What is the recommended tapering protocol for safely discontinuing alprazolam (Xanax) in an adult who has been using it regularly for several weeks?

Recommended Alprazolam (Xanax) Withdrawal Protocol

For adults who have been using alprazolam regularly for several weeks, reduce the dose by 10–25% of the current dose every 1–2 weeks, never stopping abruptly, as sudden discontinuation can cause seizures and death. 1, 2

Critical Safety Framework

Abrupt cessation of alprazolam is never appropriate and carries life-threatening risks including seizures, delirium, and death—equivalent to suddenly stopping antihypertensives or antihyperglycemics. 1, 2 The FDA label explicitly warns that seizures have been documented after discontinuation, with highest risk occurring 24–72 hours after the last dose. 2 Benzodiazepine withdrawal carries greater risks than opioid withdrawal and must always be conducted gradually. 1, 3

Recommended Tapering Schedule

For Short-Term Use (<1 Year)

• Reduce by 10–25% of the current dose every 1–2 weeks. 1 This means if you start at 2 mg/day, reduce to 1.5–1.8 mg/day in weeks 1–2, then reduce by 10–25% of that dose (not the original 2 mg) in weeks 3–4. 1
• Never use straight-line percentage reductions from the starting dose, as this subjects patients to disproportionately large final decrements. 1

For Long-Term Use (≥1 Year)

• Slow to 10% of the current dose per month. 1 Research shows that extending the taper to 10% monthly rather than 10–25% every 1–2 weeks is better tolerated for patients on benzodiazepines longer than one year. 1
• The taper will likely require a minimum of 6–12 months, and possibly several years for some patients. 1

Specific Alprazolam Tapering Example

• For a patient on alprazolam 2 mg/day, the FDA label documents that a taper of 1 mg every 3 days resulted in only 24% of patients completing withdrawal successfully. 1 A more conservative approach of 0.25 mg reductions every 1–2 weeks is safer and better tolerated. 1

Withdrawal Symptoms to Monitor

Monitor at every visit for: 1, 2

• Anxiety, panic attacks, tremor, insomnia
• Sweating, tachycardia, headache
• Weakness, muscle aches, muscle cramps
• Nausea, diarrhea, appetite decrease
• Confusion, altered mental status
• Seizures (medical emergency)
• Heightened sensory perception, paresthesias, blurred vision, dysosmia (specific alprazolam withdrawal symptoms) 2, 4, 5

Clinically significant withdrawal symptoms signal the need to slow the taper rate or pause entirely for 2–4 weeks. 1 The taper rate must be determined by the patient's tolerance, not a rigid schedule, and pauses are acceptable and often necessary. 1

Follow-Up Requirements

• Follow up at least monthly during the taper, with more frequent contact during difficult phases. 1
• Screen for depression, anxiety, and substance use disorders that may emerge during tapering. 1
• Advise patients of increased overdose risk if they return to previous doses after tolerance is lost. 1

Essential Adjunctive Strategies

Cognitive-Behavioral Therapy (Mandatory for Success)

Integrating CBT during the taper significantly increases success rates and should be incorporated. 1, 6, 7 In a controlled trial, 50% of patients who discontinued alprazolam without CBT relapsed within 6 months, but none who received CBT relapsed. 7 CBT must address:

• Cognitive appraisals of threat represented by symptoms 6
• Patients' competence to cope without medication 6
• Exposure-based techniques targeting avoidance behaviors 1

The drug taper must be completed before psychological treatment concludes. 6

Patient Education

• Educate about benzodiazepine dependence, withdrawal symptoms, and risks of continued use versus benefits of discontinuation. 1, 6
• Explain that chronic benzodiazepine use can paradoxically increase breakthrough anxiety. 1

Pharmacological Adjuncts (Optional)

• Gabapentin 100–300 mg at bedtime or three times daily, titrated by 100–300 mg every 1–7 days as tolerated (adjust in renal insufficiency). 1
• Carbamazepine may assist discontinuation, though it affects alprazolam metabolism. 1
• SSRIs (particularly paroxetine) may help manage underlying anxiety during tapering. 1
• Trazodone 25–200 mg for short-term insomnia management. 1

When to Refer to a Specialist Immediately

• History of withdrawal seizures 1
• Unstable psychiatric comorbidities 1
• Co-occurring substance use disorders 1
• Previous unsuccessful office-based tapering attempts 1
• Pregnant patients (withdrawal can cause spontaneous abortion and premature labor) 1

Critical Pitfalls to Avoid

• Never taper too quickly. Research shows that 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 as a legitimate outcome. 1
• Never prescribe opioids and benzodiazepines simultaneously due to increased risk of respiratory depression and death. 1
• Never substitute another benzodiazepine or Z-drug without a clear clinical rationale, as this may simply transfer dependence. 1

Special Populations

Elderly Patients

• Use lower doses and more gradual tapers. 1
• Consider smaller dose reductions (e.g., 10% per month minimum) to minimize adverse effects. 1
• Alprazolam is particularly problematic in elderly due to cognitive impairment, falls, fractures, and loss of functional independence. 1

Patients on Concurrent Opioids

• If both medications need tapering, reduce benzodiazepines first due to higher withdrawal risks. 1, 3

Realistic Timeline and Goals

• The taper will likely take 6–12 months minimum, possibly longer. 1
• Patient agreement and interest in tapering is a key component of success. 1
• Tapers may be considered successful as long as the patient is making progress—the goal is durability of the taper, not speed. 1
• Both complete discontinuation and attainment of a reduced, functionally acceptable dose are acceptable outcomes. 1

Rebound and Relapse Considerations

• Rebound panic attacks occurred in 27% of alprazolam-treated patients during discontinuation, and distinct withdrawal syndrome in 35%. 5
• Symptoms typically peak during the end of the tapering period and first week without medication, followed by improvement during the second post-taper week. 4, 5
• The FDA label notes that 71–93% of patients treated with alprazolam tapered completely off therapy in controlled trials of 6–8 weeks duration. 2