What Is a Xanax Addiction?

How to Spot the Signs and Find Treatment

Xanax (alprazolam) is a benzodiazepine drug widely prescribed to treat anxiety disorder. Benzodiazepine addiction is a growing concern in the United States, with around 30% of overdose deaths caused by drugs like Xanax.

The addiction, classified as a substance abuse disorder in the Diagnostic and Statistical Manual of Mental Disorders, Edition 5 (DSM-5), is often suspected when a user appears intoxicated or exhibits drug-seeking behaviors. But the addiction can also be well concealed.

Treatment may involve a combination of strategies, including detoxification, behavioral therapy, drug maintenance therapies, and medications to relieve withdrawal symptoms.

Other commonly prescribed benzodiazepines that pose a risk of dependence include Valium (diazepam) and Ativan (lorazepam).

Drug addiction can lead to isolation
Getty Images / sestovic

Signs and Symptoms

Benzodiazepines (also known as “benzos”) are commonly referred to as sedatives, hypnotics, or minor tranquilizers. They work by increasing the effect of the neurotransmitter gamma-aminobutyric acid (GABA) in the brain. This reduces the excitability of neurons (nerve cells), resulting in decreased feelings of anxiety.

Xanax, one of the most commonly prescribed benzodiazepines, is generally considered safe for short-term use (two to four weeks). But it can also cause side effects like sleepiness, headaches, lethargy, dry mouth, and memory problems. 

Among older adults, long-term use of Xanax can also lead to pseudo-dementia, a condition characterized by symptoms similar to those of dementia. Pseudo-dementia may resolve after the drug is stopped.

While Xanax is sometimes prescribed for longer than a few weeks to manage certain anxiety disorders, prolonged use can lead to a severe rebound of anxiety symptoms when the drug is eventually stopped. Prolonged use also increases the risk of withdrawal syndrome.

Withdrawal from Xanax is characterized by physical effects and emotional symptoms. Symptoms of withdrawal include:

  • Anxiety or restlessness
  • Trouble concentrating
  • Difficulty sleeping
  • Tremors
  • Muscle spasms
  • Headaches
  • Tachycardia (rapid heart rate)
  • Hyperventilation (rapid, shallow breathing)
  • Sweating
  • Convulsions or seizures
  • Depression
  • Feelings of being detached from reality
  • Panic attacks
  • Hallucinations (seeing or hearing things that aren’t there)
  • Delirium

Moreover, using Xanax for longer periods or at higher doses, such as over 4 milligrams (mg), can lead to drug tolerance. If you develop tolerance to Xanax, you may need to use higher doses to maintain a therapeutic effect and to avoid withdrawal symptoms. This can lead to excessively high dosing, intoxication, and, in some cases, drug-seeking behaviors.

Signs of Xanax addiction include:

  • Excessive drowsiness
  • Slurred speech, impaired coordination, and/or difficulty walking
  • Blurry vision
  • Inability to reduce or stop the medication
  • Lying or sneaking to get more pills from doctors, family, or friends
  • Spending excessive time and/or money to obtain, use, or recover from Xanax use
  • Buying Xanax on the street
  • Endangering yourself or others while under the effects of Xanax (such as driving when the drug has made you drowsy)

The potential for addiction is higher with Xanax than with lower-potency benzodiazepines like Librium (chlordiazepoxide).

Complications

The use of Xanax and other sedatives and hypnotics is associated with an increased risk of death, even at prescribed doses. Current research shows that these drugs can lead to death through a variety of complications related to side effects, withdrawal, or overdose.

Causes of death include a high risk of accidents, secondary infections (due to injury), and depression. Furthermore, Xanax can cause suicidal ideation.

The main concern with Xanax addiction is the risk of overdose, which can result in acute benzodiazepine toxicity.

Overdose can occur with Xanax alone, but the majority of deaths occur when Xanax is combined with other drugs, such as opioids, including heroin. Polydrug use (using multiple drugs illicitly) is common among people with benzodiazepine addiction, with 54.2% abusing opioids and 24.7% abusing alcohol.

