Beta-blockers Reconsidered

John Robert Brown

Drugs to suppress stage fright are not new. Eighty-year-old trumpeter Dick Hawdon, a veteran of broadcasts and LPs with a variety of ensembles, remembers taking Oblivon (methylpentynol) before he made recordings during the early 1950s. "We bought it over the counter,' he says.

In those days Oblivon was advertised to help with ordeals such as public speaking, job interviews, asking for pay rises or visiting the dentist. In Britain, after August 1955, Oblivon was restricted to medical prescription, at the end of an era when many psychoactive drugs had been legal. Some parts of the music profession had seen much use of alcohol, cocaine, heroin, Benzedrine (racemic amphetamine) and even Dr. J. Collis Brown's Chlorodyne.

Some of the drugs once widely used may come as a surprise to younger readers. For example, cocaine was a significant ingredient in Coca-Cola from 1888 to around 1906. Equally remarkable, during the 1950s a Pan Am airline menu offered a Benzedrine inhaler as a "service item for your flying comfort', along with a toothbrush, sewing kit, and Kleenex. Indeed, Codeine (methylmorphine) wasn't removed from most over-the-counter cough suppressants until the early 1980s. What has been called the "stage fright movement' began in the 1960s, a period covered in the USA by the book A Decade of Stage Fright Research, 1960 - 1969, and in Britain with the practical experiments of Ian James.

A pharmacologist at the Royal Free Hospital in London, Ian James was a string player who suffered bow tremor. He became interested in the link between physical and psychological aspects of playing. At the Wigmore Hall he organised an experiment, reported in The Lancet of November 5th 1977: The Effect of Oxprenolol on Stage Fright in Musicians.

24 string players volunteered to play before an invited audience. Half the musicians had taken a placebo. The other half were given a 40 milligram dose of the beta-blocker oxprenolol. The report in The Lancet summarised: "The effect of 40 mg oxprenolol on stage fright was assessed in 24 musicians in a double blind crossover trial. Musical performance judged by two professional assessors was found to improve. Greatest improvement was seen on the first performance and in those most affected by nervousness.'

Today, beta-blockers help many performers. "I have used beta-blockers to prevent horrible migraine stress headaches in performance,' clarinettist James Gillespie, Regents Professor of Music at the University of North Texas, told me. "One was so bad - before I started taking the medicine - that I had to be taken to the hospital. They work for me very well.'

Gillespie is very open about his use of the tablets. Similarly, John Mills, Head of Guitar at the Royal Welsh College of Music and Drama, Cardiff, believes that one shouldn't be secretive about such medication. "It's perfectly alright,' he says. "A tried and tested means of controlling nerves. You don't want fingers wobbling around. There was a big TV show I had to do. Doing a tour I happened to be staying with a doctor. We were talking about concert nerves. He asked: "Have you tried these beta-blockers?" I hadn't heard of them. He suggested a low dosage, to try it out before the day, "to see how you feel.' So I did. The dosage was ten milligrams; I've never taken a dose larger. They worked very well.

"When I take a beta-blocker, which may be as rarely as once a year, I allow about half an hour before the performance. I'm told it stays in the system about three to four hours. A few minutes after I take them, suddenly I feel very relaxed. Yet doctors say that that doesn't happen. Maybe it's psychological?

"On several occasions I took a small dose after the concert. Now this is really curious: if my pulse rate went really high - and this is one of the reasons why the doctor suggested it in the first place, not so much because of the shaking, but because of the very high pulse rate (I measured it once at 130) - he said this would keep my heart rate down to a more normal 70 beats per minute. What I was finding afterwards was that in the middle of the night I would suddenly wake up, bathed in sweat, with my pulse soaring. So, occasionally I would take a small dosage of beta-blocker when going to bed, which got me through the night very comfortably. That's the other side of the coin, which is not really talked about. Some people say they can't sleep very easily after taking a beta-blocker. I have no trouble.

"I never found a loss of speed, of technique. Neither did I experience cold hands, though several doctors have mentioned this to me. To students, I've never said, "go to your doctor and talk about it'. I think it's something that might come later on, when a player has got more to lose. The higher up the ladder, the longer the fall.

"Concerts are not competitions. At music competitions, do they then have to do drug testing? But with concerts, if you have musicians, particularly at the latter stages of their careers, and this gets them through, to ban these tablets is to take away their livelihood. It's a very delicate dilemma; this isn't sport. The beta-blocker is a wonderful tablet if used properly.'

Rosanna Preston, of the Musicians' Benevolent Fund (MBF), says that the MBF doesn't have a stance on beta-blockers. "But we do support the British Association for Performing Arts Medicine (BAPAM). If a musician had a problem because they had become dependent on beta-blockers to help them perform and then were needing help to move on from that, we would help. But we don't profess to be medical experts. That's why we fund BAPAM."

"Musicians take such tiny, tiny doses,' says Blair Tindall, whose oboe playing has taken her into the New York Philharmonic and onto several film music soundtracks. "My mother is 86 years old. She takes Inderal for high blood pressure. [Inderal is AstraZeneca's name for propranolol].She weighs 85 pounds, a very tiny person. She takes 80 milligrams each day, every day. I have never taken more than 20 milligrams, when I crossed over from having no nervousness to being apathetic. That's the problem; if you take a little bit too much, you just don't care how it comes out.'

