Playing Scared (12 page)

Developed in the early 1960s, the beta-blocker was a game changer in the treatment of heart disease and one of the most significant medical advances of the twentieth century. It was the invention of Sir James Black, a Scottish doctor and pharmacologist whose father had suffered from angina and died of a heart attack following a car crash. Black sought to modulate the body’s uncontrolled fear response, let loose every time the hormone epinephrine, more commonly known as adrenaline, is released. It sets off a cascade of responses: dilated blood vessels, increased respiration, and a pounding heart—all of which generate waves of anxiety and lead to more blood vessel dilation, faster respiration, and greater heart palpitation. Black envisioned a pharmaceutical umbrella that would protect the heart and cardiovascular system from this emotional rain forest of stress and fear. That’s how he described it to Rein Vos, a Dutch medical philosopher who interviewed him at length in 1983 for a doctoral dissertation on the history of the drug.

Today, beta-blockers are the fifth most widely prescribed class of medicines in the United States, with 128 million prescriptions written each year as of 2009. The vast majority is for blood pressure and heart disease, but there is also a strong market for performance anxiety. Statistics are not collected for off-label usage, but it’s safe to say the market is almost exclusively American. Many countries forbid doctors from engaging in the kind of off-label use of prescription drugs allowed by the U.S. Food and Drug Administration. In Japan and Holland, for example, it is all but impossible to get a prescription for “the public-speaking pill,” as my own doctor called it.

Whenever I reach for my beta-blocker, I think of Alice reaching for the cake that made her larger. But beta-blockers don’t make me any braver. They don’t erase my anxiety. What they do is leave me with an absence of its physical manifestations. Their effect is about what
doesn’t
happen. My hands don’t drip with sweat. My fingers don’t tremble. My knees don’t shake. My heart doesn’t palpitate. They deliver a negative space, something like what the Japanese call
ma
. And yet, in my mind, I never lose the familiar dread, my most intimate consort—the lump in the throat, the voice demanding to be heard, asking just what exactly I am doing and why I am so determined to do it.

I have always been the kind of person who eschewed medication, who could make a bottle of Tylenol last a decade and would rather suffer a raging case of poison oak than allow a shot of cortisone into my system. But once I started using beta-blockers in June 2012, I couldn’t imagine going into a performance without them. I questioned whether my body
was capable of mustering up a semblance of composure without one of the little orange pills. They were so easy to use, such a perfectly invisible crutch. Was I cheating, using them? My doctor had written me a prescription that permitted numerous refills. Dozens and dozens of little orange pills.

I told myself that I was using them strategically, to store up a new set of experiences and build up my confidence. This was my brand of exposure therapy. The new positive memories would wash away a lifetime of bad ones, and I would augment the chemical fix with a steady diet of yoga, meditation, biofeedback, and cognitive behavior therapy. In forcing my body to declare a cease-fire, they would give me the opportunity to wrest my thoughts from fear to music.

As it happens, stress reduction was one of the purposes envisaged by Black and his team of scientists at Imperial Chemical Industries in London, according to Vos, the Dutch medical philosopher. The amelioration of anxiety by propranolol was a given, and many of those scientists experimented freely on themselves, taking the pill to calm their nerves before presentations, speeches, and lectures. “I did hundreds of interviews, and many people—the top scientists in industry and academia—told me they used this drug,” said Vos, a professor of theory of health sciences at Maastricht University in southern Holland. “On the one hand, they needed it. But it was also normal practice in those days [to experiment with drugs under development].”

The early experimenters consumed enormous doses—up to 3 to 4 grams at a time, Vos said. That’s an astonishing amount: The standard dose for controlling blood pressure is
120 mg; performance anxiety is typically treated with a mere 10 mg. The scientists must have assumed that these were safe drugs, and compared with most medications they are. But despite their overall safety record, beta-blockers do carry long-term risks, presumably more so when they are consumed in megadoses. According to studies, 5 to 10 percent of men who take beta-blockers for heart disease develop sexual impotence. People who have severe asthma, diabetes, and certain other medical conditions are generally advised to avoid the drug, as are pregnant and breast-feeding women. It may interact with other medications. Side effects include fatigue, insomnia, disturbing dreams, cold hands and feet, and depression.

