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New York Times

October 17, 2004

Better Playing Through Chemistry

For the Record

RUTH ANN McCLAIN, a flutist from Memphis, used to suffer from debilitating onstage jitters.

"My hands were so cold and wet, I thought I'd drop my flute," Ms. McClain said recently, remembering a performance at the National Flute Convention in the late 1980's. Her heart thumped loudly in her chest, she added; her mind would not focus, and her head felt as if it were on fire. She tried to hide her nervousness, but her quivering lips kept her from performing with sensitivity and nuance.

However much she tried to relax before a concert, the nerves always stayed with her. But in 1995, her doctor provided a cure, a prescription medication called propranolol. "After the first time I tried it," she said, "I never looked back. It's fabulous to feel normal for a performance."

Ms. McClain, a grandmother who was then teaching flute at Rhodes College in Memphis, started recommending beta-blocking drugs like propranolol to adult students afflicted with performance anxiety. And last year she lost her job for doing so.

College officials, who declined to comment for this article, said at the time that recommending drugs fell outside the student-instructor relationship and charged that Ms. McClain asked a doctor for medication for her students. Ms. McClain, who taught at Rhodes for 11 years, says she merely recommended that they consult a physician about obtaining a prescription.

Ms. McClain is hardly the only musician to rely on beta blockers, which, taken in small dosages, can quell anxiety without apparent side effects. The little secret in the classical music world - dirty or not - is that the drugs have become nearly ubiquitous. So ubiquitous, in fact, that their use is starting to become a source of worry. Are the drugs a godsend or a crutch? Is there something artificial about the music they help produce? Isn't anxiety a natural part of performance? And could classical music someday join the Olympics and other athletic organizations in scandals involving performance-enhancing drugs?

Beta blockers - which are cardiac medications, not tranquilizers or sedatives - were first marketed in 1967 in the United States for disorders like angina and abnormal heart rhythms. One of the commonest is propranolol, made here by Wyeth Pharmaceuticals and sold under the brand name Inderal. By blocking the action of adrenaline and other substances, these drugs mute the sympathetic nervous system, which produces fear in response to any perceived danger, be it a sabre-toothed tiger or a Lincoln Center audience.

Even the most skillful and experienced musicians can experience this fear. Legendary artists like the pianists Vladimir Horowitz and Glenn Gould curtailed their careers because of anxiety, and the cellist Pablo Casals endured a thumping heart, shortness of breath and shakiness even as he performed into his 90's. Before the advent of beta blockers, artists found other, often more eccentric means of calming themselves. In 1942, a New York pianist charged his peers 75 cents to attend the Society for Timid Souls, a salon in which participants distracted one another during mock performances. Others resorted to superstitious ritual, drink or tranquilizers. The pianist Samuel Sanders told an interviewer in 1980 that taking Valium before a performance would bring him down from wild panic to mild hysteria.

Musicians quietly began to embrace beta blockers after their application to stage fright was first recognized in The Lancet, a British medical journal, in 1976. By 1987, a survey conducted by the International Conference of Symphony Orchestra Musicians, which represents the 51 largest orchestras in the United States, revealed that 27 percent of its musicians had used the drugs. Psychiatrists estimate that the number is now much higher.

"Before propranolol, I saw a lot of musicians using alcohol or Valium," said Mitchell Kahn, director of the Miller Health Care Institute for the Performing Arts, describing 25 years of work with the Metropolitan Opera orchestra and other groups. "I believe beta blockers are far more beneficial than deleterious and have no qualms about prescribing them."

But use of drugs is still largely secretive. "Inderal is like Viagra," a woodwind player at a major orchestra said. "No one admits to using it because of the implication of weakness." Robin McKee, the acting principal flutist of the San Francisco Symphony, agrees, saying, "It's too bad we're reluctant to talk about using such a great tool."

Indeed, the effect of the drugs does seem magical. Beta blockers don't merely calm musicians; they actually seem to improve their performances on a technical level. In the late 1970's, Charles Brantigan, a vascular surgeon in Denver, began researching classical musicians' use of Inderal. By replicating performance conditions in studies at the Juilliard School and the Eastman School in Rochester, he showed that the drug not only lowered heart rates and blood pressure but also led to performances that musical judges deemed superior to those fueled with a placebo. In 1980, Dr. Brantigan, who plays tuba with the Denver Brass, sent his findings to Kenneth Mirkin, a frustrated Juilliard student who had written to him for help.

"I was the kid who had always sat last-chair viola," said Mr. Mirkin, whose bow bounced from audition nerves. Two years later, he won a spot in the New York Philharmonic, where he has played for 22 years. "I never would have had a career in music without Inderal," said Mr. Mirkin, who, an hour before his tryout, took 10 milligrams.

For the last two decades, such use of beta blockers has generally met with approval from the medical establishment. "Stage fright is a very specific and time-limited type of problem," said Michael Craig Miller, the editor of The Harvard Medical Letter. Dr. Miller, who is also an amateur pianist, noted that beta blockers are inexpensive and relatively safe, and that they affect only physical, not cognitive, anxiety. "There's very little downside except whatever number you do on yourself about taking the drugs."

BUT now that the drugs have established themselves as a seemingly permanent part of the classical music world, some musicians and physicians are beginning to question the acceptability, safety, efficacy and ethics of using them. One concern is that many musicians use beta blockers without proper medical supervision. The 1987 survey of orchestra musicians revealed that 70 percent of musicians taking beta blockers got them from friends, not physicians. Mr. Mirkin, the Philharmonic violist, first obtained Inderal from his father, who took it for angina. Others buy it while touring countries where they are sold over the counter.

