Alprazolam policy too blunt to enact change: Study

The study, conducted by researchers at the University of New South Wales (UNSW), attempted to measure the effect of a February 2017 policy change that removed 2 mg-strength alprazolam tablets from the Pharmaceutical Benefits Scheme (PBS), reduced packet sizes from 50 tablets to 10, and eliminated refills.
 
The study’s authors analysed a range of data sources relating to prescribing and use of alprazolam (sold as Xanax), such as PBS dispensing databases and calls to a poisons information service.
 
Lead author and biostatistician Dr Andrea Schaffer said that while the 2014 reclassification of alprazolam to a Schedule 8 controlled drug led to a marked reduction in harms, the 2017 changes had not had the same effect.
 
‘While there was a 51% decrease in subsidised use of alprazolam after the policy change, prescription approvals went up by 18% and people were still receiving large amounts of alprazolam, which is not consistent with best practice guidelines,’ she said.
 
Removing the 2 mg-strength tablet from the PBS and reducing pack sizes also did not have the desired effect of reducing misuse, according to Dr Schaffer.
 
‘Data from the poisons information centre hotline also shows that there has been little change in poisonings, and suggests people were still obtaining 2 mg-strength tablets, whether as non-subsidised prescriptions or perhaps on the black market,’ she said.
 
‘It’s likely that many users were able to absorb the out-of-pocket cost, approximately $10 per pack of 50 tablets of 2 mg, and continue acquiring alprazolam through private, non-subsidised means.
 
‘Even among people initiating treatment, there was an increase in people initiating with more than 50 tablets, which is concerning as these larger packet sizes come with a greater risk of transition to long-term use and dependence.’
 
However, Chair of the RACGP Specific Interests Addiction Medicine network Dr Hester Wilson described the research as ‘fascinating’ and ‘very clever’. She said one-off policy changes were never likely to have much of an impact on what is a very complicated issue.
 
‘It is a high-risk, highly addictive medication and helping people who’ve been on alprazolam long term can be incredibly difficult. It’s tough for prescribers, it’s tough for the system, and it’s really tough for the patient as well,’ she told newsGP.
 
‘There’s no evidence-based treatment. It’s not like opioid dependency, where we have buprenorphine and methadone that have lots of good evidence to show they improve people’s outcomes.
 
‘The way I always describe it to patients is, it’s like you have got your body and your brain covered in a huge Elastoplast, and we’re ripping it off. If you try and rip it off all at once, it’s just intolerable. So what we’ve got to do is just peel it off little by little.
 
‘It still hurts, but it’s [finding] that balance between the pain that you’ve got and your ability to withstand and to function.’


Chair of the RACGP Specific Interests Addiction Medicine network Dr Hester Wilson believes one-off policy changes are never likely to have much of an impact on what is a very complicated issue.

Benzodiazepines, including alprazolam, are the second most common group of drugs linked to unintentional overdose in Australia, according to the Penington Institute’s annual overdose report. They were also involved in more drug-induced deaths in 2016 than heroin and methadone combined.
 
Dr Wilson believes any policy attempt to reduce long-term use needs to be part of a larger, more complex approach that includes education and upskilling for prescribers.
 
‘It’s a long-term process with lots of support and lots of follow up,’ she said.
 
‘Pharmacies are essential to help stage supply and supervise dosing. Urine drug screens are important, as is counselling so that people learn how to manage their emotions and their anxiety.
 
‘Everybody needs to work as a team with a patient in the middle of it and a focus on supporting them to slowly reduce the dose, because the reality is that [any long-term use] is not safe.’
 
The UNSW study appears to support Dr Wilson’s call for a more nuanced response, suggesting the 2017 changes had proved too blunt an instrument for affecting prescribing and misuse of the drug.
 
‘The evidence shows the policy changes made in 2017 are not the best way to improve use of this medicine and further changes are needed to better address misuse and reduce the risk of long-term dependence,’ Dr Schaffer said.
 
‘Once you’re on benzodiazepines, and alprazolam in particular, it’s very hard to go off of them, so I think we need a more multi-faceted approach to curb inappropriate use in the community.
 
‘It’s also important to note that many people are prescribed Xanax for legitimate reasons, for treatment of real pain and disorder, and its addictive properties then lead to problematic use.’
 
Dr Wilson said while there can be legitimate reasons to prescribe alprazolam – particularly for existing long-term users – the difficulties associated with dependence, and the lack of evidence supporting its therapeutic benefits, means she would advise against prescribing if at all avoidable.
 
‘From an evidence point of view, I’d say take it off the market; let’s not have it in Australia at all when we really don’t need it. We’ve got lots of other benzodiazepines that work just as well,’ she said.
 
‘The issue with that, though, is you have a group of people who’ve been on alprazolam long term … so a simple answer like, “Let’s just stop it so people can’t access it any more”, is not going to address the issues that people [already] on alprazolam have.
 
‘It’s such a hard thing to change.
 
‘You need to consider the amount of time you’re going prescribe them for and the outcomes that you’re looking for, otherwise you may end up inadvertently giving someone a benzodiazepine dependency – and that’s a life sentence.’

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