tag:theconversation.com,2011:/id/topics/xanax-5037/articlesXanax – The Conversation2019-10-18T11:25:13Ztag:theconversation.com,2011:article/1253462019-10-18T11:25:13Z2019-10-18T11:25:13ZWhere is my Xanax Rx? Why your doctor may be concerned about prescribing benzodiazepines<figure><img src="https://images.theconversation.com/files/297596/original/file-20191017-98670-1fz706i.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Xanax, sold generically as alprazolam, is a popular drug to treat anxiety -- and to sell on the street.</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/september-3-2017-ogden-utah-xanax-714836047?src=Xf9c3aT8gmECixAW1xnBUg-1-3">PureRadiancePhoto/Shutterstock.com</a></span></figcaption></figure><p>As an <a href="https://www.starclab.org/members/arash-javanbakht">academic psychiatrist who treats people with anxiety and trauma</a>, I often hear questions about a specific class of medications called benzodiazepines. I also often receive referrals for patients who are on these medications and reluctant to discontinue them.</p>
<p>There has been increasing attention into long-term risks of benzodiazepines, including potential for addiction, overdose and cognitive impairment. The <a href="https://www.ncbi.nlm.nih.gov/pubmed/?term=Cohort+Study+of+the+Impact+of+High-Dose+Opioid+Analgesics+on+Overdose+Mortality">overdose death rate</a> among patients receiving both benzodiazepines and opioids is 10 times higher than those only receiving opioids, and benzo misuse is a serious concern.</p>
<h2>What are benzodiazepines?</h2>
<p>Benzodiazepines are a class of anti-anxiety medications, or anxiolytics, that <a href="https://www.aafp.org/afp/2000/0401/p2121.html">increase the activity of the gamma-aminobutyric acid</a> receptors in the brain. GABA is a neurotransmitter, a molecule that helps brain cells, or neurons, communicate with each other. GABA receptors are widely available across the brain, and benzodiazepines work to reduce anxiety by enhancing GABA inhibitory function.</p>
<p>The benzo family includes diazepam, or Valium; clonazepam, or Klonopin; lorazepam, or Ativan; chlordiazepoxide, or Librium; and the one most commonly known to the pop culture, alprazolan, or Xanax, among others. </p>
<p>Different benzos have similar effects, but they differ in strength, how long it takes for them to work and half-life, a measure of how long the drug stays in your system. For example, while <a href="https://www.rxlist.com/valium-drug.htm#clinpharm">diazepam</a> has a half-life of up to 48 hours, the half-life of <a href="https://www.rxlist.com/xanax-drug.htm#clinpharm">alprazolam can be as short as six hours</a>. This is important, as a shorter half-life is linked with higher potential for addiction and dependence. That is one reason physicians typically are not excited about prescribing Xanax for long periods of time.</p>
<h2>When are they used?</h2>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/297429/original/file-20191016-98636-1t09kde.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/297429/original/file-20191016-98636-1t09kde.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=399&fit=crop&dpr=1 600w, https://images.theconversation.com/files/297429/original/file-20191016-98636-1t09kde.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=399&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/297429/original/file-20191016-98636-1t09kde.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=399&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/297429/original/file-20191016-98636-1t09kde.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=502&fit=crop&dpr=1 754w, https://images.theconversation.com/files/297429/original/file-20191016-98636-1t09kde.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=502&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/297429/original/file-20191016-98636-1t09kde.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=502&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">Benzos are often prescribed to treat short-term anxiety.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/young-sad-depressed-black-afro-american-1159789150?src=UUPgoCwuIcGIXa856ZIftg-1-38">TheVisualsYouNeed/Shutterstock.com</a></span>
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<p>When benzos were introduced to the market in the 1950s, there was excitement as they were considered safer compared to <a href="https://www.drugs.com/drug-class/barbiturates.html">barbiturates</a>, which had been used to treat anxiety. By the 1970s, benzos made it to the list of the <a href="https://www.ncbi.nlm.nih.gov/pubmed/24007886">most highly prescribed medications</a>.</p>
<p>Benzos are mainly used to treat anxiety disorders, such as phobias, panic disorder and generalized anxiety disorder. They are mostly used for <a href="https://www.ncbi.nlm.nih.gov/pubmed/30454582">a short period</a> at the beginning of the treatment. That is because it may take a few weeks for the main pharmacological treatment for anxiety, antidepressants, to kick in. During that time, if anxiety is severe and debilitating, benzodiazepines may be prescribed for temporary use. </p>
