducing hangover effects 4

Clinical Positioning in Treatment Guidelines

For Anxiety:

• Alprazolam is indicated but diazepam is generally preferred as first-line benzodiazepine for anxiety, given in single doses or very short courses (1-7 days maximum) 6
• Benzodiazepines should be used in conjunction with psychological treatments and antidepressants, not as monotherapy 6

For Insomnia:

• Temazepam is positioned as a first-line benzodiazepine receptor agonist alongside eszopiclone, zolpidem, and zaleplon 3, 7
• The American Academy of Sleep Medicine recommends temazepam 15 mg for both sleep onset and maintenance insomnia 3
• Cognitive Behavioral Therapy for Insomnia (CBT-I) must be initiated before or alongside temazepam 3, 7

Safety Profile Differences

Alprazolam:

• Higher risk of rebound anxiety with discontinuation 8
• Not considered a first-line hypnotic due to rebound effects 8
• Greater dependence potential compared to other benzodiazepines 6

Temazepam:

• Lower propensity for producing rebound insomnia compared to shorter-acting agents 9
• Minimal hangover effects at 15-30 mg doses in most patients 4, 5
• Studies show no significant rebound insomnia after 7 consecutive nights at 30 mg 4
• At 7.5 mg in elderly patients, produces minimal daytime sedation or memory impairment 9

Critical Prescribing Considerations

Duration of Use:

• Both medications carry FDA warnings about abuse, misuse, addiction, physical dependence, and withdrawal reactions 2
• Temazepam should be limited to 7-10 days for insomnia, with safety and efficacy beyond 2 weeks unknown 2
• Alprazolam efficacy is documented for 4 months in anxiety disorder but requires periodic reassessment 1

Withdrawal Risk:

• Both require gradual tapering to prevent serious withdrawal symptoms including seizures, severe mental changes, and suicidal thoughts 2
• Withdrawal symptoms can persist for weeks to months, including anxiety, insomnia, muscle twitching, and sensory disturbances 2

Common Prescribing Errors to Avoid

• Never prescribe alprazolam for insomnia - it lacks FDA approval and guideline support for this indication 1
• Never prescribe temazepam for anxiety or panic disorder - it is only indicated for insomnia 2
• Avoid using either medication without implementing CBT-I for insomnia or psychological interventions for anxiety 3, 7, 6
• Do not prescribe temazepam beyond 2 weeks without clear justification and reassessment 2
• Never combine either medication with alcohol or opioids due to dangerous respiratory depression risk 7, 2