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We have performed an indepth review of the alprazolam literature, summarizing older and newer publications, in an attempt to provide a better understanding of how alprazolam’s unique pharmacokinetic and pharmacodynamic properties affect its misuse liability and offer some prescription guidelines for its safe and effective use.Īlprazolam is a high-potency triazolobenzodiazepine that is US Food and Drug Administration (FDA)-approved for the treatment of anxiety and panic disorders. While more recent research studies involving benzodiazepines are scant, the subject of alprazolam misuse continues to be a reality with which many providers struggle and should continue to be addressed. There are significant discrepancies between prescribing habits and risk associated with the use of benzodiazepines, including alprazolam, largely due to the lack of important data informing clinicians on best clinical practice. Those clinicians were found to prescribe benzodiazepines disproportionately to patients with at least some known risk factors for benzodiazepine-related adverse events including increased age, pulmonary diseases, and other substance use disorders ( Kroll et al., 2016). In a longitudinal cohort study between July 1, 2011, and June 30, 2012, more than half of the patients who visited hospital and “community practice-based research network” received benzodiazepine prescriptions at least once from their primary care physician (PCP). A database review of poisoning admissions to a regional toxicology service revealed that when alprazolam was involved, the median length of stay (LOS) was 19 hours, which was 1.27 (95% confidence interval 1.04, 1.54) times longer compared with other benzodiazepines, and patients were 2.06 (95% CI 1.27, 3.33) times more likely to be admitted to the intensive care unit (ICU) compared with other benzodiazepines after multivariate analysis adjusting for age, dose, sex, time to ingestion, and co-ingested drugs ( Isbister et al., 2004). Based on national emergency department (ED) visit data, alprazolam is the second most common prescription medication and the most common benzodiazepine to be involved in ED visits related to drug misuse ( SAMHSA, 2013).īenzodiazepines are implicated in approximately one-third of intentional overdoses or suicide attempts ( Henderson et al., 1993). This persists despite the fact that many prescribers consider alprazolam to have high misuse liability and it is shown to result in a more severe withdrawal syndrome than other benzodiazepines, even when tapered according to manufacturer guidelines ( Browne and Hauge, 1986 Kantor, 1986). In this paper, we have reviewed alprazolam’s indications for use, its effect on pregnant women, misuse liability, withdrawal syndrome, pharmacodynamic properties, and suggest better clinical prescription practice of alprazolam by presenting an indepth theory of its clinical effects with use and withdrawal.Īlprazolam is not only the most commonly prescribed benzodiazepine, but it is the most commonly prescribed psychotropic medication in the United States, accounting for more than 48 million prescriptions dispensed in 2013 ( Grohol, 2016).
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We have replaced it in our manuscript with “misuse liability” as it reflects a more updated terminology consistent with the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). “Abuse liability” is the degree to which a psychoactive drug has properties that facilitate people misusing it, or becoming addicted to it, and is commonly used in the literature. Clinical research data has not fully shed light on its “abuse liability,” yet it is one of the most frequently prescribed benzodiazepines.
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Its clinical use has been a point of contention as most addiction specialists consider it to be highly addictive, given its unique psychodynamic properties which limit its clinical usefulness, whereas many primary care physicians continue to prescribe it for longer periods than recommended. Alprazolam is one of the most widely prescribed benzodiazepines for the treatment of generalized anxiety disorder and panic disorder.