<p>Benzos are also prescribed for occasional situations of high anxiety, such as that caused by phobias. The main treatment of phobias, such as excessive fear of animals, places and social interactions, is <a href="https://www.mayoclinic.org/tests-procedures/cognitive-behavioral-therapy/about/pac-20384610">psychotherapy</a>. Sometimes, however, phobias can interfere with one’s functioning just sporadically, and the person may not be interested in investing in therapy. For example, a person with fear of flying who may fly on a plane once or twice a year may choose to take a benzo before flying. However, for a businessman or woman who flies several times a months, psychotherapy is recommended. </p>
<p>Benzos may also be used for situations of short-term stress, such as a stressful job interview. </p>
<p>Benzos are also used for other medical conditions, such as <a href="https://www.ncbi.nlm.nih.gov/pubmed/25323468">treatment of seizures</a> or alcohol withdrawal in the hospital. There is <a href="https://www.healthquality.va.gov/guidelines/MH/ptsd/VADoDPTSDCPGClinicianSummaryFinal.pdf">no good evidence for use of benzos in post-traumatic stress disorder</a>.</p>
<h2>So why the worry?</h2>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/297597/original/file-20191017-98632-df4e6h.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/297597/original/file-20191017-98632-df4e6h.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=394&fit=crop&dpr=1 600w, https://images.theconversation.com/files/297597/original/file-20191017-98632-df4e6h.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=394&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/297597/original/file-20191017-98632-df4e6h.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=394&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/297597/original/file-20191017-98632-df4e6h.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=495&fit=crop&dpr=1 754w, https://images.theconversation.com/files/297597/original/file-20191017-98632-df4e6h.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=495&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/297597/original/file-20191017-98632-df4e6h.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=495&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Doctors often are reluctant to prescribe benzodiazepines, and many prefer to talk to their patients about the risks and also about other potential treatments, such as psychotherapy.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/asian-doctor-talking-middle-aged-woman-769470607?src=H24N3M5KnjChVCHoWtmrpA-1-23">Pormezz/Shutterstock.com</a></span>
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<p>Now we get to the part about why I and other doctors are not eager to prescribe benzodiazepines for long-term use: We have a Hippocratic oath to “first do not harm.” I sometimes tell patients who insist on getting benzos: “I am not paid differently based on the medication I prescribe, and my life would be much easier not arguing with you about this medication. I do this because I care about you.” </p>
<p>A major risk of long-term use of benzos is <a href="https://www.ncbi.nlm.nih.gov/pubmed/21714826">addiction</a>. That means you may become dependent on these meds and that you have to keep increasing the dose to get the same effect. Actually benzos, especially Xanax, have street value because of the pleasant feeling they induce. In 2017, there were more than <a href="https://www.drugabuse.gov/related-topics/trends-statistics/overdose-death-rates">11,000 deaths involving benzos</a> alone or with other drugs, and in 2015, a <a href="https://www.drugabuse.gov/drugs-abuse/opioids/benzodiazepines-opioids">fifth of those who died of opioid overdose</a> also had benzos in their blood. </p>
<p>Benzos to anxiety can be seen like opioids to pain. They both are mostly for short use, have a potential for addiction and are not a cure. Benzo overdose, especially when mixed with alcohol or opioids, may lead to slowing of breathing, and potentially death. Benzo misuse can also lead to lack of restraint of <a href="https://www.ncbi.nlm.nih.gov/pubmed/30454581">aggressive or impulsive behavior</a>. </p>
<p>As benzos are sedating medications, they also <a href="https://www.ncbi.nlm.nih.gov/pubmed/28448593">increase the risk of accidents and falls</a>, especially in the elderly. This is worse when they are mixed with other central nervous system suppressants like alcohol or opioids.</p>
<p>Recently, we have been learning more about the <a href="https://www.ncbi.nlm.nih.gov/pubmed/21714826">potential cognitive, memory and psychomotor impairment</a> in long-term use of benzodiazepines, especially in older adults. Cognitive functions impacted may include <a href="https://www.ncbi.nlm.nih.gov/pubmed/15762814">processing speed and learning</a> among others. <a href="https://www.ncbi.nlm.nih.gov/pubmed/15841867">Such effects may persist</a> even after discontinuation of long-term use of the benzos.</p>
<p><a href="https://www.ncbi.nlm.nih.gov/pubmed/7841856">Stopping benzos abruptly</a>, especially if high dose, can cause withdrawal symptoms, such as restlessness, irritability, insomnia, muscle tension, blurred vision and racing heart. Withdrawal from high doses of benzos, especially those that are shorter acting, may be dangerous, leading to seizure, and getting off of these medications should be done under supervision of a physician.</p>
<h2>Safer options abound</h2>
<p>There are safer effective treatments for anxiety, but they require patience to work. A first line treatment for anxiety disorders is psychotherapy, mainly <a href="https://www.mayoclinic.org/tests-procedures/cognitive-behavioral-therapy/about/pac-20384610">cognitive behavioral therapy</a>. During therapy, the person learns more adaptive coping skills, and corrects cognitive distortions to reduce stress. </p>
