# A client on long-term high-dose alprazolam admits to abruptly stopping it 36 hours ago. He has tremor, anxiety, BP 168/98, HR 116, and one witnessed generalized seizure. Which action is the priority?

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> language: en  
> subject: NCLEX-RN  
> category: SIPC

## Question

A client on long-term high-dose alprazolam admits to abruptly stopping it 36 hours ago. He has tremor, anxiety, BP 168/98, HR 116, and one witnessed generalized seizure. Which action is the priority?

## Option

1. Immediately resume alprazolam at maintenance dose and discharge home
2. Initiate IV long-acting benzodiazepine such as diazepam, then plan a gradual outpatient taper **✔ Correct answer**
3. Administer haloperidol IM for agitation and observe
4. Use cold packs and physical restraint until symptoms resolve

**Correct answer: 2**

## Explanation

Abrupt cessation of high-dose long-term benzodiazepines can cause life-threatening withdrawal: seizures, autonomic instability, even delirium. Treatment is substitution with a long-acting BZD (diazepam, chlordiazepoxide) — or phenobarbital in some protocols — at a stabilizing dose followed by gradual taper over weeks to months. Discharge after one dose is unsafe. Haloperidol does NOT prevent BZD withdrawal seizures and may lower seizure threshold. Restraint without pharmacologic management is harmful.

## In-depth explanation

Tapers typically reduce dose by 10-25 percent every 1-2 weeks. Faster tapers in inpatient with monitoring. Avoid abrupt discontinuation — can be fatal.

## Clinical scenario

Long-term alprazolam 2 mg q6h for 4 years. Last dose 36 hours ago.

## Key concepts

- **benzodiazepine withdrawal** — GABAergic rebound after abrupt cessation; potentially fatal seizures.
- **cross tolerance** — Tolerance to one drug confers tolerance to similar agents — basis for substitution therapy.
- **phenobarbital protocol** — Alternative for severe BZD withdrawal using long-acting barbiturate.

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