Short-term anxiolytic choice, interactions and taper planning (MEQ)

(i) Durable GAD treatment and BZD place. BAP-style guidance prioritises SSRI/SNRI (here sertraline already started) plus psychological therapy (CBT) as durable care. Optimise antidepressant trial (dose/duration/adherence) rather than converting acute distress into lifelong alprazolam. Benzodiazepines may have a short-term bridge role for severe arousal while the SSRI works, but are not long-term first-line maintenance for GAD.^[1]

(ii) Opioid interaction. Concurrent opioids and benzodiazepines associate with increased overdose risk (Sun et al.). Counsel: avoid stacking CNS depressants and alcohol; do not drive if sedated; consider whether any GABAergic drug is justified at all; if used, lowest dose, shortest time, close review; naloxone access education does not make the combination safe.^[2]

(iii) Example short bridge (if still chosen after risk discussion). Prefer a lower-misuse-risk intermediate agent over alprazolam — e.g. lorazepam 0.5 mg orally as needed up to a limited daily maximum for days to a few weeks only, with a written stop/review date, no automatic repeats, and parallel sleep hygiene/CBT skills. Document indication and exit. Avoid high-potency short-acting alprazolam as first choice when dependence risk and interdose anxiety are concerns.^[1][3]

(iv) Non-GABAergic options. Buspirone (5-HT1A partial agonist): start 5 mg two–three times daily, titrate toward often 15–30 mg/day total; delayed onset (weeks); not for BZD withdrawal cover; azapirone evidence in GAD.^[5] Pregabalin (α2δ Ca channel): e.g. 75 mg twice daily titrating toward common 150–300 mg/day ranges with renal caution — supported by placebo-controlled GAD trials.^[4] Hydroxyzine (H1 antagonist) is another non-GABAergic symptomatic option (e.g. 25–50 mg dosing patterns per label) with RCT support but sedation/anticholinergic limits.^[6]

(v) Established alprazolam taper. Do not abrupt-stop. Reconcile dose; convert toward a longer agent (often diazepam equivalents) if interdose withdrawal; reduce by about 10–25% every 1–2 weeks (slower near end); treat primary GAD with SSRI/CBT; psychosocial support; reinstate cover if seizure/severe withdrawal. Structured strategies beat abrupt advice (Voshaar; Soyka; Ashton).^[3][7][8]