<p>Exposure therapy is an effective treatment for phobias, social phobia, obsessive compulsive disorder and PTSD. During exposure therapy, the person is gradually exposed to the feared situation under the guidance of the therapist, until the situation does not create anxiety anymore. Importantly, the skills earned during therapy can always be used, allowing better long-term outcome compared to medications.</p>
<p><a href="https://adaa.org/finding-help/treatment/medication">Medications are also used</a> for treatment of anxiety disorders. The main group of such medications is selective serotonin reuptake inhibitors, commonly known as antidepressants. Examples of such medications are fluoxetine, sertraline and citalopram. Especially when combined with psychotherapy, these medications are effective and are safer options than the benzos, and without a risk of addiction.</p>
<p>[ <em><a href="https://theconversation.com/us/newsletters?utm_source=TCUS&utm_medium=inline-link&utm_campaign=newsletter-text&utm_content=expertise">Expertise in your inbox. Sign up for The Conversation’s newsletter and get a digest of academic takes on today’s news, every day.</a></em> ]</p><img src="https://counter.theconversation.com/content/125346/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Arash Javanbakht does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Benzodiazepines, or benzos, are some of the most widely prescribed drugs in the US. They are meant to be used only short-term, but thousands use them long-term. That’s a big worry.Arash Javanbakht, Assistant Professor of Psychiatry, Wayne State UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1103192019-01-23T14:39:07Z2019-01-23T14:39:07ZInstadrugs: new research reveals hidden dangers when young people use apps to buy illicit substances<figure><img src="https://images.theconversation.com/files/255145/original/file-20190123-135157-70hoja.jpg?ixlib=rb-1.1.0&rect=0%2C4%2C3000%2C1693&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Quick, easy – and very, very risky. </span> <span class="attribution"><span class="source">The Conversation UK.</span></span></figcaption></figure><p>Markets for illicit drugs are constantly evolving to increase profits and reduce risks to suppliers in response to law enforcement tactics. New technologies have been taken up with enthusiasm: from the use of <a href="https://www.nytimes.com/1988/09/25/us/schools-responding-to-beeper-tool-of-today-s-drug-dealer-by-banning-it.html">pagers</a> and mobile phones in the 1990s, to the more recent growth of online pharmacies and <a href="https://theconversation.com/explainer-what-are-drug-cryptomarkets-64596">drug cryptomarkets</a>, which host large numbers of illicit drug vendors operating in the hidden portion of the internet known as <a href="https://theconversation.com/digital-refugees-flee-via-silk-road-to-black-markets-in-drugs-31465">the “dark net”</a>. </p>
<p>The most recent trend – which, until now, has only been recognised through anecdotal evidence and <a href="http://www.bbc.co.uk/newsbeat/article/40601036/teens-found-selling-drugs-on-snapchat-and-instagram-bbc-three-investigation-finds">media reports</a> – is the use of common social media and encrypted messaging apps, such as Instagram, Snapchat, WhatsApp and Wickr, to supply and access illicit drugs. Our <a href="https://www.sciencedirect.com/science/article/pii/S0955395918302111">latest research</a> provides the first exploration of this new market, analysing people’s motivations, methods, experiences and perceptions in relation to buying illicit drugs via apps. </p>
<p>We found that, for our participants, apps offer an intermediary option between street-level and online drugs markets, as they offer a quick, convenient and “secure” method for buying illicit drugs – especially since many of these apps are already installed on their phones. Snapchat, Instagram, Wickr and Kik were the preferred apps, while cannabis, LSD and ecstasy were the most common drugs purchased. </p>
<p>People use apps in different ways to buy and sell drugs, depending on the original purpose of the app. For example, Instagram is more likely to be used as a commercial marketplace, where a potential buyer could locate a dealer by searching and browsing their products. But when it comes to making a deal, users are more likely to move across to an encrypted messaging app, such as Wickr or WhatsApp, to establish a physical meeting place. </p>
<p>Inbuilt security features can also make a difference to the way people use an app for this purpose – Snapchat, for example, provides a platform for connecting buyers with a seller, but with the additional feature of being able to receive self-deleting snaps.</p>
<p>Dating apps, meanwhile, rely on a mobile phone’s location service to connect people, and required users to swipe through profiles looking for particular emojis, which indicate a potential dealer – for example, the use of the maple leaf emoji to signify cannabis. </p>
<h2>Welcome to the 21st century</h2>
<p>Social supply – that is, buying from friends or acquaintances – remains the most popular method of supplying drugs. But apps are increasingly being used because of their convenience and speed, which circumvents the need to hassle friends, seek out a street dealer or use the complex technology related to dark net markets.</p>
