T

he pill works like magic, people who’ve used it say, to quell their anxiety around public speaking.

For decades, doctors have written off-label prescriptions for the heart drug propranolol to help anxious musicians, poker players, and tech executives calm their racing hearts and still their trembling hands before a big performance. Now, a San Francisco startup called Kick is planning to bring the beta blocker to a mass market — a plan that’s giving some psychiatrists and psychologists anxiety of a different kind.

Kick wants to become a telemedicine platform that makes it easy for nearly anyone who needs a confidence boost — before a first date, perhaps, or a big work presentation — to get a prescription for propranolol. They just need to pass a screening by filling out an online form and interacting in some way with a physician — the current idea is a video call.

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As for the medication itself, Kick has reformulated the traditional pill into a minty lozenge, like an Altoid, that dissolves in your mouth, releasing 10 milligrams of the cardiac drug. The company wants to make it available in different colors and flavors, like watermelon.

“Our hope is to try to de-clinify the whole experience,” said Dr. Alex Dimitriu, a psychiatrist in private practice in Silicon Valley who has a stake in Kick and expects to prescribe propranolol through its platform.

The concept does not sit well with some mental health professionals.

“That’s a horrible idea. It’s a horrible idea!” said Stefan Hofmann, a psychologist who directs the social anxiety program at Boston University.

“No, you shouldn’t do that,” Hofmann said. “You want to do a very thorough assessment with a patient before you prescribe a psychoactive drug of any kind. You can’t do this via the internet.” (Hofmann, it should be noted, has ties to a competing business model of sorts: He advises a startup called SilverCloud that markets online cognitive behavioral therapy programs for anxiety and other conditions.)

Even physicians who sometimes prescribe propranolol for performance anxiety were critical of Kick’s pitch. Dr. Franklin Schneier, a psychiatrist who co-directs Columbia’s clinic for anxiety disorders, warned that Kick’s plan to repackage propranolol like Altoids “trivializes both the condition of social anxiety and the treatment of propranolol.”

Or as Stanford psychiatrist Dr. Anna Lembke put it: “To suggest that propranonol is entirely benign and equal to an Altoid, I think, is a really dangerous notion.”

“That’s a horrible idea. It’s a horrible idea!”

Stefan Hofmann, Boston University psychologist

That’s because although propranolol is an old drug with a strong safety profile, it still carries a small but real risk of side effects, ranging from lightheadedness all the way up to reports of congestive heart failure and the serious allergic reaction known as anaphylaxis.

Justin Ip, Kick’s founder and CEO, called these “legitimate concerns.” But he also characterized the fields of psychology and psychiatry as “relatively reticent to change” and “against anything that’s new” — even though there’s an acute need for innovation, given the severe shortage of mental health providers, particularly in rural areas.

Ip declined to compare his minty pills to candy, saying that “feels too fun.” But he said it was important to repackage the drug to reach a wider market of people who might not seek traditional psychiatric treatment but could benefit from propranolol if they saw it in a new light. (He also plans to offer a normal pill as an alternative to the lozenges.)

He pointed to other ways this is being done in more powerful drugs, such as an ADHD medication repackaged as a fruity chew — a move that also drew sharp criticism from some in the medical community.

Ip hopes to launch in the next few months in California, home to a vibrant culture of self-experimentation with pharmaceuticals, and then expand to other states. He expects a prescription to cost about $50 out of pocket.

A treatment for anxiety that’s fallen out of favor

Many people are afraid of public speaking. But when it gets severe and persistent enough, it’s codified in the DSM-5 as a type of social anxiety disorder specific to performance. About 15 million adults in the U.S. are believed to have social anxiety disorder, often undiagnosed and untreated.

Those who do seek treatment have a few options: Cognitive behavioral therapy, which involves talking to a therapist or completing online exercises. The class of antidepressants known as selective serotonin reuptake inhibitors, such as Paxil and Zoloft, which block the reabsorption of a neurotransmitter that regulates anxiety. Benzodiazapines like Xanax, which relieve anxiety by enhancing the effects of a neurotransmitter called GABA in the brain.

Then there are beta blockers like propranolol, which take a different tack. They suppress the autonomic arousal associated with fear — meaning no more racing heart. No more shaking hands.