News about their magic powers spread rapidly through the medical community in the 1960s and 1970s, sparked by anecdotal reports of surgeons taking them to steady their hands in the operating room. Beta-blockers were the first performance-enhancing drug—long before the term
PED
was invented. When, in 1978 and 1982, a couple of independent studies suggested as much, they set off a storm in the performing arts world. The studies were conducted by two brothers—one, a vascular surgeon in Denver; the other, a professional organist from Towson, Maryland. The organist, Thomas Brantigan, had been searching for a remedy for stage fright all his adult life. He developed the problem as a boy performing in his teacher’s piano recitals, and his anxiety had grown intractable through his years of study. When he heard about a new medication for blood pressure and heart disease, he told me his ears pricked up. “Just the word
beta-blocker
! If you can stop the beta-receptor, stop the physical response, then okay, you’ve
solved stage fright. I did a bunch of literature searches, put together a bunch of Xeroxed studies, and went to my brother John, who’s an orthopedic surgeon. He told me to get the hell out of his profession. So then I went to my brother Charles.”

The elder Brantigan was intrigued. In addition to being a surgeon, he was a professional tuba player. Though he had no personal experience with stage fright, the more he researched the subject, the more he came to understand it as “a catecholamine storm,” a form of “self-poisoning by adrenaline.” (Catecholamines are hormones produced by the adrenal gland.) People like his little brother simply might have an overabundance of beta-receptors, he reasoned. He agreed to design a small, double-blind clinical trial, and together the brothers arranged for adjudicated performances by music students at the University of Nebraska and the Juilliard School. At each performance, half the students were given propranolol (brand name Inderal), the most commonly prescribed of all beta-blockers; the other half performed chemical-free. A portable telemetric unit monitored their physiological responses with unsurprising results: The students who got the beta-blockers had lower heart rates, lower blood pressure, and effective elimination of “the physical impediments to performance caused by stage fright.” More unexpected was the verdict of three judges—a player in the New York Philharmonic Orchestra, a Juilliard faculty member, and Thomas Brantigan (who says he had no knowledge of who was given the drug). They preferred the chemically assisted performances.

The Brantigans’ study was published in the journal the
Lancet
in 1978.
⁹
It was bolstered by their second study, conducted at the
Eastman School of Music in Rochester, New York, and published in the January 1982 issue of the
American Journal of Medicine
.
¹⁰
The response was almost immediate. In some quarters, the brothers were reviled as drug pushers, accused of using powerful medicine to treat a mere annoyance and of contributing to the end of classical music. Musicians, on the other hand, quietly began bombarding their doctors with prescription requests. By 1987, a survey by the International Conference of Symphony and Opera Musicians, which represents instrumentalists in dozens of major orchestras, revealed that 27 percent of its members used beta-blockers. Of those, 70 percent got the drug from colleagues.

But it’s the rare musician who admits to it. A few years ago, Charles Brantigan was backstage with members of the Denver Symphony Orchestra when he heard a prominent player loudly condemn the practice. Anyone who can’t stand the heat should get out of the kitchen, the musician declared. Brantigan was taken aback but also amused. “I had just given him a prescription for beta-blockers the day before,” he said. Many musicians still quote Sara Sant’Ambrogio, cellist of the popular Eroica Trio, who in 2008 told the
New York Times
: “If you have to take a drug to do your job, then go get another job.” Detractors insist that beta-blockers turn performance into a sterile and mind-numbing exercise. Angela Chan, a pianist in Montreal, told me that it made her feel like a zombie on the one occasion she tried it. “It was the most devastating experience I ever had. I became a machine to puncture all the notes. It was a total waste of time for me and for the audience. There was no music to speak of. It should be banned for musicians!”

*

Propranolol is a drug with at least nine lives, one of which holds the potential to interfere with memory formation. Neurologists at the University of California at Irvine discovered this in 1995, with a simple and very clever experiment based on the power of story. They told one group of study participants about a woman and her son who visited the boy’s father at the hospital where he worked. On the way there, they saw a disaster preparedness drill featuring a simulated accident victim. The boy stayed with his father at the hospital and the mother went home. Done, end of story. The second group heard a very different account. On the way to the hospital, the boy was in a car accident in which his feet were severed. He was rushed to the hospital, where surgeons reattached his limbs, and he remained to convalesce while his mother returned home.