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Read more:
<a href="https://theconversation.com/not-all-drug-dealers-are-the-same-its-time-to-ditch-outdated-stereotypes-93773">Not all drug dealers are the same – it's time to ditch outdated stereotypes</a>
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<p>The wide range of substances available for purchase also motivated our participants to use apps, as they thought prescription medicines such as Xanax and codeine would be more readily accessible on those platforms. Because apps are so commonplace in modern society, some participants felt that buying drugs in this way was a simple matter of “moving with the times” – one participant said: “I felt like I’d woken up in the 21st century.”</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/255137/original/file-20190123-135160-1cpexp0.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/255137/original/file-20190123-135160-1cpexp0.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/255137/original/file-20190123-135160-1cpexp0.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/255137/original/file-20190123-135160-1cpexp0.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/255137/original/file-20190123-135160-1cpexp0.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=502&fit=crop&dpr=1 754w, https://images.theconversation.com/files/255137/original/file-20190123-135160-1cpexp0.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=502&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/255137/original/file-20190123-135160-1cpexp0.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=502&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">Know what you’re looking for?</span>
<span class="attribution"><a class="source" href="https://www.flickr.com/photos/grumpy-puddin/5161814652/sizes/l">Grumpy Puddin/Flickr</a>, <a class="license" href="http://creativecommons.org/licenses/by/4.0/">CC BY</a></span>
</figcaption>
</figure>
<p>While dark net markets <a href="https://journals.sagepub.com/doi/abs/10.1177/1748895813505234">use feedback systems</a> to establish the quality of the products being sold and the trustworthiness of the dealer, app-based drug markets cause potential buyers to rely on photos and videos of products as assurances that the seller is legitimate and the substance is safe to consume. </p>
<p>One participant thought “it was a better idea to buy it that way because I could look to see if it seemed cut with anything”. This flies in the face of <a href="https://www.sciencedirect.com/science/article/pii/S2211266915300050">pharmacological evidence</a> showing that the quality and safety of drugs can only be measured through forensic testing. Any belief that it’s possible to discern the quality and safety of a particular substance is problematic – if not downright dangerous. </p>
<h2>Gateway apps</h2>
<p>The security of encrypted messaging has been <a href="https://www.engadget.com/2018/09/03/five-eyes-countries-anti-encryption-policy/">called into question</a> in the UK and abroad, as <a href="https://theconversation.com/the-devil-is-in-the-detail-of-government-bill-to-enable-access-to-communications-data-96909">new laws require</a> companies to proactively assist law enforcement agencies in collecting information. Although our participants felt comfortable with the security provided by apps, and did not believe that they would be personally targeted by law enforcement, it is not yet apparent whether these new measures will have an impact on the popularity of these new forms of drug supply.</p>
<p>Apps have changed the drug supply landscape by providing a route to an illicit drugs market that is easy to access, and giving drug users with a means of connecting directly with commercial drug suppliers and substances that may otherwise remain elusive. The vast majority of participants in our research who had used apps to buy drugs were 18 years old, so the potential for apps to trigger a “<a href="https://www.ncbi.nlm.nih.gov/pubmed/28766792">supply gateway effect</a>” – whereby the search for one substance leads to others on the new platform – warrants further investigation. </p>
<p>As app-based drug markets continue to grow, experts and health professionals must work to demystify common assumptions that apps are “secure” and that being able to “see” the drug promotes safer purchasing practices – this could change the behaviour of prospective users and help protect them from danger. And with increasing law enforcement crackdowns likely, leaders need to provide a balanced approach which prioritises reducing harm.</p><img src="https://counter.theconversation.com/content/110319/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Monica Barratt receives funding from the National Health and Medical Research Council, the National Institutes of Health, the Australian Institute of Criminology and the Marsden Fund. She is also the Director of Research at Bluelight.org</span></em></p><p class="fine-print"><em><span>Ross Coomber receives funding from the National Health Medical Research Council and the Australian Institute of Criminology</span></em></p><p class="fine-print"><em><span>Andrew Childs and Leah Moyle do not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Buyers think you can tell the purity of a substance by looking at on an app – evidence shows they’re mistaken.Andrew Childs, Doctoral Candidate, Griffith UniversityLeah Moyle, Lecturer in Criminology, Royal Holloway University of LondonMonica Barratt, NHMRC Post-Doc Research Fellow, National Drug and Alcohol Research Centre, UNSW SydneyRoss Coomber, Professor of Criminology and Sociology, University of LiverpoolLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/945942018-04-11T13:15:12Z2018-04-11T13:15:12ZXanax: how does it work and what are the side effects?