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Many psychiatrists embraced beta blockers for social anxiety and performance anxiety in the 1970s. But they’ve since fallen out of favor and are not considered a first-line treatment, in part because they aren’t as effective for people whose anxiety doesn’t manifest in mainly physiological ways.

“Bringing up propranolol is resurrecting a dead body,” said Hofmann, the Boston University psychologist.

Ip said he chose propranolol because it’s a cheap generic drug with few side effects and a long history of off-label use. He also pointed to a 2015 study that found that people who are afraid of spiders had a significant reduction in their anxiety after taking propranolol and being exposed to tarantulas, compared to people who were only exposed to the tarantulas or only took propranolol.

Still, anxiety experts caution that propranolol is a powerful drug. (It’s usually taken at a higher dosage than Kick is planning on.) It’s not recommended, for example, in people with asthma, and doctors take caution before prescribing it in people who have a history of arrhythmia, low blood pressure, or an elevated risk of fainting. Lembke, the Stanford psychiatrist, said she’s had patients who experienced withdrawal symptoms when they stopped taking propranolol after months or years.

“It’s a serious cardiac medication. I don’t think it’s something that should be prescribed lightly,” she said.

“It’s a serious cardiac medication. I don’t think it’s something that should be prescribed lightly.”

Dr. Anna Lembke, Stanford psychiatrist

Propranolol isn’t approved by the Food and Drug Administration to treat social anxiety or performance anxiety. But because Kick won’t be manufacturing the drug, it won’t be subject to FDA rules restricting off-label marketing by manufacturers. (The company worked with a compounding pharmacy to develop a proof of concept for the mint-style pill and is now talking to manufacturers.) Still, Ip’s being careful to comply with regulations.

“The way I think we’re going to message this is: Fear gets in the way of living your best self and achieving what you want to achieve and reaching your full potential, especially around the things that you value the most,” Ip said. “So what if there was a cure for that that involved an app and potentially a prescription drug?”

Kick Health
Kick, a San Francisco startup, plans to soon launch a telemedicine platform where people can get off-label prescriptions for a heart drug meant to be taken an hour before an anxiety-producing event. Alissa Ambrose/STAT

He envisions reaching not just people nervous about public speaking, but those who are shy. Or who fear going to the dentist. Or flying on a plane. Kick’s website also pitches the drug as a good bet for professionals experiencing “imposter syndrome” — meaning they worry they don’t deserve their seat at the table. It’s meant to be taken about an hour before the anxiety-producing event.

Kick is Ip’s first health-related business venture. His background is in consumer tech products; he previously worked on an app for finding hiking trails.

He developed an interest in mental health after he ruptured his Achilles tendon and found himself unable to walk and in an emotional rut.

“Fear gets in the way of living your best self. … So what if there was a cure for that that involved an app and potentially a prescription drug?”

Justin Ip, founder of Kick

Ip, who’s raised an undisclosed amount of venture funding, launched the first iteration of Kick in June. It’s an app that sends users a “kick of the day” to help them tackle their fears. Monday’s advice: “Eat a dinner item in the morning” — and then reflect on how breaking the rules made you feel. Ip worked with psychologists to design the content, which he said combines tenets of exposure therapy, mindfulness, and cognitive behavioral therapy.

Ip hasn’t yet figured out, he said, whether the telemedicine platform will be part of this app, a different app, or part of the company’s website. But he suspects that however he launches, he’ll tap into an eager market.

After all, Dimitriu, the psychiatrist working with Kick, already prescribes the drug several times a week to clients in Silicon Valley. He’s even taken the drug himself before big presentations. But he says he’s mindful that it’s not appropriate for everyone and will take care in screening online clients.

A ‘magic pill’ jump-starts a career

Before he became a high-powered tech CEO, Jim Safka was a high school kid so nervous about speaking in front of the classroom that he’d stay home from school.

Later, as a young assistant brand manager promoting Molly McButter butter-flavored sprinkles, he was so terrified about speaking during an advertising meeting that he could only get out a few words.

Safka tried everything he could think of: Taking an SSRI. Popping Xanax. Downing a few beers before big meetings. None of them worked.

Then, when he was about 30, a doctor prescribed him propranolol. He tried it at a regular meeting, and felt so confident, he even volunteered to speak.

“It was literally like a magic pill to me from that point on,” Safka said. And it marked “the beginning of the acceleration of my career.”