Due to the risks, the FDA issued a black box warning in 2016 warning against the concomitant use of benzodiazepines and opioids.

Signs and symptoms of Xanax overdose can include:

  • Lethargy
  • Confusion
  • Impaired coordination
  • Dysarthria (slurred speech)
  • Nystagmus (jerking eyes)
  • Diminished reflexes or low muscle tone on physical examination
  • Seizures
  • Hypothermia (low body temperature)
  • Hypotension (low blood pressure)
  • Respiratory depression (slow or shallow breathing)
  • Agitation, aggression, and /or combativeness
  • Hallucinations (seeing or hearing things that aren’t there)

Signs of overdose usually develop within four hours of a dose, which is the time when the drug concentration is highest in the body, and the symptoms of an overdose may persist for 12 to 36 hours.

However, even after the symptoms of a Xanax overdose wear off, the consequences to the body may persist, potentially with lasting effects. For example, pulmonary aspiration during a lethargic state can lead to aspiration pneumonia or permanent lung damage.

Xanax overdose causes central nervous system (CNS) depression, which is a direct result of the drug's effect on reduced neuronal excitability. CNS depression leads to impaired respiration and bradycardia (slow heart rate), which can cause coma or cardiac arrest (interruption of the heartbeat). Xanax overdose is also associated with a risk of suicide.

If you suspect that you or someone else may be experiencing Xanax overdose, contact Poison Control (800-222-1222).

Causes

Unlike opioids or stimulants, addiction to Xanax is not associated with pleasurable effects or a sense of feeling “high” or euphoric. Addiction is generally due to an avoidance of withdrawal symptoms, which tend to be more severe the longer you take the drug.

Fear of Withdrawal

Even at relatively low doses, Xanax addiction can develop—in part because the drug has a relatively short half-life of 11 hours, which means that the effects wear off quickly.

And, as you develop tolerance to the drug (this can happen with any dose), the duration of its therapeutic effects becomes shorter, while the feeling of “comedown” leading to the withdrawal comes quicker. Generally, taking Xanax for longer than eight months increases the risk of addiction.

Even if a person tries to stop taking Xanax, the fear of withdrawal and rebound can be so strong that the adverse consequences of stopping seem to outweigh the benefits. This is when the condition can be medically classified as substance use disorder. Xanax addiction is specifically part of a subcategory of substance use disorder known as sedative, hypnotic, or anxiolytic use disorder.

Risk Factors

Benzodiazepine addiction can happen to anyone, but certain groups are at greater risk. Risk factors for developing Xanax addiction include:

  • Age group 18-25
  • Family history of substance abuse
  • Having other co-occurring psychiatric disorders, such as depression or bipolar disorder
  • Having antisocial personality disorder
  • A history of alcohol abuse

There are several proposed explanations for why these groups may be at risk. Research shows that young adults who use Xanax tend to use it along with illegal drugs and are also more likely to have psychiatric conditions, which might be undiagnosed or untreated.

Additionally, some people are predisposed to substance addiction, possibly due to genetic factors and altered activity of neurotransmitters in the brain.

Diagnosis

A substance use disorder is a condition in which misuse of a drug results in adverse health or emotional effects or problems at work, school, or home.

Like many drugs, the presence of Xanax can be detected with laboratory tests. This drug can be detected in urine, saliva, and hair follicles, although the reliability of these tests is not consistent.

And while the drug can be identified in the body, there are no blood or lab tests that can diagnose Xanax addiction. The diagnosis of Xanax addiction is based on whether a person meets certain diagnostic criteria outlined in the DSM-5.