<figure><img src="https://images.theconversation.com/files/214290/original/file-20180411-592-17j2le2.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.flickr.com/photos/deanslife/1270344046/sizes/l">Dean812/Flickr</a>, <a class="license" href="http://creativecommons.org/licenses/by/4.0/">CC BY</a></span></figcaption></figure><p>More teenagers and young people use drugs than any other age group: <a href="https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/642738/drug-misuse-2017-hosb1117.pdf">in 2017</a>, 16.5% of 16- to 19-year-olds and 21.2% of 20- to 24-year-olds across England and Wales said they had taken drugs in the past year. And although drug use has declined over the past decade, new and potentially life-threatening trends continue to appear. Most recently, doctors <a href="https://www.theguardian.com/society/2018/feb/05/xanax-misuse-uk-dark-web-sales-health">have warned</a> of an “emerging crisis” relating to Xanax use among young people. </p>
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<a href="https://images.theconversation.com/files/214285/original/file-20180411-587-1gs5wa3.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/214285/original/file-20180411-587-1gs5wa3.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/214285/original/file-20180411-587-1gs5wa3.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=514&fit=crop&dpr=1 600w, https://images.theconversation.com/files/214285/original/file-20180411-587-1gs5wa3.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=514&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/214285/original/file-20180411-587-1gs5wa3.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=514&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/214285/original/file-20180411-587-1gs5wa3.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=646&fit=crop&dpr=1 754w, https://images.theconversation.com/files/214285/original/file-20180411-587-1gs5wa3.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=646&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/214285/original/file-20180411-587-1gs5wa3.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=646&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Alprazolam (Xanax) is a short-acting anxiolytic of the benzodiazepine class of psychoactive drugs.</span>
<span class="attribution"><span class="source">Igor Petrushenko / www.shutterstock.com</span></span>
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</figure>
<p>Xanax is a brand of alprazolam – a <a href="https://www.mind.org.uk/information-support/drugs-and-treatments/sleeping-pills-and-minor-tranquillisers/about-benzodiazepines/#.Ws3ks9PwalM">benzodiazepine</a> drug, or “benzo” – which is marketed as an alternative to Valium (diazepam) and used to treat anxiety, panic attacks and problems associated with depression. It works by affecting the way that the brain functions, to increase feelings of pleasure and reduce stress and anxiety. </p>
<p>Doses range from 0.25mg to a maximum of 3mg per day (by comparison, a teaspoon of sugar is about 1,300 times this amount). A dose can take up to an hour to have an effect, which then typically lasts for between five and 12 hours, depending on the formulation of the drug. It can take four or five days to clear the drug from the body. </p>
<h2>Here to stay</h2>
<p>While it is the most frequently prescribed benzodiazepine in the US, Xanax is not available in the UK, but it can be obtained on private prescriptions and online. Recent data suggests that <a href="https://www.theguardian.com/society/2018/feb/05/xanax-misuse-uk-dark-web-sales-health">the UK is the second largest market for Xanax on the dark web</a>, after the US. Its widespread availability on the internet has made the situation around this drug especially perilous. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/214282/original/file-20180411-540-wtry47.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/214282/original/file-20180411-540-wtry47.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/214282/original/file-20180411-540-wtry47.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=450&fit=crop&dpr=1 600w, https://images.theconversation.com/files/214282/original/file-20180411-540-wtry47.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=450&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/214282/original/file-20180411-540-wtry47.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=450&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/214282/original/file-20180411-540-wtry47.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=566&fit=crop&dpr=1 754w, https://images.theconversation.com/files/214282/original/file-20180411-540-wtry47.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=566&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/214282/original/file-20180411-540-wtry47.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=566&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<span class="caption">A bottle of prescription alprazolam pills.</span>
