This article originally appeared on Tonic in the US.
Alarm was the general consensus when online wellness company Hers advertised a “Performance Anxiety Aid” on social media earlier this month. The Facebook and Instagram ads for propranolol, a medication meant to treat heart conditions that doctors prescribe off-label for anxiety, said: “Nervous about your big date? Propranolol can help stop your shaky voice, sweating and racing heart beat.”
After Instagram users expressed outrage—some because they felt the ads suggested normal feelings needed to be “fixed,” and others saying it undermined their own experiences with debilitating anxiety—the company removed the ads and replaced them with an apology.
But what of it? What if you, consumed by anxiety over an upcoming date, presentation, or whatever, did want to buy a quick-fix pill on the internet to soothe your nerves? Amid this anxiety economy filled with products for soothing your symptoms, just how bad is it for people to take advantage of one increasingly available pharmaceutical option?
Propranolol is a beta blocker, a type of drug that’s FDA-approved to lower blood pressure and treat cardiovascular conditions but is prescribed off-label to treat performance anxiety (which is considered a type of social anxiety), says Greg Fonzo, assistant professor of psychiatry at Dell Medical School at the University of Texas at Austin. Many doctors prescribe beta blockers to people who report having physiological symptoms of anxiety—like a thumping heart, sweaty palms, and dry mouth—to dampen those effects. According to the Mayo Clinic, beta blockers work by limiting the effects of the hormone adrenaline.
While that sounds pretty great, especially as you head into a situation that has your heart beating out of your chest, it’s not ideal in the long run. “Taking a pill to get over a performance anxiety situation is not necessarily the best approach,” he says. “From a psychological learning perspective, it’s best to have people therapeutically face their fears without any sort of secondary anxiety-management tool like a medication. Medications like benzos or beta blockers are more of a temporary fix.”
One effective way to deal with anxiety long-term is to do a form of treatment called exposure therapy, Fonzo explains, in which you gradually confront nerve-wracking situations, working your way up to the real deal without needing any sort of additional aid. “Your brain learns to adapt to that anxiety, and the next time you’re in that situation it’s not as anxiety-provoking.”
That said, “if you just need something to get you through it, right away, it might be useful,” he concedes. “But in general, anxiety is something that’s very treatable in using more long-term approaches.”
“I think in some ways [the availability of these drugs] reinforces this idea that anything can be fixed and done away with quickly by taking a pill,” Fonzo says. “It’s never quite that simple. To some extent, ‘buyer beware’ applies.”
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Is it safe to get meds from an online service?
Hers is a direct-to-consumer health and wellness venture that launched in November 2018. Its brother brand Hims is reportedly worth $1 billion. The site offers birth control pills, a libido enhancer called Flibanserin, hair-growth stimulants, and acne treatments, most of which are available via a prescription that you can get through an online consult with a licensed doctor.
For $30 a month, and with the prescription from a doctor, Hers will mail you five little 20mg propranolol pills, packaged in a small pouch not dissimilar in design to a condom. They work “taken on an as-needed basis, typically in a single dose 30-60 minutes prior to the stressful event,” the website says.
Ateev Mehrotra, an associate professor of health care policy and medicine at Harvard Medical School, says there are both positives and negatives to companies that offer healthcare online, and that while there are concerns with quick-fix beta blockers, they can be relatively safe for many people. (Having blood pressure problems and a history of fainting are among the red flags suggesting you should avoid propranolol.)
“While I certainly want to assess [the service’s] quality, make sure they are screening appropriately, giving the correct advice to someone for getting propranolol—that you need to be careful, that you might have dizziness and side effects etc.,” Mehrotra says, “I am also conscious that the basic structure of most of these companies is that, for the vast majority of patients, these kind of drugs are safe after asking a simple set of questions.
“These [telemedicine] companies are taking that approach and at least, in theory, this could be a safe way to provide care,” Mehrotra says.
This model is an efficient use of physicians’ time, and it offers convenience and privacy for people who might be embarrassed to see a doctor about their anxiety, he adds. “It has this enormous advantage of potentially increasing the efficiency of the healthcare system, and making healthcare more accessible from a price perspective.”
On the flip side, there are issues of quality and coordination of care. “If [these companies] aren’t appropriately managing care, and they just become pill mills,” he says, “this can lead to inappropriate prescribing, where patients who shouldn’t be on these medications get them.”
When contacted for comment about the advertisements for propranolol?, Hers sent the following statement from Adrian Rawlinson, vice president of medical affairs:
Patient care and safety is of paramount importance to hers. A quarter of women in the US do not have health insurance, and we are dedicated to driving convenient access to the healthcare system, ensuring women get the care and support they deserve from medical professionals. Our goal is to provide women with information around occasional situational anxiety and access to effective, evidence-based treatment options like propranolol, when deemed medically appropriate.
Hers isn’t the only company that offers such a service. There’s Kick, which exclusively targets the performance-anxiety market; Roman, which sells erectile dysfunction meds, genital herpes treatments, and other “taboo” products for men; and Lemonaid, which covers a broader range of services, like birth control, blood tests, and treatment for UTIs and sinus infections.
“The rapid growth [of companies like Hims] suggests that yes, we’re going to see more and more of these kinds of options out there,” Mehrotra says. “I’m just blown away by how quickly this has happened—how we have seen this huge increase in both the number of companies providing care in this space, as well as the range of conditions they have managed [to cover].”
While these services may be convenient, Mehrotra is concerned about some people getting medical care from multiple sources . “We recognize increasingly that patients who get care coordinated by a practice or a team of providers generally seem to have better outcomes, as opposed to people going to one specialist here and another specialist there,” he says. “That kind of dispersed care can lead to a lot of poor outcomes, and these kinds of companies are moving in the direction of dispersed care.”
Take one of his patients, for example, who has several medical problems like heart failure, diabetes, and obesity. “He should not be going to one of these new companies to get some more medication because they don’t understand the complexity of his illness,” Mehrotra says. “A single medication could be quite harmful. If anything, he should be seeing fewer providers.”
“In contrast, a young woman who is otherwise healthy but does have social anxiety, or does need contraception, or has acne but doesn’t have any other medical problems—maybe this concern about coordination is much less and she can get the care she needs in a quick and efficient way.”
Is it a good or bad thing to make anxiety meds easier to get?
Where’s the line between feeling anxious in a normal way and having anxiety that requires intervention? If it wasn’t already blurred, advertisements like the controversial Hers posts certainly raise the question. “Is it possible that we are now treating patients that didn’t need to get that care by increasing the convenience?” Mehrotra asks.
“What’s abnormal versus normal has been termed ‘medicalization,’ and we see it in a broad range of areas,” Mehrotra says of the process by which standard human problems come to be defined and treated as medical conditions. “These kinds of companies could speed up that medicalization process.”
“On the one hand, why are we making what’s normal abnormal?” Mehrotra asks. “On the other hand, if people are getting value out of it, who are we to question them? “If it helps people and they like it, I will play the devil’s advocate,” he says. “If you’re going to present in front of 200 people, and you’re scared out of your mind…if you can take a medication that’s going to make you just a little bit better, so be it.”