Tindall, whose book "Mozart in the Jungle, Sex Drugs and Classical Music' caused a stir when it appeared in 2005, adds: "You think as clearly as you ever did. It doesn't affect your cognitive ability. Because it blocks these adrenaline-like chemicals you are able to play like you play when you don't have the adrenaline flowing through your body. Fantastic!'

Jeff Howard, principal clarinet of the Haifa Symphony Orchestra, Israel, says: "I never used to use them, even during concertos. But about 5 years ago I played a Vivaldi concerto on sopranino recorder. While I may be a good recorder player, I am not a professional recorder player. I realized this after it was too late to back out of the performance, of course! A friend who plays French horn in the orchestra uses beta blockers before every concert. I borrowed a few pills from him. While my performance was okay, I was amazed at how relaxed I was when a passage didn't come out as I wanted. Since then, I borrow the pills from my friend every time I play a concerto, once or twice a season.

"When I'm playing the clarinet in the orchestra I rarely get nervous, even if we're doing Capriccio Espagnol or Scheherazade. Occasionally I get a bit excited, but I don't have the kind of fear that interferes with my playing. If I played concertos a few times a month instead of a few times a year I would get used to that and not use the beta blockers.'

Useful and up-to-date information about beta-blockers is given in The British National Formulary (BNF), which contains details of medicines prescribed in the UK, with special reference to their uses, cautions, contra-indications [a specific situation in which a drug, procedure, or surgery should NOT be used], side-effects, dosage and relative costs. Updated every six months, the BNF claims that it: "reflects current best practice as well as legal and professional guidelines relating to the use of medicines.' The BNF is intended for use by prescribers, pharmacists and other healthcare professionals; it is not written for musicians, neither is it written in layman's language. You should always consult your GP.

Concerning anxiety, the BNF says: "Beta-blockers do not affect psychological symptoms such as worry, tension and fear, but they do reduce autonomic symptoms, such as palpitation and tremor; they do not reduce non-autonomic symptoms, such as muscle tension. Beta-blockers are therefore indicated for patients with predominately somatic symptoms [somatic means "of the body']; this in turn may prevent the onset of worry and fear. Patients with predominantly psychological symptoms may obtain no benefit.'

The BNF also tells us that: "Many beta-blockers are now available and in general they are all equally effective. There are, however, differences between them which may affect choice in treating particular diseases or individual patients.'

About the problem of cold fingers, mentioned by John Mills, we are also told that: "Oxprenolol, pindolol, acebutolol and celiprolol have intrinsic sympathomimetic activity.' Sympathomimetic drugs mimic the effects of sympathetic activation on the heart and circulation. "They tend to cause less bradycardia [bradycardia is an abnormally slow heart rate of less than 60 beats per minute] than the other beta-blockers and may also cause less coldness of the extremities.' And for those who suffer difficulty sleeping after taking beta-blockers: "Some beta-blockers are lipid-soluble and some are water soluble. Atenolol, celiprolol, nadolol and sotalol are the most water-soluble; they are less likely to enter the brain, and may therefore cause less sleep disturbance and nightmares.'

Coming from so many instrumentalists, such uncritical enthusiasm for beta-blockers makes one instinctively cautious. A hospital consultant speaking to me about the disadvantages said: "Long term use can cause insulin resistance, leading to higher blood glucose levels. Also, adrenaline release when nervous reduces blood pressure. Combined with the blood pressure reducing effects of the beta-blockers, this can cause a person to faint. Propranolol is probably the best beta-blocker for this purpose.'

And the ethics of using them? "It's alright to use them on a one-off occasion,' says my consultant. "If they're required long-term to enable you to cope with your job, then you should ask if you are in the right profession. And I would query the ethics of their use for competition or audition. Everyone is nervous for such events; using beta-blockers could confer an unfair advantage. A doctor can't define an unethical use. It's up to competition organisers and those arranging auditions. Remember that the use of beta-blockers is already banned in certain sports in the UK, such as billiards and shooting. Don't use them lightly!' Bill Kerr, Musicians' Union Orchestral Organiser, says: "Provided they are prescribed by a doctor, there is no fundamental problem. Where people have stage fright, if they calm the symptoms of that, then it's a good thing.'

Open enthusiasm isn't universal. Helen Wilson, orchestra manager at Opera North says that none of her musicians mention if they use them. "I don't remember ever talking to a player about this; it's not the sort of thing they would tell the manager." Similarly, Mark Pemberton, of the Association of British Orchestras, says that he knows little about beta-blockers. "Through the initiatives that we are developing via the Healthy Orchestra Charter, where the orchestra signs up to a statement and good practice regarding the health and well-being of the players, we would hope that the effect would be to reduce the need to take artificial mechanisms for destressing", he added.

Blair Tindall reports a similar trend in the USA: "Here, people are relying a lot more on holistic solutions to stage fright, combined with psychological treatment,' she says. And at least one British Conservatoire now offers help away from beta-blockers. Birmingham Conservatoire Vice-Principal Mark Racz says that they address performance stress through their performance coach, Karen O'Connor, who is also principal oboe with the CBSO. "Karen uses the principles of sports psychology to work with individual students on mental preparation for performance,' says Racz. "Karen O'Connor does amazing things.The Metropolitan Opera, New York City, I am told, have two full-time sports psychologists on the staff. It works.'

With thanks to Ruth Hansford, of the British Association for Performing Arts Medicine, for locating information about Ian James.
This article first appeared in Classical Music magazine

Updated and maintained by: routeToWeb