<span class="attribution"><span class="source">PureRadiancePhoto/Shutterstock</span></span>
</figcaption>
</figure>
<p>To be clear, there is no such thing as a “safe” drug. A drug – whether swallowed, smoked, inhaled, injected – is going to have an effect on the physiology and, potentially, the mental state of the person who takes it. Every person is different, and will react differently to different drugs, doses and ingredients. It is never clear exactly what is actually in the recreational drugs that people take which is why we should be so concerned about the effects that they might have. </p>
<p>But we can’t pretend that recreational drugs are going to go away. People have used drugs for thousands of years; whether for religions reasons, as a way of life, due to peer pressure, to experiment, or to escape from reality. Some are legal, while others carry severe fines, prison sentences or penalties as harsh as the death sentence in some parts of the world. People will use drugs such as Xanax regardless of legal controls, so it’s best to be clear how it works, and why it presents a health risk.</p>
<p>When people use Xanax regularly, they build up a tolerance to the drug, which means they need to take larger and more frequent doses for the drug to have the desired effect. Eventually, this results in a physical dependence – where the brain needs the drug to function “normally”. People can also develop a psychological dependence – they feel like they “need” the drug. Together, these effects lead to what we understand as addiction. </p>
<h2>Know the risks</h2>
<p>If someone becomes addicted to prescription drugs, including Xanax, then the effect of the drugs has to be reversed - normal functioning of the brain cells must be restored and this is a long, slow and often painful process. Under the influence of the drug, there are <a href="https://drugabuse.com/library/the-effects-of-xanax-use/">side effects</a> – apathy, sleepiness, decreased cognitive functioning, as well as the possibility of slurred speech or violent outbursts. </p>
<figure class="align-left zoomable">
<a href="https://images.theconversation.com/files/214288/original/file-20180411-566-y0h123.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/214288/original/file-20180411-566-y0h123.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/214288/original/file-20180411-566-y0h123.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=900&fit=crop&dpr=1 600w, https://images.theconversation.com/files/214288/original/file-20180411-566-y0h123.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=900&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/214288/original/file-20180411-566-y0h123.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=900&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/214288/original/file-20180411-566-y0h123.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=1131&fit=crop&dpr=1 754w, https://images.theconversation.com/files/214288/original/file-20180411-566-y0h123.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=1131&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/214288/original/file-20180411-566-y0h123.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=1131&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Unhealthy combination.</span>
<span class="attribution"><span class="source">Burlingham/Shutterstock</span></span>
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</figure>
<p>Like any other benzodiazepine drugs, Xanax should not be taken with alcohol. This can increase the drug’s effects, potentially leading to loss of consciousness and coma. What’s more, Xanax levels could build up in the body, which increases the chance of an overdose the next time the drug is taken. All of these effects present risks to the user’s health, or to their livelihood and future aspirations. </p>
<p>The drug market contains products manufactured legally and illegally. Some drugs are diverted onto the black market from legal pharmaceutical sources, while others are powders imported from overseas and pressed into tablet form. In our work as forensic chemists, we have seen this with many other drug types over the years through our <a href="http://pubs.rsc.org/en/content/articlelanding/2014/ay/c3ay41020j#!divAbstract">casework and research</a> on MDMA, piperazines and cathinones. There is always a risk that the drug in the powder is not what it seems – even if the pill looks legitimate. </p>
<p>Drugs which are legally manufactured and sold undergo quality control procedures - for example controlling the amount of drug in each pill and its purity. On the black market, these processes are completely missing. Most users can’t determine the materials and processes used to make illegal drugs, so there is no way of knowing the toxicity of the drugs or of the chemicals made from the side reactions of the drug making process. </p>
