Dispatch August 2008

In Defense of the Beta Blocker

Is this a performance drug that could actually increase the fairness of Olympic contests?
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Nobody seemed terribly surprised when two North Korean athletes tested positive for performance enhancing drugs at the Olympics last week. By now, stories of disgraced athletes sound familiar almost to the point of tedium. But if you had the patience to read beyond the headlines, you might have noticed something unusual about this particular scandal—namely, the nature of the banned drug the athletes were using. That drug was propranolol, and the athletes using it were pistol shooters. Propranolol is not exactly a cutting-edge performance enhancer. If you are familiar with propranolol, it is probably because you (or your parents) take it for high blood pressure. Its value as a performance enhancer comes from its ability to mask the effects of anxiety, such as the tremor that might cause one’s hand to shake when aiming a pistol. That propranolol can improve athletic performance is clear, and not just for pistol shooters. Whether it ought to be banned is a more complicated question.

Propranolol comes from a class of drugs known as beta blockers, which lower blood pressure by blocking particular sympathetic nervous system receptors. These receptors also happen to be the ones that get activated in times of fear or anxiety, which is why beta blockers are useful as performance enhancers. A beta blocker can keep a person’s hands from trembling, his heart from pounding, and his forehead from beading up with sweat. It can also keep his voice from quavering, which is why shy people sometimes sneak a beta blocker before giving a big speech or a public presentation. Beta blockers do not directly affect a person’s mental state; taking a beta blocker before firing a pistol is not like taking a Valium, or tossing back a shot of Jack Daniels, because beta blockers do not alleviate anxiety so much as block the outward signs of anxiety. A pistol shooter on beta blockers will still be nervous, but his nervousness will be less likely to make his hand tremble.

Beta blockers seem to be especially good performance enhancers when the performance in question involves an anxiety-producing public setting. This is because a large part of the anxiety of performing in public comes from the worry that one’s anxiety will become outwardly obvious. Most people who worry about public speaking, for example, aren't worried that they'll flub their lines, trip and fall as they approach the podium, or deliver an hour-long speech on television with their pants unzipped. They worry that their anxiety will become apparent to the audience. They're terrified that their hands will tremble, that their voices will become high-pitched and quivering, and that beads of sweat will appear on their foreheads and upper lip, like Richard Nixon trying to explain Watergate. This is why beta blockers are so useful; people who have taken a drug that blocks the outward effects of their anxiety become less anxious—not because the drug is affecting their brain, but because their worst fears are not being realized.

Beta blockers have been around since the 1960s, but it took a while before anyone noticed how useful they were for performance anxiety. Probably the first performers to start using them widely were musicians, especially classical musicians, whose hands can get clammy or tremble during a concert performance. In the mid-’70s, a team of British researchers tested the effects of a beta blocker on the performances of skilled violinists and other string musicians. They made sure that the musicians were playing under maximally stressful conditions by booking them in an impressive concert hall. They also invited the press to attend, and recorded all the sessions. The musicians were asked to perform four times each, twice on placebo and twice on beta blockers, and their performances were scored by professional judges. Not only did the musicians tremble less on the beta blocker, they also performed better. Usually the improvement was minimal, but for a handful of musicians it was dramatic.

From a competitive standpoint, this is what makes beta blockers so interesting : they seem to level the playing field for anxious and non-anxious performers, helping nervous performers much more than they help performers who are naturally relaxed. In the British study, for example, the musician who experienced the greatest benefit was the one with the worst nervous tremor. This player's score increased by a whopping 73%, whereas the musicians who were not nervous saw hardly any effect at all.

One of the most compelling arguments against performance enhancing drugs is that they produce an arms race among competitors, who feel compelled to use the drugs even when they would prefer not to, simply to stay competitive. But this argument falls away if the effects of the drug are distributed so unequally. If it's only the nervous performers who are helped by beta blockers, there's no reason for anyone other than nervous performers to use them. And even if everyone did feel compelled to use beta blockers, it's unlikely that anyone would experience untoward health effects, because beta blockers are safe, cheap, and their effects wear off in a few hours. So unlike users of human growth hormone and steroids, users of beta blockers don’t have to worry about their heads growing or their testicles shrinking. You don’t even have to take them regularly. All you have to do is take a small, 10 mg tablet about an hour before your performance.

Beta blockers are banned in certain sports, like archery and pistol shooting, because they're seen as unfairly improving a user’s skills. But there is another way to see beta blockers—not as improving someone’s skills, but as preventing the effects of anxiety from interfering with their skills. Taking a beta blocker, in other words, won’t turn you into a better violinist, but it will prevent your anxiety from interfering with your public performance. In a music competition, then, a beta blocker can arguably help the best player win.

Does the same hold true for pistol shooting? That beta blockers generally help pistol shooters seems clear. It's even been demonstrated in a controlled study. A group of Swedish researchers found that the performance of a group of shooters was improved by an average of about 13% upon the administration of beta blockers. The improvement was deemed to be the result of the effect of the beta blocker on hand tremor. (What was unclear from the study is whether the beta blocker helped nervous shooters more than calm ones, and whether its effect would have been any different if the shooters had performed in a stress-inducing public competition, like the London musicians.)

Even assuming that the effect was the same for the Swedish shooters as it was for the London violinists, however, it’s not obvious whether or not the drug should be banned. The question is whether the ability to perform the activity in public is integral to the activity itself. For some sports, being able to perform under stress in front of a crowd is clearly a crucial part of the game. Back in March, when the Davidson College basketball team was making its amazing run through the NCAA tournament, for example, the real thrill came from the ice-water-in-the-veins performance by shooting guard Steph Curry. The Davidson games were so unbearably intense that I thought my head would explode just from watching, yet it was always at the point of maximum tension that Curry’s 3-pointers would start dropping miraculously through the net. In a sport like basketball, where a player’s performance in public under pressure is critical to the game, taking a drug that improves public performance under pressure would feel like cheating. So the question for pistol shooting is this: should we reward the shooter who can hit the target most accurately, or the one who can hit it most accurately under pressure in public?

Given that we’ve turned big-time sports into a spectator activity, we might well conclude that the answer is the second—it is the athlete who performs best in front of a crowd who should be rewarded. But that doesn’t necessarily mean that that athlete is really the best. Nor does it mean that using beta blockers is necessarily a disgrace in other situations. If Barack Obama decides to take a beta blocker before his big stadium speech at the Democratic Convention next week, I doubt his audience will feel cheated. And if my neurosurgeon were to use beta blockers before performing a delicate operation on my spine, I am certain that I would feel grateful.

Carl Elliott teaches at the Center for Bioethics at the University of Minnesota and is the author of several books, including Better Than Well: American Medicine Meets the American Dream (2003), and the co-editor of The Last Physician: Walker Percy and the Moral Life of Medicine (1999).
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