Issue 7 / 4 March 2013

AUSTRALIAN taxpayers are paying to help young people kill themselves with alprazolam, says a leading addiction expert.

Professor Kate Conigrave, from the University of Sydney’s School of Medicine, said the listing of 2 mg alprazolam on the Pharmaceutical Benefits Scheme (PBS) was a prescription for disaster. (1)

Professor Conigrave was responding to a new Victorian study published in the latest MJA detailing an increase in the detection of alprazolam in heroin-related deaths (HRDs). (2)

In a population-based study of community alprazolam supply and HRDs from January 1990 to December 2010, researchers found a 1426% increase in alprazolam supply. Detection of the drug in HRDs rose from 5.3% in 2005 to a peak of 35.5% in 2009.

The researchers also reported a disproportionate increase in prescribing of the high-dose 2 mg formulation compared with other formulations — from 4.1% to 27.9% between 1998 and 2010.

“I can see no indication for the 2 mg dose of alprazolam”, Professor Conigrave told MJA InSight.

“The only patients who need that high a dose are the ones who have developed tolerance for the drug, and that alone is an indication that they probably should be weaned off it. This is done by converting to a slower onset, longer acting drug, like diazepam. Regulated dispensing (eg, twice weekly) cuts down the risks.”

Professor Conigrave said a 2 mg dose of alprazolam was equivalent to 20 mg of valium and that she regularly saw patients taking between three and five 2 mg doses per day.

“If I was a GP I would never prescribe alprazolam”, she said. “… it’s highly addictive and the risk is considerable. Ordinary people can have an accidental overdose if they take it with alcohol. There’s also a huge black market out there for it.”

The findings of the study should increase pressure on federal and state governments to reschedule alprazolam from a Schedule 4 to a Schedule 8 drug, and to introduce live, real-time monitoring of S8 prescriptions, Professor Conigrave said.

In 2010, the Therapeutic Goods Administration (TGA) was lobbied to reschedule alprazolam as an S8 drug but did not do so, saying there was “insufficient evidence to support an S8 restriction for alprazolam, at this stage” and that doing so would be “inconsistent with current international practice”. (3)

Alprazolam was scheduled in the least restrictive categories in the UK, New Zealand, the US and Canada, as well as in the United Nations Convention on Psychotropic Substances. (4)

“Why shouldn’t Australia lead the world in this, as we have done with tobacco?” Professor Conigrave said. “There is absolutely not enough being done about this.”

A TGA spokeswoman said the rescheduling of benzodiazepines, including alprazolam, would be considered at a meeting later this month of the Advisory Committee on Medicines Scheduling. (5)

Asked how she would seek to regulate the increasing problems with alprazolam, Professor Conigrave said: “First I would introduce live, real-time pharmacy monitoring of all psychoactive drugs. Yes, the rescheduling to S8 would be great but I don’t think it is as important as live monitoring.

“Secondly, I would ban the 2 mg alprazolam preparation outright. There is just no need for it.”

GP and addiction medicine trainee, Dr David Outridge, of the Opiate Replacement Clinics in Cessnock and Newcastle, agreed that real-time monitoring of S8 medications would be helpful in curbing the alprazolam problem but said there were other options.

“PBS data show that the numbers of clonazepam [an anticonvulsive benzodiazepine medication] scripts have been steadily decreasing”, he said.

“My impression is that that was due to the PBS making it more difficult to get an authority by requiring a neurologist-confirmed diagnosis of epilepsy.”

Dr Outridge said this had made alprazolam a popular alternative, partly because an authority script for 6 months’ supply was available.

“Changing the authority conditions for alprazolam would be relatively easy, and at no state government expense”, Dr Outridge said.

– Cate Swannell

1. Pharmaceutical Benefits Scheme
2. MJA 2013; 198 : 206-209
3. National Drugs and Poisons Schedule Committee; Record of reasons of meeting: June 2010
4. United Nations: Convention on Psychotropic Substances 1971
5. Therapeutic Goods Administration Advisory Committee on Medicines Scheduling

Posted 4 March 2013

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19 thoughts on “Alprazolam linked to heroin deaths

  1. Daniel Graham says:

    As a long term Alprazolam addict allow me to dispel some myths and to reinforce what is already known.

