Emergency Department Visits Involving Nonmedical Use of the Anti-anxiety Medication Alprazolam

In Brief
  • The estimated number of alprazolam-related emergency department (ED) visits involving nonmedical use doubled from 57,419 visits in 2005 to 124,902 visits in 2010, but then remained stable in 2011 (123,744 visits).
  • Between 2005 and 2011, the estimated number of ED visits involving nonmedical use of alprazolam among patients aged 25 to 34 increased threefold; visits in this age group accounted for approximately one third (32 percent) of visits in 2011.
  • Among alprazolam-related ED visits involving nonmedical use, 19 percent involved alprazolam only. Alprazolam was used in combination with another drug in 39 percent of visits, with two drugs in 21 percent of visits, and with three or more drugs in 21 percent of visits.

Alprazolam falls into a class of drugs known as benzodiazepines, which are prescription medications used to treat anxiety, insomnia, depression, and panic disorders. Alprazolam, which is known by brand names Xanax®, Xanax XR®, and Niravam®, was the 13th most commonly sold medication in 2012 and was the psychiatric medication most commonly prescribed in 2011.1,2

When used as directed, alprazolam can be safe and effective; however, this drug can have serious health consequences when taken without medical supervision or in larger amounts than prescribed. Even short-term use can lead to dependence, causing withdrawal symptoms such as tremors and seizures.3 Alprazolam also has been shown to be significantly more toxic than other benzodiazepines if more than the prescribed amount is taken.4 Furthermore, if alprazolam is combined with other drugs that depress the central nervous system (CNS)—such as narcotic pain relievers—the effects of these drugs on the body can be dangerously enhanced.3

The Drug Abuse Warning Network (DAWN) is a public health surveillance system that monitors drug-related emergency department (ED) visits in the United States and can be used to track alprazolam-related ED visits involving nonmedical use. To be a DAWN case, an ED visit must involve a drug, either as the direct cause of the visit or as a contributing factor. Nonmedical use of drugs includes: (1) taking more than the prescribed dose, (2) taking a drug that was prescribed for another individual, (3) being deliberately poisoned with a drug by another person, or (4) documented misuse or abuse of a drug. Nonmedical use visits may include the use of alprazolam only or in combination with other pharmaceuticals, illicit drugs, or alcohol. This issue of The DAWN Report highlights characteristics of alprazolam-related ED visits involving nonmedical use in 2011 as well as recent trends.


Overview and Trends


The estimated number of alprazolam-related ED visits involving nonmedical use doubled from 57,419 visits in 2005 to 124,902 visits in 2010, but then remained stable in 2011 (123,744 visits) (Figure 1). These visits accounted for 10 percent of all ED visits involving nonmedical use of pharmaceuticals in 2011.

Figure 1. Trends in Alprazolam-Related Emergency Department (ED) Visits Involving Nonmedical Use, by Gender*: 2005 to 2011
This is a line graph comparing trends in alprazolam-related emergency department (ED) visits involving nonmedical use, by gender*: 2005 to 2011. Accessible table located below this figure.

Figure 1 Table. Trends in Alprazolam-Related Emergency Department (ED) Visits Involving Nonmedical Use, by Gender*: 2005 to 2011
Gender 2005 2006 2007 2008 2009 2010 2011
Total** 57,419 65,236 80,313 104,762 112,552 124,902 123,744
Male** 28,902 30,534 38,453   44,674   54,307   63,678   66,325
Female** 28,491 34,699 41,754   60,074   58,233   61,045   57,419
* Because gender is unknown in a small number of visits, estimates for males and females do not add to the total.
** The change from 2005 to 2011 is statistically significant at the .05 level.
Source: 2005 and 2011 SAMHSA Drug Abuse Warning Network (DAWN)


Gender and Age


The proportion of alprazolam-related ED visits involving nonmedical use was approximately equal for males and females, and there was a significant increase in the number of visits from 2005 to 2011 for both genders (Figure 1). However, trend patterns over time were somewhat different. For males, there was a steady increase in the estimated number of visits from 28,902 visits in 2005 to 66,325 visits in 2011. For females, the estimated number of visits increased from 28,491 visits in 2005 to 60,074 visits in 2008, then remained steady through 2011.

Visits made by patients aged 25 to 34 accounted for approximately one third (32 percent) of alprazolam-related ED visits involving nonmedical use in 2011. The number of ED visits in this age group increased threefold from 12,731 visits in 2005 to 39,651 in 2011 (Figure 2). Review of annual estimates shows that during 2005 and 2006, the highest percentage of alprazolam ED visits occurred in the 35 to 44 age group, and shifted in 2007 through 2011 to the 25 to 34 age group (data not shown). Visits for other age groups, except for patients aged 12 to 17 and patients aged 35 to 44, also experienced statistically significant increases from 2005 to 2011.

