Everyone is crazy about the pill for performance anxiety In the United States, medications used to feel less nervous before an important event are becoming increasingly popular

While in Europe the use of medications to combat performance anxiety before an important event – such as a wedding or a public speech – is rather sporadic and generally not very widespread, in the United States it is increasingly popular and viewed positively. For example, before accepting the award for Best Supporting Actor at the Golden Globes 2024 for his performance in Oppenheimer, Robert Downey Jr. stated that he did not feel particularly nervous about going on stage at one of the world’s most important film events, thanks to having taken a beta-blocker, that is, a medication used against performance anxiety. Similarly, Rachel Sennott mentioned it during an interview on the night of the Oscars, recommending its use. But this is not an isolated case: more and more people – famous and not – openly talk, online and offline, about these medications, although it should be clarified that beta-blockers act (at controlled and low dosages) on the so-called “situational anxiety”, reducing its typical physical effects, but they do not alleviate the mental symptoms associated with anxiety states.

Specifically, beta-blockers act on the so-called "beta receptors", which are structures in our body that respond to stress hormones, such as adrenaline. When these hormones bind to these receptors, the heart rate increases, blood pressure rises, and one may experience unpleasant sensations, such as performance anxiety. Beta-blockers, on the other hand, bind to these receptors, preventing the hormones from acting. This way, the person tends to feel calmer and physically more relaxed, especially in situations of high tension. However, beta-blocker drugs were not originally intended for this purpose: they were developed in the 1950s and 1960s by Scottish researcher James W. Black, who was awarded the Nobel Prize in Medicine in 1988 for this discovery, and they were aimed at correcting irregular heart rhythms and controlling possible cardiac dysfunctions. There are various types of beta-blockers: the most common is “propranolol”, which, being the most powerful, can also lead to more side effects; its use had decreased over time, until a few years ago – mainly in the United States – when it began to be prescribed, at controlled dosages, to treat mild and temporary anxiety states.

Do beta-blockers work?

The clinical evidence supporting the effectiveness of beta-blockers in managing momentary anxiety is still limited, and so far, reliable large-scale tests have not been conducted – therefore, this is not considered a first-line treatment, and in many countries (including Italy) they are still recommended primarily for other purposes. As reported by the Wall Street Journal, beta-blocker prescriptions in the US have instead increased by nearly 30 percentage points since 2020: most users take them off-label, meaning for a purpose different from the one for which the medication was originally developed. The drug first became popular especially among actors and musicians, who took it before performing, but its use has since expanded to a wide range of situations – from a university exam to a work meeting, among many others. However, beta-blockers cannot be purchased in pharmacies without a specific authorization, which is why they are increasingly requested through telemedicine platforms.

Not everyone knows that in the United States it is possible to buy certain prescription medications through online portals, which, besides selling and delivering them, also offer remote medical consultations – often very quick and rather superficial – at the end of which the necessary prescription is issued. This situation has allowed some telemedicine sites to significantly increase sales of beta-blockers, also because they are quite affordable in price, which has further encouraged their diffusion. In these cases, the dosages offered are much lower than those used to treat cardiac problems, but users are still exposed to the risk of side effects – including dizziness, fatigue, and fainting, among others.