    In the mid-80s Prof. Heather Ashton saw this problem coming. Her research and findings on Alprazolam addiction, withdrawl, abuse, contra-effects, etc. have been well documented in addition to tapering methodologies; moving the patient from Alprazolam to Valium/Diazapam was seen to be the most effective. On this note: yes, it works and is painless. After 19 years of abuse I no longer have a need for Alprazolam.

    The contra-effects, specifically depression, are horrendous and this in itself warrants a total ban on Aprazolam. Tolerance is equally destructive. I could easily ‘drop’ 6 mg and get by just fine and regularly did so. However, and let me state quite categorically, there is NO EUPHORIA associated with Alprazolam. Euphoria is a highly subjective term and if there is a standard definition it should not be associated with this drug. The only ‘euphoric’ effects reside in a complete divorce from reality. This is hardly euphoric but does, again, reinforce the need to rid society of this drug.

    Withdrawl should follow the Ashton Method and practitioners would do well to aquaint themselves with her research. This article is somewhat a bit after the fact and of course, had people done the research, the horse would not have bolted. Lives would have been saved.

    In short: talk to the addicts.

  2. Caroline Ash says:

    People with panic disorder have chronic hyperventiation and its resultant hypocapnia, leading to  hypoxia and reduced blood supply to the brain. Retraining their breathing should be the first imperative, no one can be expected to be really well if their breathing is disordered. The Buteyko Institute Method is the only breathing retraining method  I am aware of that “really works”. Unfortunately, it requires self-discipline to do the retraining exercise several times a day over at least 4 weeks, and not everyone wants to do that. However, even people on benzos and heroin addicts could do it if they wished, and improvements are often noticed within 5 days.  As the hypocapnia and its psychological symptoms improve, the need for benzos and hopefully even heroin to maintain the greater sense of calmness and well-being could realistically be expected to naturally decrease. I have had clients who have benefited greatly, though none were on regular medication with benzos or heroin.

  3. Anonymous says:

    I also agree with the sentiments of the article. I am amazed at the number of scripts some pts are able to get for their Xanax. The patients I see who are addicted to Benzoes in general are the hardest group to manage, and of the benzoes Xanax is the most destructive. It is certainly time to make it a schedule 8 drug.

  4. Shrink says:

    I’ve refused to prescribe alprazolam for many years, because of the highly addictive pattern of use commonly associated with it. I would be happy to see this specific benzodiazepine discontinued or made S8.

    However, I would not like to see all benzodiazepines restricted. While they are addictive, they are in general less toxic than other products that may be then become more widely used in their place – quetiapine, and risperidone, for example. There may also be an inappropriate drift to using some antidepressants, whose makers claim efficacy for them in anxiety, as substitutes.

    Any of these have more harmful side-effects that benzo’s. So don’t have benzo’s banned or made S8 to diminish the demand, but have the guts to prescribe them ONLY when genuinely appropriate.

  5. Colin McIver says:

    Crazy isn’t it? Can’t have buproprion for depression (even though it’s proven effective, doesn’t put on weight, cause sedation, cause impotence, or create dependence), and can’t have it for more than 3 months to stop a life-time smoking habit. But alprazolam – how much do you want?!

  6. William Huang says:

    Removal from the Australian formulary, i.e. removing availability of Alprazolam on any legal basis in my opinion would be the most cost effective blow for public health. Non drug treatments are the best for anxiety, safer alternatives drugs are widely available.

  7. Rose says:

    The problem with restricting Alprazolam to Psychiatrists is that it continues to support the drug as a valid treatment for Panic disorder where other treatments have failed etc when, like Dexamphetamine, it is in fact just another street drug for sale, regardless of who prescribes it. The Medicare and PBS budgets should be directed to appropriate referrals, such as to Drug Dependence Units, which are supposed to include comprehensive counselling and support programs with a view to maintaining abstinence, not continuing to peddle prescription medication.

  8. Tracy Soh says:

    @Docpob – the problem with removal from the PBS is that this will not restrict private prescriptions. Alprazolam is relatively cheap on private prescription (I think some of the discount pharmacies have 50 tablets bottles for around $15) so availability will still be very liberal. Making Listing it as schedule 8 means that a permit will be required, which will restrict availability to the minority of patients who legitimately require it. As an aside… there is a significant black market demand for alprazolam – a person can get 50 tablets for around $15 then sell them for $5 per tablet on the black market.

