Pharmaceutical Services Branch
This information is intended to assist medical practitioners in Western Australia to:
 become familiar with current concerns of alprazolam abuse
 critically examine personal alprazolam prescribing practices
 identify signs of misuse and determine where specialist referral may be necessary
 prescribe appropriately for panic disorder.
Alprazolam is a highly potent benzodiazepine with a rapid onset (less than one hour after oral administration) and a short half-life (6 to12 hours).
1
Ralozam
®
, and Alprax
®
.
Trade names include Xanax
®
, Kalma
®
,
Alprazolam is indicated for treatment of anxiety and panic disorder. Alprazolam is subsidised by the Pharmaceutical Benefits Scheme (PBS) for the treatment of panic disorder ‘where other treatments have failed or are inappropriate’.
2 Prior to availability of non-benzodiazepine alternatives, alprazolam was recommended first-line treatment for panic disorder.
3 Alprazolam is no longer recommended for routine treatment of panic disorder without specialist review and advice.
4
Alprazolam may produce tolerance and dependence. It is recommended that prescribing be for short periods, ideally two to four weeks. Evidence suggests there is no long-term benefit to extended use in treatment of panic disorder.
3
Alprazolam abuse is being reported more frequently, especially in drug dependent populations.
Alprazolam has a sort-after pharmacological profile: a combination of a short-half life and high potency together with large pack sizes makes alprazolam the benzodiazepine of choice for abuse.
As with other benzodiazepines, there are many risks associated with alprazolam. These not only affect individuals but have a significant impact on the wider community.
Risks to the community:
 diversion of alprazolam to people other than the intended patient
 black market trading and crime to support illicit drug use habits
 driving whilst under the influence.
Risks for the individual:
 sedation and impaired attentiveness leading to driving accidents, injury using machinery/tools, or falls in the elderly
 overdose, especially in combination with other central nervous system depressants
(alcohol or opioids)
 disinhibition, leading to risk taking behaviour and violence
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Pharmaceutical Services Branch
 impaired memory
 dependence resulting in tolerance, escalating doses, and withdrawal when ceased
 reinforced maladaptive false beliefs in sleep or anxiety disorders contributing to inability to manage in other ways
 delay in receiving appropriate treatment.
When considering use of alprazolam, thought should be given to:
 appropriately selecting patients
 consider non-pharmacological treatments and other preferred pharmacological options
 not prescribing for:
 patients on their first appointment
 Registered Drug Addicts (contact Pharmaceutical Services Branch on 9222 6883)
 patients unwilling to consider non-benzodiazepine treatments.
 verifying claims made by patients, such as prior treatment or specialist initiation of therapy.
After deciding to prescribe alprazolam, clearly communicate treatment boundaries:
 agree on treatment goals with the patient
 consider use of a “
Treatment Contract
” to cover dose limits or prescribing boundaries, remaining with a single prescriber, and attending appointments
 use other treatment providers to support care as necessary (e.g. pharmacists)
 follow up patients on a regular basis to review compliance and treatment effectiveness.
Seek specialist referral for high risk patients 5 :
 patients under 18 years of age
 patients with a history of substance dependence (including alcohol) or illicit drug use
 Registered Drug Addicts or those on opiate substitution treatment (methadone, Suboxone ® or Subutex
®
)
 patients displaying drug seeking behaviour or identified as doctor shoppers.
Behaviours that may indicate drug seeking behaviour or alprazolam dependence include:
 specific requests for alprazolam
 circumstances that are difficult to verify (e.g. visiting from interstate, late or after hours presentations, letters from other prescribers)
 lost, stolen or otherwise misplaced scripts
 threatening behaviour or aggressive demands for more medication or higher doses
 history of alcohol or illicit drug use, or prior treatment on a pharmacotherapy program
 drug intoxication or signs of intravenous drug use (e.g. track marks).
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Pharmaceutical Services Branch
Isolated panic attacks in the general population are common. Psychological interventions are recommended treatment for single panic attacks.
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Panic disorder, as characterised by recurrent panic attacks without a situational trigger, is uncommon. In the developed world, life-time prevalence is between 1.4% and 2.9%. It is more common in females. Estimated point-prevalence of panic disorder in Australia is 0.7%.
3, 4, 6
Cognitive behavioural therapy (CBT) is the treatment of choice for panic disorder.
When CBT is not available or effective, pharmacological treatment may be indicated. Medicine choice will depend on adverse effects, tolerability, coexisting depression, history of misuse and risk of overdose. Current recommendations for pharmacological treatment include:
1. First-line
 selective serotonin reuptake inhibitors (SSRI), such as: citalopram, escitalopram, fluoxetine, fluvoxamine, paroxetine, sertraline, or
 serotonin and noradrenaline reuptake inhibitors (SNRI), such as venlafaxine.
 for those not responding to first line agents, consider a tricyclic antidepressant (TCA)
 monoamine oxidase inhibitors (MAOIs) may be considered, but should generally be restricted to specialist practice.
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Note: Occasionally benzodiazepines may be used in patients who have not responded to or cannot tolerate antidepressants. The most effective benzodiazepines have been shown to be those of high-potency but these also have the highest risk of the development of dependence.
Seek specialist review and advice before considering prescribing benzodiazepines.
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 WA Department of Health, Pharmaceutical Services Branch, Monday to Friday, 8.30am to
4.30pm. Telephone: (08) 9222 6883 | Facsimile: (08) 9222 2463 | Email: poisons@health.wa.gov.au
Web: www.health.wa.gov.au/pharmacy
 Medicare Australia: Prescription Shopping Information Service - 1800 631 181. Register at: www.medicareaustralia.gov.au/provider/pbs/prescription-shopping/
 Drug and Alcohol Office: Clinical Advisory Service (CAS) - (08) 9442 5042 or 1800 688 847
This document is adapted from Alprazolam prescribing: A resource for South Australian prescribers .
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Pharmaceutical Services Branch
1. Mims Online. Alprazolam-GA 2013 [July 18, 2013]. Available from: https://www.mimsonline.com.au/Search/FullPI.aspx?ModuleName=Product
Info&searchKeyword=alprazolam&PreviousPage=~/Search/QuickSearch.aspx&SearchType=&
ID=84040001_2.
2. Department of Health and Ageing. Pharmaceutical Benefits Scheme: A-Z medicine listing
2013 [June 24, 2013]. Available from: http://www.pbs.gov.au/medicine/item/2130D-2131E-
2132F-8118G.
3. Moylan S, Giorlando F, Nordfjærn T, Berk M. The role of alprazolam for the treatment of panic disorder in Australia. Australian & New Zealand Journal of Psychiatry. 2012;46(3):212-
24.
4. Therapeuti c Guidelines Limited. eTG complete: ‘Panic Disorder’ 2013 [July 18, 2013].
Available from: http://www.tg.org.au/index.php?sectionid=71.
5. Department of Health. Schedule 8 Medicines Prescribing Code. Perth, Western Australia:
Pharmaceutical Services Branch, Public Health and Clinical Services Division, Department of
Health; 2012.
6. National Collaborating Centre for Mental Health: The Royal College of Psychiatrists.
Generalised Anxiety Disorder in adults: The NICE Guideline on management in primary, secondary and community care. Great Britain: The British Psychological Society; 2011.
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