Stephen J. Gottlieb, a professor of medicine who published a study on the effects of beta blockers in The New England Journal of Medicine in 1998, says beta blockers should be obtained only after a medical examination, since people with asthma or heart disease could develop problems like shortness of breath or a slowing of the heart rate. "One-time use of low doses of beta blockers should be safe in healthy people," Dr. Gottlieb said, adding that the fatigue, hallucinations, tingling and vivid dreams listed as side effects in Physicians' Desk Reference would be unusual in those using Inderal only occasionally. The risks are far more serious for those who use beta blockers consistently and take up to 700 milligrams of Inderal a day. Musicians typically take 5 to 20 milligrams in isolated doses.

But some performers object to beta blockers on musical rather than medical grounds. "If you have to take a drug to do your job, then go get another job," said Sara Sant'Ambrogio, who plays cello in the Eroica Trio. Chemically assisted performances can be soulless and inauthentic, say detractors like Barry Green, the author of "The Inner Game of Music," and Don Greene, a former Olympic diving coach who teaches Juilliard students to overcome their stage fight naturally. The sound may be technically correct, but it's somewhat deadened, both men say. Angella Ahn, a violinist and a member of the Ahn Trio, remembers that fellow students at Juilliard who took beta blockers "lost a little bit of the intensity," she said. Ms. Ahn doesn't use the drugs, she said: "I want to be there 100 percent."

Indeed, the high stakes involved in live performance are part of what makes it so thrilling, for both performers and audiences. A little onstage anxiety may be a good thing: one function of adrenaline is to provide extra energy in a threatening or challenging situation, and that energy can be harnessed to produce a particularly exciting musical performance. Performance anxiety tends to push musicians to rehearse more and to confront their anxieties about their work; beta blockers mask these musical and emotional obstacles.

Some musicians are also grappling with the ethics of better performing through chemistry. In auditions, which are even more nerve-racking than regular performances, do those who avail themselves of the drug have a better chance of success than those who do not? Should drug testing apply to performers, as it does to some athletes and to job applicants at some companies?

"If you look at the logic of why we ban drugs in sport, the same should apply to music auditions," said Charles Yesalis, a professor at Pennsylvania State University who studies performance-enhancing drugs. But the issue receives little attention because, unlike athletes, classical musicians are seldom called on to represent big business ventures. "If Nike offered musicians ad contracts," Dr. Yesalis said, "more people would pay attention."

Speaking from the Athens Olympics in August, Steven Ungerleider, a sports psychologist and the author of "Faust's Gold," said that beta-blocking medications are prohibited for some events, like riflery, in which competitors use the drug to slow the pulse so that they can fire between heartbeats to avoid a jolt. The drugs are banned in a number of other sports, including motorcycling, bobsledding and freestyle snowboarding.

But Dr. Miller, the Harvard physician, points out that beta blockers differ significantly from steroids, which use testosterone to increase muscle mass, strength and speed. Inderal enables rather than enhances, by removing debilitating physical symptoms; it cannot improve tone, technique or musicianship, or compensate for inadequate preparation.

As Ms. McClain's firing demonstrates, the use of beta blockers by students is a particularly delicate issue. Those who openly use the drugs believe they have a responsibility to mention them to students suffering from severe stage fright.

"If I'm looking out for the welfare of my students, I cannot in good conscience not tell them about beta blockers," said Ms. McClain, adding that she would be more careful about how she represented the information in the future.

Some teachers believe that coping with performance anxiety is an essential part of a classical music education and that early use of beta blockers deprives students of the chance to confront their stage fright. Robert Barris, a bassoonist and a co-chairman of the music performance studies faculty at Northwestern University, encourages students to address the roots of their anxieties while avoiding psychological dependence on chemicals. Unlike previous generations of musicians, these students can draw on a rich array of nonchemical treatment options. The new field of performing-arts medicine includes some 20 centers across the country, many of which treat stage fright with therapies that range from Inderal to more holistic approaches like hypnosis, yoga and aerobic exercise.

But several musicians interviewed for this article expressed impatience with these treatments, which can seem slow and uncertain compared with the instant gratification and convenience offered by the beta blockers. "Holistic solutions take work and time to be effective, whereas Inderal is a quick fix," Mr. Barris confirmed. As it happens, he takes Inderal by prescription for a heart ailment, and he said that he works to combat any soporific effects the drug might have on his musicianship by putting extra energy into his concerts. "No one wants to listen to a secure, accurate but disconnected performance," he added.

Jim Walker, a former principal flutist of the Los Angeles Philharmonic who has recorded more than 400 movie soundtracks, says that preparation is the best medicine. Still, he describes himself as an Inderal advocate, with the caveat that the drug be approved by a physician. Some of his best students at the University of Southern California, he said, are too nervous to deliver a representation of how well they really play and might stand to benefit from beta blockers.

"It's absolutely legitimate to recommend Inderal to a student who's unable to perform because of nerves," he added. "If I'd never heard the story about Ruth Ann McClain, I'd be far more blatant in recommending it."

Blair Tindall, a professional oboist, is writing "Mozart in the Jungle" for Grove/Atlantic Press. Elaine Aradillas contributed reporting for this article.

For the Record: Oct. 24, 2004, Sunday

An article on Oct. 17 about the use of beta blockers by classical musicians to combat stage fright misidentified the journal edited by Dr. Michael Craig Miller, who said there was "very little downside" to their use. It is The Harvard Mental Health Letter, not the Harvard Medical Letter.