Klarinet Archive - Posting 000867.txt from 1997/07

From: "David B. Niethamer" <dnietham@-----.edu>
Subj: Beta Blockers (FLUTE FAQ) (long)
Date: Mon, 28 Jul 1997 15:34:47 -0400

Since there seemed to be a lot of controversy over the Beta Blocker
issue, I got permission to share a retrievable file from the FLUTE list
which sheds more factual/non-judgemental light on the subject. Hope you
all find it enlightening.

BTW, you can also look for an article in "The American Journal of
Medicine", Vol 72, Jan 1982 entitled "Effect of Beta Blockade and Beta
Stimulation on Stage Fright". It was given to me by a friend who is an
M.D. doing research in cardiac issues. He was somewhat appalled at the
use of Beta Blockers, particularly Inderol, for control of stage fright,
and suggested there were better beta blockers available. He didn't
elaborate further.

Hope this helps. Apologies in advance for the length of the post.

David Niethamer
dnietham@-----.edu

---------------- Begin Forwarded Message ----------------

BETA BLOCKERS AND PERFORMANCE ANXIETY IN MUSICIANS:
FREQUENTLY ASKED QUESTIONS

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.

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.

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.

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.

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, nasal stuffiness, joint pain, and muscle cramps.

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.

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.

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 for heart conditions, etc.,
11% had a prescription for occasional use (concerts, auditions, etc.) and
the remaining 70% reported occasional use, but without a doctors
prescription. (Again, these percentages are of the 27% who reported
taking
beta blockers, not of the whole population.)

When the musicians who took beta blockers for medical reasons are factored
out, slightly under 22% of musicians in this study reported using beta
blockers occasionally, with or without a prescription.

Among those who reported occasional use, with or without a prescription,
the events they said they used them for were: Auditions, 72% ; solo
recitals, 52%; difficult orchestral performances, 50%; concerto
performances, 42%; before every performance, 4%.

In our highly unscientific survey based on the FLUTE Internet mailing
list,
there were 103 respondents total. Of these, 24 (23%) said they use or
used
beta blockers, 79 (77%) said they didn't.

Of those who called themselves professional performers and/or teachers,
52%
said they used beta blockers, 48% said they didn't. Of those who called
themselves students, amateurs or non-professional teachers, 2% said they
used beta blockers, 98% said they didn't.

8. How does the music community view the use of beta blockers for
performance anxiety?

As you might expect, opinions vary widely. Here are what a few well-known
musicians have said on the subject:

Trevor Wye, flutist and teacher: After saying that beta blockers "should
seriously be considered for important occasions," he writes: "Readers who
may have some misgivings about the use of alcohol or drugs may care to
reflect on the effect of nerves and strain on the body which can cause a
great deal of damage over a period of time." From "A Trevor Wye Practice
Book for the Flute, Volume 3: Articulation," (Novello & Co. Ltd., Borough
Green, U.K., 1983).

Geoffrey Gilbert, flutist and teacher, as quoted by biographer Angeleita
S.
Floyd: "[Gilbert] did not advocate the use of [beta-blocker] drugs or
alcohol for controlling nerves in performance....Gilbert's reasoning
stemmed from the fact that although they may work, one can easily become
addicted." From "The Gilbert Legacy" by Angeleita S. Floyd (Winzer
Press,
Cedar Falls, Iowa, 1990).

Mary Stolper, flutist and teacher, tours with Chicago Symphony Orchestra:
"I have never taken [beta blockers] and my one brother has never taken
them. But my other brother swears by them. I think it's a very personal
choice.
"I don't give them to my students. If they come and we talk about
it,
I'm not going to stop them from taking them. I probably would encourage
them to take them if they're curious about it; go ahead, take them and
see.
But don't take them for the first time on your first audition!
"Taking the audition is so difficult, the odds are so against you to
begin with, if that little thing makes you think you've got an edge, why
not?....But I don't think it's ever been proven that they help." From a
taped interview with K. Harby, January 1997.

Stuart Edward Dunkel, oboist and composer: "The use of drugs in
controlling symptoms of fear felt at an audition should be thought out
carefully. The underground musician's drug, Inderal, is in widespread use
today. However, one should use caution by understanding the side effects
of a given drug and by realizing that an addiction to drugs may occur and
that this may therefore not be the ideal approach to the problem of stage
fright." From "The Audition Process: Anxiety Management and Coping
Strategies," Juilliard Performance Guides No. 3 (Pendragon Press,
Stuyvesant, New York), 1989.

9. What other approaches are helpful for dealing with performance anxiety?

Because the fight or flight response occurs only when we perceive danger,
it can be avoided or minimized if we can convince ourselves there is
nothing to fear. This is the goal of many non-medication approaches. The
physical sensations of fear can also be managed in specific,
non-medication
ways.

There are many books and articles that may help you understand your stage
fright and manage it. Some of the following are, unfortunately, out of
print. If you are unable to find any book in your local library, ask your
librarian, who may be able to obtain it from another library.

* "The Audition Process: Anxiety Management and Coping
Strategies,"
by Stuart Edward Dunkel (Juilliard Performance Guides No. 3, Pendragon
Press,Stuyvesant, New York, 1989).

* "A Soprano on Her Head: Right-side-up Reflections on Life and
Other Performances," by Eloise Ristad (Real People Press, Moab, Utah,
1982).

* "Making Music for the Joy of It: Enhancing Creativity, Skills
and
Musical Confidence," by Stephanie Judy (Jeremy P. Tarcher, Inc., Los
Angeles,1990).

* "The Inner Game of Music," by Barry Green with W. Timothy
Gallwey(Doubleday, New York, 1986).

* "Anxiety and Musical Performance: On Playing the Piano From
Memory," by Dale Reubart (Da Capo Press, New York, 1985).

You can also try eating dairy products and turkey, which are rich in
substances that are known to enhance relaxation. Some flutists recommend
bananas. Nicotine and caffeine can contribute to shakiness and anxiety in
some people.

Biofeedback, yoga, relaxation techniques, and cardiovascular fitness are
recommended in the books listed above. Classes and seminars exist in
most
communities that can help you with any of these activities.

Cognitive therapy, the area of psychotherapy that holds that your
understanding of a situation can change your emotional response to it, is
often sought by people with stage fright. Hypnosis may also used. If you
decide to seek a therapist, try to find one who is experienced in treating
anxiety disorders, and especially one who has experience treating
performers.

Karla Harby, freelance writer and amateur flutist
Kathrin Kucharski, clinical pharmacist and amateur flutist
Sarah Tuck (committee chair), professional flutist
Julia Vasquez, professional flutist
March 17, 1997

----------------- End Forwarded Message -----------------

David Niethamer
Principal Clarinet, Richmond Symphony
dnietham@-----.edu
http://members.aol.com/dbnclar1/