Two weeks after hearing these stories, both groups were tested for their recall memory. The subjects who heard the second, emotionally rousing story were able to recall many more details than those who heard the bland first story. That was no surprise. The human brain best remembers events and stories that activate the amygdala; the more emotionally activated the amygdala, the better the recall. With this in mind, the neurologists next sought to test what happens to memory formation when adrenaline is blocked. Again, they turned to narrative. This time, they told two new groups the same gruesome tale of the boy and his accident. But before hearing it, one group was given propranolol, the idea being that the drug would prevent stress hormones from activating the amygdala. The other group heard the story drug-free. While
members of the first group tended to recall many of the story’s details—what happened, when, and where—they didn’t suffer much emotional upset. In science-speak, propranolol blocked the memory-enhancing effects of emotional arousal and stress.

Other studies followed, including one in 2010 of a Montreal man who developed symptoms of post-traumatic stress disorder after being hit on the head with the butt of a gun during a bank holdup. The incident traumatized him. He gave up his longtime hobby of bird-watching, became housebound, and broke up with his partner of many years. According to the study, the man received six treatment sessions with a psychologist: At each, he revisited the original memory after being given propranolol. By the fifth treatment, he reported that he felt unengaged when recounting the story. Two years later, he resumed his normal activities and said that although he remembered the events at the bank, he wasn’t unnerved by them anymore.

Accounts like these have fired the imaginations of scriptwriters, who have portrayed propranolol as a mind-altering drug that even Aldous Huxley could never have envisaged. In 2007, the television drama
Boston Legal
aired an episode about a sixteen-year-old girl who was molested by a rabbi. Against the advice of her lawyer (who called it “the forgetting pill”), she wanted to take propranolol and put the whole thing behind her. “Why is it so difficult to understand?” she demanded. I have often wondered the same. Propranolol helps me walk the tightrope. I may not be a professional pianist, but I do know that propranolol doesn’t “devastate” my playing, as it did Angela Chan’s. It may not
erase my negative thoughts or put me in the zone, but it dampens the adrenaline rush (“the catecholamine storm”) and shuts down the feedback loop. My fear is denied its feeding frenzy, and for now I can’t foresee giving up my 10 mg beta-blocker pills. And yet, what I take so casually has sunk major careers in the sporting world.

In 2008, a North Korean pistol shooter was stripped of his medals and expelled from the Olympic Village in Beijing after testing positive for propranolol. In 2009, Doug Barron became the first player in the history of golf to be suspended for doping—the dope, in this case, being testosterone and beta-blockers. Barron, who had requested a medical exemption for both drugs, sued the PGA Tour for reinstatement and returned after a year.

Beta-blockers have been listed on the World Anti-Doping Code since 2009. The International Olympic Committee, Professional Golfers Association, and National Association for Stock Car Auto Racing have, in one way or another, all joined in banning the drug. Such restrictions make sense in sports such as archery and pistol shooting, where a beta-blocker gives a distinct advantage, allowing the shooter more time to fire between heartbeats. (That is why it is classified as a performance-enhancing drug, along with anabolic steroids, peptide hormones, beta2-agonists, hormone antagonists, and other substances.) But for the rest of us, it’s the drug that saves us from ourselves.

The piano keyboard has always been my touchstone, what the Soviet poet Vera Inber described, in a very different context, as “the zone of memory, where the lightest touch wounds mortally.” It conjures up memories, resurrecting the past with near cinematic precision. Sometimes, playing Brahms, I pictured my mother in her late eighties, pacing up and down the length of her basement on a winter afternoon. She wasn’t willing to brave the ice and snow, but she was determined to walk and would do so for a good hour, usually to the music of Brahms. Cleaning out my parents’ house a few years ago, I found her boom box on the basement ironing board, and when I popped it open, there was the CD of Brahms’s Piano Concerto no. 2. Other times, memories that were long forgotten would emerge full-blown. Like the time I began giggling in the middle of a dense contrapuntal Bach partita, as I remembered my uncle Benny’s anger when I failed to deliver on a promise. “Sara’s promises are as good as Hitler’s,” he burst out in a fit of pique. I was nine years old.