Figure 2. Age Distribution of Alprazolam-Related Emergency Department (ED) Visits Involving Nonmedical Use, by Year*: 2005 and 2011
This is a bar graph comparing age distribution of alprazolam-related emergency department (ED) visits involving nonmedical use, by year*: 2005 and 2011. Accessible table located below this figure.

Figure 2 Table. Age Distribution of Alprazolam-Related Emergency Department (ED) Visits Involving Nonmedical Use, by Year*: 2005 and 2011
Year Aged
12 to 17
Aged
18 to 24**
Aged
25 to 34**
Aged
35 to 44
Aged
45 to 54**
Aged
55 to 64**
Aged
65 or Older**
2005 2,358 11,827 12,731 15,142   9,201   4,219 1,711
2011 4,769 20,929 39,651 22,080 21,985 10,317 3,978
* Because age is unknown in a small number of visits, age group estimates do not add to the total.
** The change from 2005 to 2011 is statistically significant at the .05 level.
Source: 2005 and 2011 SAMHSA Drug Abuse Warning Network (DAWN).


Drug Combinations with Alprazolam


In 2011, most alprazolam-related ED visits involved nonmedical use in combination with another drug (81 percent); only 19 percent involved alprazolam only. Alprazolam was combined with one drug in 39 percent of visits, two drugs in 21 percent of visits, and three or more drugs in 21 percent of visits (Figure 3).

Figure 3. Number of Drugs Involved in Emergency Department (ED) Visits Involving Nonmedical Use of Alprazolam, with Drug Combination Details for Visits Involving Alprazolam Combined with One Drug*: 2011
This is a pie graph comparing number of drugs involved in emergency department (ED) visits involving nonmedical use of alprazolam, with drug combination details for visits involving alprazolam combined with one drug*: 2011. Accessible table located below this figure.

Figure 3 Table. Number of Drugs Involved in Emergency Department (ED) Visits Involving Nonmedical Use of Alprazolam, with Drug Combination Details for Visits Involving Alprazolam Combined with One Drug*: 2011
Drug Combinations Percent
Alprazolam only 19%
Alprazolam with one drug 39%
Alprazolam with two drugs 21%
Alprazolam with three or more drugs 21%
Among ED visits involving alprazolam with one drug:
Alprazolam with another pharmaceutical 63%
Alprazolam with alcohol 20%
Alprazolam with an illicit drug 18%
* Percentages may not sum to 100 due to rounding.
Source: 2011 SAMHSA Drug Abuse Warning Network (DAWN).

Among the 47,756 ED visits involving alprazolam with one other drug, 63 percent involved another pharmaceutical (Figure 3). More specifically, 36 percent involved pain relievers (e.g., oxycodone) and 9 percent involved other anti-anxiety or insomnia medications (including other benzodiazepines) (Table 1). The remaining visits involving alprazolam with one other drug involved alcohol (20 percent) or an illicit drug (18 percent).

Among the 51,898 ED visits involving alprazolam with two or more drugs, 85 percent involved other pharmaceuticals (Table 1). More specifically, 64 percent involved pain relievers, and 25 percent involved other anti-anxiety or insomnia medications. Nearly half (46 percent) involved illicit drugs, and 39 percent involved alcohol.

Table 1. Drug Combinations among Emergency Department (ED) Visits Involving Nonmedical Use of Alprazolam, by Number of Drugs Involved: 2011
  Percentage of ED Visits
Involving Alprazolam
with One Drug*
Percentage of ED Visits
Involving Alprazolam
with Two or More Drugs**
Total Visits Involving Alprazolam 100% 100%
Other Pharmaceuticals   63%   85%
Pain Relievers   36%   64%
Narcotic Pain Relievers   32%   57%
Other Anti-anxiety or Insomnia Medications     9%   25%
Other Benzodiazepines     4%   17%
Muscle Relaxants     5%     9%
Alcohol   20%   39%
Illicit Drugs   18%   46%
Heroin     8%     7%
Marijuana     4%   29%
* Percentages may not sum to 100 due to rounding.
** Because multiple drugs are involved in each visit, percentages add to more than 100 percent.
Source: 2011 SAMHSA Drug Abuse Warning Network (DAWN).


Disposition of ED Visits, by Drug Combination


Alprazolam is known to interact with other drugs, including other CNS depressants (i.e., pain relievers and other anti-anxiety and insomnia medications). As expected, visits involving alprazolam only resulted in a lower percentage of hospital admissions (21 percent) than visits involving alprazolam and other CNS depressants (30 percent) (Table 2). The percentage of hospital admissions involving alprazolam and other CNS depressants was similar to the percentage of admissions involving alprazolam combined with drugs other than CNS depressants (29 percent).