<p>Drug testing kits are available on the internet, but at best, these will only tell you the group of drugs that a pill may contain - not which of the many possible drugs are present. They won’t accurately tell you how much drug is present, or how the drug was made or what impurities the pill might contain. Some employers use drug testing in the workplace: these tests are accurate, and employees who test positive for drugs often face dismissal. The best way to avoid the risks associated with recreational drugs is to avoid taking them altogether.</p><img src="https://counter.theconversation.com/content/94594/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Michael Cole has received funding from the EPSRC, EU (Framework V), EU AGIS programme, Botswanan Government and South African Police Service for carrying out research on the analysis and profiling of controlled substances.</span></em></p><p class="fine-print"><em><span>Agatha Grela and Lata Gautam do not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.</span></em></p>More young people are using Xanax – but overdose, addiction and side effects present serious risks.Michael Cole, Professor of Forensic Science, Anglia Ruskin UniversityAgatha Grela, Postdoctoral researcher, Anglia Ruskin UniversityLata Gautam, Senior Lecturer in Forensic Science, Anglia Ruskin UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/128972013-03-19T03:52:17Z2013-03-19T03:52:17ZWhy the TGA should make it harder for people to get Xanax<figure><img src="https://images.theconversation.com/files/21410/original/9jnghy6d-1363657382.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">This class of drug poses significant risks of misuse and dependence, paradoxical reactions, disinhibition, amnesia and intoxication.</span> <span class="attribution"><span class="source">Jacek Becela</span></span></figcaption></figure><p>The body responsible for regulating drugs in Australia, the Therapeutic Goods Administration (TGA), is poised to decide whether to restrict access to benzodiazepines, such as Xanax, Valium and Normison. </p>
<p>The drugs are commonly – <a href="http://dx.doi.org/10.1111/j.1360-0443.2011.03563.x">but controversially</a> – used to treat anxiety and insomnia. However, there is a growing body of evidence that they’re increasingly being misused. </p>
<p>A TGA committee meeting on Wednesday will consider <a href="http://www.tga.gov.au/newsroom/consult-scheduling-acmcs-1303.htm">rescheduling benzodiazepines</a> to restrict their use. </p>
<p>More than 7.5 million benzodiazepine prescriptions were dispensed across Australia in 2010 - including more than 680,000 for alprazolam (AKA Xanax). The proposal is to move benzodiazepines from Schedule 4 to the more restrictive <a href="http://www.australianprescriber.com/magazine/20/1/12/3">Schedule 8</a>. Medicines on Schedule 8 are considered potentially addictive, and have an additional layer of monitoring and control to support quality prescribing, and reduce drug dependence and diversion. </p>
<p>Benzodiazepines are not <a href="http://jop.sagepub.com/content/19/6/567.short">first-line treatments</a> for anxiety and there’s limited medical evidence of their efficacy beyond two to four weeks. In fact, they’re only approved and recommended for short-term use. </p>
<p>There’s good evidence that, in most cases, non-pharmaceutical treatment of <a href="http://www.biomedcentral.com/1471-2296/13/40">insomnia</a> <a href="http://onlinelibrary.wiley.com/doi/10.1111/j.1440-1614.2004.01423.x/full">and</a> <a href="http://journals.lww.com/co-psychiatry/Abstract/2009/01000/Current_use_of_benzodiazepines_in_anxiety.16.aspx">anxiety</a> are as effective as these drugs. And that their benefits are more enduring, with less risk of adverse effects. </p>
<h2>What’s the harm?</h2>
<p>There’s been growing concern about the misuse and harms of <a href="http://www.health.vic.gov.au/aod/pubs/benzoresponse.htm">benzodiazepines</a> in recent years. The drug poses significant risks of misuse and dependence, paradoxical reactions, disinhibition, amnesia and intoxication. </p>
<p>There’s particular concern about <a href="http://www.mjainsight.com.au/view?post=alprazolam-linked-to-heroin-deaths&post_id=12343&cat=issue-7-4-march-2013">alprazolam</a>, a potent, fast-acting benzodiazepine that has been associated with <a href="http://au.news.yahoo.com/sunday-night/features/article/-/14207856/expressInstall/">serious</a> <a href="http://www.theage.com.au/national/experts-warn-xanax-usage-may-reach-epidemic-proportions-20120713-2223j.html">health risks</a>, such as misuse, dependence and crimes including <a href="http://www.theage.com.au/victoria/tranquilliser-use-causing-accidents-20121120-29o1j.html">traffic injuries</a>, <a href="http://ecite.utas.edu.au/74824">violence</a>, property damage, <a href="http://abcnews.go.com/US/xanax-defense-utah-woman-allegedly-mowed-husband-suv/story?id=16975190">blackouts</a>, theft and <a href="http://www.mjainsight.com.au/view?post=alprazolam-linked-to-heroin-deaths&post_id=12343&cat=issue-7-4-march-2013">overdoses</a>. Alprazolam has also been implicated in a number of celebrity drug-related deaths, including Heath Ledger’s.</p>
<p>Benzodiazepines were responsible for <a href="http://www.turningpoint.org.au/site/DefaultSite/filesystem/documents/Ambo%20Project%20Annual%20Trends%20Report%202010-11%20edit.pdf">3,135 ambulance attendances</a> in Victoria alone in 2010-11. In terms of all alcohol and drug related attendances, they were second only to alcohol, and there was a disproportionate increase in involvement of alprazolam compared to all benzodiazepines in ambulance attendances. </p>
<p>Health-care professionals, including general practitioners, needle syringe program workers and forensic workers, have experienced incidents of <a href="http://www.racgp.org.au/afp/2011/november/benzodiazepines/">extreme violence and aggression</a> resulting from Xanax misuse; this drug is often described as “angry pills”.</p>