  9. Kate Conigrave says:

    We usually use the conversion that 2mg of alprazolam is equal to 20mg of diazepam.
    A lot of GPs and patients aren’t aware how strong 1 or 2mg alprazolam is compared to other benzos.
    Of course, important that people are weaned off (e.g. after conversion to diazepam), rather than stopped outright, else we’ll get a spate of seizures. People using high doses (e.g. more than 6mg alprazolam per day) probably need inpatient detox to get the reduction process started safely.

  10. L says:

    Agree with many of the above comments. My understanding was that 1mg of alprazolam was equivalent to 20mg of diazepam. One would think prescribing this dose of diazepam TDS or QID would raise alarm bells, although xanax seems to be given out without too much thought by some practitioners. I support calls for an S8 listing and restricting prescribing to psychiatrists.

  11. phil says:

    when i started as a gp some years ago it was pretty clear looking at the eyes of patients who asked for xanax or rohypnol that all benzos were not the same! so without any science other than a sense of foreboding i made sure i have never initiated any patient on them.s8 for sure

  12. M. Mofizul Islam says:

    Very timely article. I think immediate action is needed to stop Alprazolam in general and its 2mg dose in particular. Otherwise with the current increasing trend of its misuse a growing black market will be difficult to control.

  13. Docpob says:

    As a psychiatrist the only time I use alprazolam is prior to changing it as i deal with problems of its use. When I do need a benzodiazepine for panic I use clonazepam which unfortunately needs to be done as a private script. A good solution would be the PBS listing of clonazepam for panic and the removal of alprazolam from the PBS. The longer half life of clonazepam like diazepam decreases the problems. It would lead to a significant decrease in problems if the above was to occur.
    Alprazolam is a highly problematic drug. The use of clonazepam for panic decreases problems but it is not a first line medication and the other medications needs to be utilised in conjunction with other treatment strategies

  14. Rose says:

    Simple, remove Alprazolam from the PBS. As I have said previously, PBS treatment for narcotic addiction has specific guidelines. These do not include prescribing medications for sale, nor for polypharmacy for patients claiming ” I am jumping down off the ‘done’.” Speak to your local drug dependence unit- Alprazolam is not a recognised treatment for narcotic addiction. While narcotic addicts may panic when you do not prescribe a PBS narcotic for them to sell, this is not Panic Disorder, it is narcotic addiction, so refer them them to the Drug Dependence Unit. This takes more time than prescribing Alprazolam, so bite the bullet.

  15. Anonymous says:

    The pharmaceutical companies are the only winners in this and we medical practitioners need to take responsibility.

  16. BH says:

    I feel very sad when I read comments like ‘I don’t really care about the heroin adddicts on it’ (Comment 2, attributed to ‘The Mysterious Person’). Really? In what way is that an acceptable public statement for a doctor to make? It’s particularly disappointing as a comment on an article about preventing heroin-related deaths.

  17. Tracy Soh says:

    Working as an addiction medicine specialist in Melbourne, I can only reiterate the comments from Kate Conigrave and David Outridge in this article. Alprazolam is particularly problematic due to its high potency and relatively rapid onset of action.

    Use of alprazolam is associated with high levels of instability in our patients – the patients taking alprazolam are the ones who overdose, miss appointment or attend appointments intoxicated, act erratically and often aggressively (it seems cause paradoxical aggression more so than many other benzodiazepines – possibly as it is a triazole benzodiazepine similar to Halcyon which is notorious for causing the same), have increased difficulties with the legal system. A magistrate from the drug diversion court in Melbourne has openly stated that taking alprazolam is a predictor for poor outcomes and failure to complete diversion orders. It is astounding that a medication that can potentially cause so much harm is so easily and readily available.

  18. The Mysterious Person says:

    I agree whole heartedly. It is much more addictive than diazepam. Patients love it because it makes them feel euphoric and has a rapid onset. If someone is on it, they can be in a withdrawal state every morning. I am happy to say that I have never started anyone on it ever, and sad to say that I have very rarely got anyone off it. I don’t really care about the heroin addicts on it, but Mr and Mrs Citizen who get put on it are in real strife.

  19. Colin McIver says:

    Totally agree. All benzo’s are addictive so why aren’t they all classed as S8? Alprazolam in particular should also be further restricted to initiation by a Psychiatrist with regular follow up required to re-approve the prescriptions. This would relieve much of the pressure placed on GPs to prescribe, allow proper interventions for those dependent, and curb the number of prescriptions.

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