BETA BLOCKERS AND PERFORMANCE ANXIETY IN MUSICIANS A Report by the beta blocker study committee of FLUTE: Karla Harby, freelance writer and amateur flutist Kathrin Kucharski, clinical pharmacist and amateur flutist Sarah Tuck (committee chair), professional flutist Julia Vasquez, professional flutist Beta blockers have been called "the musicians underground drug." Often musicians form their opinions, and may risk their health, based on locker-room- type information. Performance anxiety can be a deeply personal subject for musicians, and many are reluctant to discuss all the possible remedies. It is our intention to bring this subject into the open, and to provide accurate information to inform personal opinions and decisions. z 1. What are beta blockers (such as Inderal)? Beta blockers block the receptors for the physical effects of a person's natural fight or flight response. They are not sedatives, and they can't help anxiety of a purely psychological nature. Beta receptors are found in a number of places in the body: heart, lung, arteries, brain and uterus, to name a few. Like a key in a lock, beta blockers chemically fit into beta receptors and prevent norepinephrine from binding to the receptors that cause the symptoms of the fight-or-flight response. The degree of these effects depends on the dose and the individual's sensitivity to the medication. Peak effect occurs in one to one and a half hours. Ideally, this could allow a performer to play at his or her best, without the distraction or interference of excessive fight or flight symptoms. Blocking beta receptors can cause decreased heart rate; decreased force of heart contractions; bronchoconstriction (can cause asthma attacks in people with asthma); uterine contractions; decreased blood pressure; relief of migraines; and decreased tremor. The beta receptors found in the different areas of the body are not all the same, thus different beta blockers may affect these areas differently. For instance, metoprolol (Lopressor) and atenolol (Tenormin) are beta-1 selective, which means they block only beta-1 receptors found primarily in the heart, but not the beta-2 receptors found in the lung and uterus. Thus, they can decrease blood pressure, heart rate and force of cardiac contraction, but are less likely to cause bronchoconstriction and uterine contractions. This selectivity is not absolute and depends on the dose. Some beta blockers enter the brain better than others. Propranolol (Inderal) crosses the blood-brain barrier particularly well. This may be why propranolol causes more central nervous system side effects, such as hallucinations, nightmares, and depression, than the beta blockers that do not cross into the brain as easily. Interestingly, the ability of beta blockers to help anxiety seems related only to their blockade of beta receptors outside of the brain. Beta blockers will not help the emotional symptoms of stage fright (for example, sleep problems or negative inner voices). Everyone's body responds differently to beta blockers. For this reason it is important that each person experiment, under medical supervision, to find the ideal dosage for a performance situation. Similarly, it is important to take the beta blocker a few times and under different circumstances before a major performance to be sure the individual has no adverse reactions. z 2. Do I need to see a doctor before taking them? Everyone, without exception, must obtain their beta blockers from a physician. It is a violation of federal law in the United States, and many other countries, to give prescription medications to someone other than the person for whom they were prescribed. Beta blockers are prescription medications for good reason. There are several conditions, such as slow heart rate, bronchial asthma, and heart failure, which can cause serious medical problems, even death, when taking this medication. In addition, you should know that some psychiatrists and psychologists feel that beta blockers ought only to be used in the context of psychological intervention, and only as a temporary measure. z 3. What kinds of problems are beta blockers good for? One reference lists 29 different uses, including high blood pressure, angina, irregular heart rhythms, migraines, prevention of a second heart attack, tremors, alcohol withdrawal, anxiety and glaucoma. In the United States, a physician can prescribe medications for uses not approved by the Food and Drug Administration, so long as there is scientific literature to support the use. Usually the pharmaceutical company involved will only research and develop a few uses to submit to the FDA to get the medication approved for marketing. Once the medication wins FDA approval, the pharmaceutical company is only allowed to advertise it for FDA-approved uses. Over time, however, researchers and physicians gain experience using the medication for uses not approved by the FDA. Beta blockers are not FDA approved for use in anxiety or stage fright, but these medications can be prescribed for this purpose because there is scientific literature to support this use. z 4. Are beta blockers safe? Only your physician can tell you whether beta blockers are safe for you. Beta blockers can significantly worsen some medical conditions. As a general rule, beta blockers should not be used in asthmatic people. Beta blockers can worsen congestive heart failure, Raynaud's syndrome, and diabetes. Musicians who take beta blockers often do so in small doses and only on special occasions, so they may experience no side effects at all from their use. However, many side effects have been reported from these medications, including rash, anaphylactic shock (sudden unconsciousness or death), slowed heart rate, low blood pressure, cold extremities, worsening of heart failure, fainting, rapid heart beats, dizziness, fatigue, headache, depression, sleep disturbances, nightmares, hallucinations, short term memory loss, high or low blood sugar, stomach ache, flatulence, constipation, nausea, diarrhea, dry mouth, vomiting, heartburn, bloating, impotence or decreased libido, difficulty urinating, bronchospasm, cough, wheezes, naal stuffiness, joint pain, and muscle cramps. z 5. Do beta blockers cause addiction? Beta blockers do not cause addiction -- which means physical and psychological dependence on a substance that is beyond the user's control. But beta blockers, when used on a regular basis, can cause physical dependence. Physical dependence is when the body becomes accustomed to having a medication in the body, thus over time, more medication is required to achieve the same effect. It also means that if the medication is suddenly stopped, the person can experience a rebound in the symptom the medication was being used to treat. Not all medications cause physical dependence. To develop physical dependence, the medication must be used on a chronic basis. In the case of beta blockers, physical dependence is not usually an issue when they are used for stage fright, as they are used in low doses and are not taken on a chronic basis. When beta blockers are taken on a chronic basis, as for high blood pressure, suddenly stopping them can cause a severe, dangerous elevation in blood pressure that could lead to a stroke or heart attack. Addiction causes the person who drinks alcohol, abuses a medication, or takes an illegal substance to exhibit substance-seeking behavior, perhaps even committing criminal acts to obtain it. What makes this issue confusing is that alcohol, narcotics, cocaine, and amphetamines can cause both physical dependence and addiction, and usually both must be treated at the same time. Beta blockers do cause physical dependence when used on a chronic basis, but it would be highly unusual for them to cause addiction. z 6. Will beta blockers help my performance? The answer varies greatly among individuals. Obviously, if you have a medical condition that makes beta blockers dangerous for you, they will not help. Beta blockers don't make you play better by themselves; they just relieve physical problems resulting from the fight or flight response. On the other hand, some musicians feel that adrenalin helps their performing, giving them an edge that adds intensity to the performance. Beta blockers have not been shown to directly improve a musician's emotional state, except to the extent that some musicians feel better when their physical problems are relieved. If your performance anxiety shows itself mainly in psychological ways (e.g. negative inner voices), beta blockers will not help you. The scientific studies and articles we looked at clearly show that beta blockers significantly reduce symptoms that can hinder some people's playing. The musicians in the studies said they felt better about their performance after taking beta blockers, and music critics consistently judged their performances to be better. Be aware, however, that one article raised the concern of whether beta blockers help only technical aspects of performance, but may in fact diminish emotional elements. A note about dry mouth: Anecdotal reports show that some musicians who've tried beta blockers say they don't help dry mouth, or can even make it worse. In our research, however, we found a study that conclusively showed beta blockers to help dry mouth among brass players. z 7. How many musicians use beta blockers? A study reported in 1986 of 2,122 musicians in major U.S. symphony orchestras showed that 27% reported taking beta blockers. Of that 27%, 19% took them daily under a doctors prescription