(#174) Unique Challenges in Alprazolam Withdrawal: Success with a Combined Tapering Strategy

Abstract: Benzodiazepines (BZDs) are known to carry a high risk for misuse and dependence, with alprazolam being commonly implicated for those with another comorbid substance use disorder. Increasing prevalence of BZD use disorder makes it imperative for physicians to understand the presentation and management of BZD withdrawal. The unique features of alprazolam withdrawal syndrome can be understood through an examination of its chemical structure and pharmacokinetic properties. We present a case involving a patient admitted to the inpatient detoxification unit for alprazolam withdrawal syndrome, whose neuropsychiatric symptoms were refractory to just a chlordiazepoxide taper alone. He ultimately required a combined chlordiazepoxide/alprazolam taper. We discuss the literature surrounding this topic with the goal of conveying the atypical presenting symptomatology and treatment of alprazolam withdrawal syndrome. Key points of this case report include: the epidemiology of benzodiazepine use disorder, with a focus on alprazolam; alprazolam's molecular classification as a triazolobenzodiazepine, and the resulting effects on its pharmacokinetic profile; the potential for atypical, severe, and complicated withdrawal from alprazolam dependence; how the management of alprazolam withdrawal syndrome may differ from management of other benzodiazepine or alcohol withdrawal syndromes. The implications of this case highlight the lack of formal guidelines surrounding combined benzodiazepine tapers, and the importance of understanding that recognition of refractory alprazolam withdrawal may be difficult and confounded by the presence of neuropsychiatric and nonfocal neurological symptoms.

Short Description: This is a case report on a patient admitted to the inpatient detoxification unit for alprazolam withdrawal syndrome, whose neuropsychiatric symptoms were refractory to just a chlordiazepoxide taper alone and ultimately required a combined chlordiazepoxide/alprazolam taper.

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