For a person to be diagnosed with substance use disorder, they must meet at least two of 11 criteria within a 12-month period:

  • Using the drug in a harmful way
  • Experiencing social and relationship problems due to drug use
  • Neglecting duties due to drug use
  • Drug tolerance (need higher doses to achieve the same effect)
  • Experience withdrawal symptoms when the drug is reduced or stopped
  • Using increased amounts of the drug or using it more frequently
  • Being unable to decrease the drug dose or stop using the drug, despite attempts to stop or decrease it
  • Spending excessive time obtaining, using, or recovering from the drug
  • Experiencing adverse physical or psychological effects of the drug
  • Giving up normal activities to use the drug

The severity of the disorder can be classified as “mild” if two to three criteria are met, “moderate” if four to five are met, and “severe” if six or more are met. These classifications may help direct the most appropriate course of treatment.

Your doctor cannot know the answers to these questions unless you are willing to participate in your diagnostic process—this means that you have to be interested in getting diagnosed and treated. Sometimes family and friends can help in encouraging you to seek help and in pointing out these issues to you.

Treatment

In the treatment of Xanax addiction, abstinence is often a goal. This means discontinuing the drug. The process of reaching abstinence may involve detoxification (often referred to as “detox”), behavioral therapies, and possibly taking flumazenil, a prescription drug that is administred to reduce symptoms of withdrawal.

In some situations, an alternative approach—stabilization and maintenance therapy—may be considered, particularly for people in whom abstinence is difficult.

Treatment can sometimes be delivered on an outpatient basis, but it often requires a period of inpatient care in a treatment center. Because Xanax addiction is usually associated with abuse of other substances, rehabilitation for opioid or alcohol addiction may also be needed.

Detoxification

Detox is a process during which a person stops taking a harmful drug. The process can be rapid or gradual, depending on the drug.

With Xanax, the effects of drug withdrawal can be severe, and even dangerous, so detox is often a gradual process, especially if it had been used in high doses and/or for a prolonged period of time. For example, to reduce the risk of seizures, the Xanax dose is gradually tapered over weeks—under medical supervision.

During Xanax detox, you would be monitored for signs of withdrawal, and you might need to receive treatment to alleviate and prevent harmful complications.

Flumazenil

Flumazenil is a benzodiazepine antagonist (it counteracts the effects of benzodiazepines by inhibiting the actions of GABA). It is used to counteract the effects of benzodiazepines after surgery or overdose.

For people undergoing treatment of Xanax addiction, flumazenil may be use off-label to temper the symptoms of withdrawal. It is usually delivered over four days via a slow subcutaneous infusion.

In overdose situations, flumazenil is very effective at reversing CNS depression (drowsiness, lack of coordination, slurred speech), but it is far less effective if there are signs of respiratory depression (slow breathing).

Behavioral Therapy

Behavioral therapy is an important component of recovery from drug addiction. While detox and flumazenil are focused on avoiding adverse effects of withdrawal, behavioral therapy is a process that is focused on maintaining recovery.

You might need to continue to meet with a therapist for months after your detox is complete, or even for longer. The purpose of behavioral therapy is for you to understand your addiction and to gain control so you can avoid misusing Xanax or another drug in the future. 

The different types of therapy used in the treatment of substance abuse disorders include:

You may benefit from one or more of these types of behavioral therapy. Upon leaving the treatment center, many people will pursue a 12-step recovery program to maintain abstinence or stabilization and maintenance.

The long-term abstinence rates after recovering from Xanax addiction vary significantly—about 80% of older adults achieve abstinence, while about 25% of those with complicated addiction with polydrug use achieve abstinence.

Stabilization and Maintenance

For some people, abstinence may be unrealistic. Rather than aiming for abstinence, recovery stabilization and maintenance therapy may be recommended, in which the Xanax dose is gradually tapered and substituted with another drug.

In such instances, Xanax is often substituted with a longer-acting drug like Valium (diazepam) or Klonopin (clonazepam).

How to Find Help

If you or a loved one is struggling with substance abuse or addiction, you can contact the Substance Abuse and Mental Health Services Administration (SAMHSA) National Helpline at 1-800-662-4357. SAMHSA also provides an online treatment center location.

And if you or someone you know is having suicidal thoughts, contact the National Suicide Prevention Hotline at 800-273-8255 (800-273-TALK).

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