T H E R o Y A LA U S T R A L I A N C o L L E G Eo F G E N E R A LP R A C T I T I O N E R S THE ROYAL AUSTRALIAN AND NEW ZEALAND COLLEGEOF PSYCHIATRISTS ALPRAZOLAM PRESCRIBINGGUIDELINES t rJ I ltflFj tr L-'l':ilN Alprazolam is a short-acting drug in the benzodiazepine class of medications. It is used to treat anxiety disorders and panic attacks. It is usually taken two to four times a day. Alprazolam is sometimes used in the treatment of depression and agoraphobia. Alprazolam may cause drowsiness and affect alertness. Ideally it should only be taken for short periods of time such as 2 to 4 weeks. Benzodiazepines are very effective for treating acute symptoms,butif short acting benzodiazepines such as alprazolarn are used long term, the intended effect diminishes with tolerance, there is a high risk of the development of dependency, and the rapidly fluctuating blood levels may exacerbatethe symptoms of anxiety disorder. "Benzodiazepines act more rapidly than antidepressants but are more likely to cause physical dependencies, and such adverse effects as somnolence, ataxia, and memory problems. Antidepressants and benzodiazepines are sometimes used in combination initially with a slow taper from the benzodrazepine after the antidepressant becomes effective".l l{I3f{"i {-}Fl*h,{llti\I\:il A1 fRAZf}LAht 1,1}TFIOP{OIDS Alprazolam, like other benzodiazepines, acts on the central nervous system (CNS). The effects of alprazolam are increased when combined with other central nervous system depressants such as methadone and other opiate related medications. "Major clinical issues occur with the concurrent use of benzodiazepines and opiates. Benzodiazepines and opiates used together increase the risk of fatal overdose and similarly the use of methadone and benzodiazepines increasesthe risk of sedation." 2 The mortality and harm that is associatedwith abuse of opioids prescribed in the community is an important emerging issue and associated with that abuse is the concurrent abuse of alprazolam (Alprax@, Kalma@, Xanax@ and Zamhexal@). There are also indications that harm levels in the use of this drug are increasing in line with the steadily increasing medical use of opioids. l-jlir f N llA\li{'i}1SO{tl}Ri?. 'for the treatment of Alprazolam is approved on the Pharmaceutical Benefits Scheme (PBS) panic disorders where other treatments have failed or are inappropriate'.3 Consideration needs to be given to whether the patient is suffering from panic disorder and not a generalised anxiety disorde4 or from anxiety symptoms generally, including those associatedwith drug abuse. Whilst isolated panic attacks are common, panic disorder is uncommon. It is quoted as affecting2to 3% of the population in a L2 month period and is 2to 3 times more prevalent in women than men 1 The Merck Manual 18'hEdition, 2006, Page 1.677: 2 National Comorbidity Project - Comorbidity of mental disorders and substanceuse; National Mental Health Strategy; National Drug Strategy. 3 S"h"d.rl" of Pharmaceutical Benefits August 2006 - Psycholeptics; Alprazolam "The initial approachfor the prophylaxis of panic disorder should include psychological measures such as cognitive behavioural therapy (CBT). While these will suffice for somepatients,otherswill need drugs as well. Somepatientsinitially do not relateto a psychologicalapproachand cannotuse CBT. They should be commencedon a first line pharmacologicaldrug, with CBT added later if possible. Regardingeffectiveness, the number needed-to-treatto get one personpanic free is 3 for CBT and 5 for medication. Pharmacotherapyfor panic disorder may need to be continuedfor 6 to 12 months in the first instance"a First line therapy is statedto be "newer antidepressantsparticularly paroxetineand sertraline".5 Benzodiazepinesare listed as secondline therapy along with tricyclic antidepressantsand MAOI's. The bi-national Committeeof PsychotropicDrugs and Other PhysicalTreatment (COPDOPT)take the view that there is some,be it small, evidence-basedsupport for the use of alprazolamfor short periods. In using it considerationshould be given to the fact that: . the enduring benefit is small . cognitive and motor side-effects of long term use must be considered the relatively greater development of tolerance and problems with withdrawal ' in patients using short acting agents such as alprazolam. In the caseof drug abuse very careful consideration needs to be given to the use of benzodiazepines, with diazepam being a preferred treatment for anxiety associated with drug withdrawal. Ideally such patients should be referred to an Alcohol and Drug specialist/services. ii : "i: :;lAJ-ill" 4.1.4;iii U 3ii Pharmaceutical Benefits Scheme data suggest that alprazolamprescribing in Tasmania is approximately 700% higher than the national average. Similarly the use of opioids in Tasmania is approximately 50% higher than the national average. The reported use of intravenous alprazolam in conjunction with methadone to achieve a "heroin" like high is of particular concern.6 In Tasmania there is an illicit drug problem associatedwith legally prescribed drugs and very little heroin. The practice of intravenously injecting alprazolam with methadone presents a very serious risk of overdose. Consistent with other jurisdictional arrangements, alprazolam is listed as a declared restricted substance under the Tasmanian Poisons (Declared Restricted SubstancesOrder 1990). This requirement means that prescriptions dispensed in Tasmanian must be written by prescribers registered in Tasmania. It also places other conditions on its supply by the dispensing pharmacist as a declared restricted substance. Possessionexcept in accordancewith a legal prescription is illegal and prescribers cannot prescribe this for drug dependent persons receiving Schedule 8 medications unless they are the holder of an authority issued under 522 of the Alcohol and Drug DependencyAct 1968 for those medications. (Refer- DHHS - Legalrequirements for theprescribingof Alprazolam)luly 2007 4 5 6 TherapeuticGuideline:PsychotropicYersion 5 Melbourne 2003,Page 176 TherapeuticGuideline:PsychotropicYersion 5 Melbourne 2003,Page 176 R Bruno; Tasmanian Drug Trends 2006 - Findings from the Illicit Drug Reporting System (IDRS) NDARC R. X t",t4' z Legal rcqufuements for the prescribingof alprazolam Cunent Regul atory St ah,ts Alprazolam is listed as a declared restricted substanceunder the Tasmanian Poisons (Declared RestrictedSubstanceOrder 1990)commonly referred to as a S4D.This requires: . e . . . o Prescriptions dispensedin Tasmaniamust be written only by prescribersregisteredin Tasmania. Repeatinterval must be stated on prescriptions. Prescription is valid for 5 months from date of writing. No emergencysupply by a pharmacist without a prescriber's authority. Possessionwithout authority is illegal unlessin accordancewith a legal prescription. Patients declared as drug dependent can only be prescribed an S4D by their authorised opioid prescriber. Changes as of L September 2007 All the above requirements remain and in addition: . . o . All prescriptions dispensed for alprazolamwill be added to the currently required monthly reporting of dispensedschedule8 substancesfrom Tasmanianpharmacies.(Note: alprazolam remains S4D) The prescribing of alprazolam for more than 4 weeks in conjunction with any opioid will require the prescriber to obtain an authority to prescribe. Authorities will be issued in a similar manner to the opioid authorities. ,\lprazolam prescribing to patients receiving a pharmacotherapywill not be legally authorised unless endorsedby the Clinical Director of the Alcohol and Drug Services.This is also a requirement of the TasmanianPharmacotheraPyPolicy. Prescriberswill be notified not to prescribe alprazolamif a patient is already under the care of another medical practitioner who is also prescribing benzodiazepinesandlor opioids. e Departmentof Health andHuman Services Tasmania klaa ;L- *\il!a"