<p>People who inject drugs or use opioids may take benzodiazepines for insomnia or anxiety, or to enhance the intoxicating effects of opioids. But benzodiazepine use causes particular problems for opioid dependent people. </p>
<p>One <a href="http://onlinelibrary.wiley.com/doi/10.1111/j.1360-0443.2005.01051.x/abstract">study</a> found people using a benzodiazepine within 12 hours of using heroin were at 28 times the risk of overdose compared with those who did not. Several studies have found that opioid users who also take benzodiazepines have poorer health and are at greater risk of contracting <a href="http://onlinelibrary.wiley.com/doi/10.1111/j.1465-3362.2012.00514.x/abstract">HIV</a>.</p>
<p>A <a href="https://www.mja.com.au/journal/2013/198/4/recent-increase-detection-alprazolam-victorian-heroin-related-deaths">study we recently published</a> investigated prescription rates of alprazolam and its detection in heroin-related deaths over the past 21 years. We found there was a disproportionate increase in the supply of the high-dose two milligram formulation of alprazolam (compared to other formulations). We also found a significant increase in the detection of alprazolam in heroin-related deaths since 2005. </p>
<p>The relationship between the increase in supply and increasing detection in deaths was linear. While we can’t definitively know whether alprazolam contributed directly to the deaths, we know that opioids and benzodiazepines (and alcohol) are central nervous system depressants, meaning that it’s easier to overdose if they’re taken together. That people who inject drugs are increasingly using this potent benzodiazepine is a huge concern.</p>
<h2>What’s the source?</h2>
<p>While some prescriptions are provided directly to opioid users, <a href="http://www.ncbi.nlm.nih.gov/pubmed/22141578">recent research</a> shows most (81%) people who inject drugs in Melbourne obtained alprazolam from illicit sources. Users pay between $3 and $5 for one tablet. A concessional prescription for 50 alprazolam tablets subsidised by the Pharmaceutical Benefits Scheme (PBS) costs $5.90, yielding a potential street value between $150 to $250. </p>
<p>This is a considerable profit for those on-selling their medication. And there’s been a considerable increase in reports of forged and altered prescriptions to obtain Xanax, which is the preferred brand name of alprazolam. </p>
<p>A 2012 Victorian review of reports of forged benzodiazepine prescriptions found 65% were for Xanax. This is the main reason why alprazolam should be rescheduled to S8. Before dispensing S8 drugs, pharmacists are required to recognise the prescriber’s handwriting or check whether she actually wrote the prescription.</p>
<p>Pharmacists report that it’s not uncommon for them to see prescriptions for 100 or 200 tablets. This is worrying for a product that has no proven benefit beyond short-term use.</p>
<h2>Would restrictions help?</h2>
<p>The proposed rescheduling of benzodiazepines could have significant infrastructure and workforce implications for already stretched addiction and <a href="http://www.agedcare.org.au/national-report/acsa-national-report-issue-297-24-january-2013/tga-proposal-to-reschedule-benzodiazepines">aged care</a> sectors. Still, many health professionals <a href="http://www.mjainsight.com.au/view?post=alprazolam-linked-to-heroin-deaths&post_id=12343&cat=issue-7-4-march-2013">support</a> a selective rescheduling of alprazolam because of the problems stemming from its higher potency.</p>
<p>The effectiveness of this kind of rescheduling is well demonstrated by the case of flunitrazepam (Rohypnol). This drug was rescheduled to S8 in 1998, leading to a significant drop its detection in heroin-related deaths. </p>
<p>Similarly, in May 2001, the PBS started to require authority for temazepam gel capsules, which became favoured for injection in the late 1990s (causing serious injection wounds and gangrene). This resulted in a <a href="https://www.mja.com.au/journal/2004/181/6/effects-restricting-publicly-subsidised-temazepam-capsules-benzodiazepine-use">reduction in its use</a> by people who inject drugs. And the product was eventually <a href="http://www.ncbi.nlm.nih.gov/pubmed/18264874">withdrawn</a> and remaining stocks destroyed by the manufacturer in 2004.</p>
<p>Given the success of the restrictions applied to flunitrazepam and temazepam, and the substantial harm resulting from the increased supply of alprazolam, we hope the TGA’s scheduling committee will acknowledge the evidence of its significant harms and make it more diffuclt for people to access alprazolam.</p><img src="https://counter.theconversation.com/content/12897/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Suzanne Nielsen does not work for, own shares, or consult for any company or organisation that would benefit from the article. She is the current recipient of an NHMRC Early Career Fellowship. </span></em></p><p class="fine-print"><em><span>Angela Rintoul and Louisa Degenhardt do not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.</span></em></p>The body responsible for regulating drugs in Australia, the Therapeutic Goods Administration (TGA), is poised to decide whether to restrict access to benzodiazepines, such as Xanax, Valium and Normison…Angela Rintoul, Doctor of Public Health Candidate, Monash UniversityLouisa Degenhardt, Professor of Epidemiology, NDARC, UNSW SydneySuzanne Nielsen, NHMRC Early Career Research Fellow Addiction Medicine, University of SydneyLicensed as Creative Commons – attribution, no derivatives.