Safka rose through the corporate ranks, becoming CEO of Match.com and Ask.com in the 2000s. For about a decade, he took a 20 milligram dose of propranolol three or four times a week, an hour before he made a TV appearance, gave a speech, or ran a big meeting. He never experienced any side effects.

Eventually, Safka found, he rarely needed propranolol. Now 49, he’s working in nonprofit fundraising, as the founder of a new project to aid the victims of the recent Mexico City earthquake.

He’s also a fan of Kick’s vision of offering propranolol to the masses.

“I honestly believe it changed my life,” Safka said. “I hope that other people can realize that it’s available.”

Though he rarely uses it, he still keeps propranolol pills in his briefcase. Just in case.

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  • In terms of dealing with fear of public speaking, there’s another very effective approach: joining a Toastmasters club. Years ago I joined a club which meets near where I live.

    Seven years ago, I entered a Humorous Speech Contest. I won in my club, then in the larger Area, then in the larger Division, and finally in the District
    Contest where I spoke before a very large audience and got a lot of laughs.

    I’m still a member of a Toastmasters club and regularly attend its meetings.

  • Propranolol doesn’t even remotely work for this “indication” (other than as a placebo). I know; I’ve tried it. This is a joke.

  • Funny, psychiatrists are happy to give out chronic bzds for anxiety but a tiny dose of propranolol is cause for alarm? The drug is barely psychoactive and at such a low dose the risk of adverse effects is low.

    As long as a physician is a part of the process to ensure the drug is safe for a person and that they “test” their first dose well before they need it for a speech or whatever I see little issue.

  • Mindfulness meditation has worked like magic for me not just for anxiety but for many other issues in life. I think a medication like this could have serious long-term adverse effects to say the least.

  • Talk to enough folks with MH diagnoses and you will plenty of anecdotal evidence that beta blockers can exacerbate depression. Considering the comorbidity of the 2 dx, prescribing a beta blocker to a person for anxiety seems short sighted at best.

    • I’d encourage you to refer to UpToDate for the latest clinical information around this topic:

      Depression, fatigue, and sexual dysfunction are commonly cited side effects
      of beta blockers, and may be one reason why use of beta blockers is lower than desired for some approved indications.

      However, these associations are primarily based upon case series and randomized trials with methodologic flaws.

      The best available data on this issue comes from a systematic review of randomized trials, which found no increased risk of depression with beta blocker therapy. The review included 15 randomized, placebo-controlled trials involving more than 35,000 patients who were followed for a minimum of six months. Both patient reported symptoms and withdrawal of therapy were investigated.”

  • Calling a beta blocker a “psychoactive” drug seems a stretch. If I’m not mistaken, beta blockers lower blood pressure by lowering pulse. They can make you feel sluggish, so the effect on the physiologic consequences of performance anxiety makes total sense.
    The safety issues (outside of hypotension, i.e., lightheadedness, falls, fainting) strike me as issues associated with long term daily use, which is what beta blockers are indicated for. If this is prescribed for PRN use and the Rx quantities are kept small (say not more than 10 pills per Rx), then a good screening seems reasonable to me.

    • hi TW – Justin from Kick here. You are absolutely correct. Beta blockers aren’t considered “psychoactive” and it amazes us that doctors often prescribe Xanax instead for performance anxiety. We are limiting the number of doses and don’t intend to prescribe for long-term daily use.

    • It may be used primarily for hypertension but propranolol specifically over most othe rbeta blockers has the ability to cross the blood brain barrier allowing it to exhibit effects not just on the heart but the brain as well. That is also why compared to other beta blockers it has the most neurological side effects. However you are absolutely correct in that most side effects are seen at high doses and maintained use over time. But neither side is right to discount what the other is saying. Yes it may be fine to be prescribed via telemedicine but clearly the side pushing for it wants to downplay the side effects. Also to be aware is that it is being made by a compounding pharmacy and is not the traditional tablet form where all of the effects have been noted. It would be nice to see if the pharmacy has on file the absorption rate and onset time of a sublingual troche versus a tablet and to see if a patient sees a much higher/lower absorption and onset/offset time. Compounded drugs are not equivalent to their fda approved counterparts, its the main reason a pharmacy is allowed to compound it.

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