Table 2. Disposition of Alprazolam-Related Emergency Department (ED) Visits Involving Nonmedical Use of Pharmaceuticals, by Drug Combination: 2011
  Alprazolam
Only
Alprazolam
with Other CNS
Depressants*
Alprazolam
with Other Drugs,
Excluding
CNS Depressants*
Number of ED Visits 24,090 60,041 39,614
Percentage Treated & Released 64% 58% 62%
Percentage Admitted 21%    30%** 29%
Percentage Transferred   8%   8%   6%
Percentage with Other Disposition   7%   4%   4%
* CNS depressants include pain relievers and anti-anxiety and insomnia medications.
** Compared to visits involving alprazolam only, the difference is statistically significant at the .05 level.
Source: 2011 SAMHSA Drug Abuse Warning Network (DAWN).


Discussion


Over the 7-year period from 2005 to 2011, alprazolam-related ED visits involving nonmedical use increased substantially through 2010 and then remained stable from 2010 to 2011. The same trend was found for substances secured in law enforcement operations and analyzed by Federal, State, and local forensic laboratories; these data are summarized in the National Forensic Laboratory Information System (NFLIS) Annual Report. In 2011, alprazolam was ranked seventh on the NFLIS list of the 25 most frequently reported drugs in laboratory reports, with an estimated 43,231 total reports.5

The age distribution of alprazolam-related ED visits involving nonmedical use changed between 2005 and 2011. In 2005, patients aged 25 to 34 had a similar number of visits as other young and middle adult age groups (18 to 24 and 35 to 54). However, by 2011, the 25 to 34 age group had nearly twice the number of visits as other young and middle adult age groups. This suggests that adults aged 25 to 34 may have the greatest need for interventions addressing nonmedical use of alprazolam.

Physicians prescribing alprazolam should warn patients against combining alprazolam with other medications, alcohol, or illicit drugs.3 Patients should also be advised to only take prescription medications prescribed for themselves and take no more than the prescribed amount of alprazolam to avoid adverse health effects that may require urgent medical attention. Prevention and education campaigns should continue to focus on the dangers of sharing prescription medications, the importance of preventing others from having access to personal prescription medications, and methods for properly disposing of remaining dosage units once the need for medication has passed.


References


1 IMS Health. (2013). Top 25 medicines by dispensed prescriptions (U.S.). Retrieved from http://www.imshealth.com/deployedfiles/imshealth/Global/Content/Corporate/Press%20Room/2012_U.S/Top_25_Medicines_Dispensed_Prescriptions_U.S..pdf
2 Grohol, J. M. (2012). Top 25 psychiatric medication prescriptions for 2011. Psych Central. Retrieved from http://psychcentral.com/lib/top-25-psychiatric-medication-prescriptions-for-2011/00012586
3 Pfizer, Inc. (2011). Xanax®. Retrieved from http://www.accessdata.fda.gov/drugsatfda_docs/label/2011/018276s045lbl.pdf
4 Isbister, G. K., O'Regan, L., Sibbritt, D., & Whyte, I. M. (2004). Alprazolam is relatively more toxic than other benzodiazepines in overdose. British Journal of Clinical Pharmacology, 58(1), 88-95.
5 U.S. Department of Justice, Drug Enforcement Administration, Office of Diversion Control. (2012). National Forensic Laboratory Information System: 2011 annual report. Retrieved from http://www.deadiversion.usdoj.gov/nflis/2011annual_rpt.pdf


Suggested Citation


Substance Abuse and Mental Health Services Administration, Center for Behavioral Health Statistics and Quality. (May 22, 2014). The DAWN Report: Emergency Department Visits Involving Nonmedical Use of the Anti-anxiety Medication Alprazolam. Rockville, MD.

The Substance Abuse and Mental Health Services Administration (SAMHSA) is the agency within the U.S. Department of Health and Human Services that leads public health efforts to advance the behavioral health of the nation. SAMHSA's mission is to reduce the impact of substance abuse and mental illness on America's communities.

The Drug Abuse Warning Network (DAWN) is a public health surveillance system that monitors drug-related morbidity and mortality. DAWN uses a probability sample of hospitals to produce estimates of drug-related emergency department (ED) visits for the United States and selected metropolitan areas annually. DAWN also produces annual profiles of drug-related deaths reviewed by medical examiners or coroners in selected metropolitan areas and States.

Any ED visit related to recent drug use is included in DAWN. All types of drugs—licit and illicit—are covered. Alcohol involvement is documented for patients of all ages if it occurs with another drug. Alcohol is considered an illicit drug for patients under age 21 and is documented even if no other drug is involved. The classification of drugs used in DAWN is derived from the Multum Lexicon, copyright 2012 Lexi-Comp, Inc., and/or Cerner Multum, Inc. The Multum Licensing Agreement governing use of the Lexicon can be found at http://www.samhsa.gov/data/DAWN.aspx.

DAWN is one of three major surveys conducted by SAMHSA's Center for Behavioral Health Statistics and Quality (CBHSQ). For more information on other CBHSQ surveys, go to http://www.samhsa.gov/data/. SAMHSA has contracts with Westat (Rockville, MD) and RTI International (Research Triangle Park, NC) to operate the DAWN system and produce publications.

For publications and additional information about DAWN, go to http://www.samhsa.gov/data/DAWN.aspx.

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