Needle fear can complicate many doctor-patient relationships, but in the case of patients with insulin-dependent diabetes, fear of needles can become a serious barrier to compliance.
Studies show that up to one-quarter of people with diabetes have needle anxiety (Diabetes Res. Clin. Pract. 1999;46:239–46), and that extreme needle phobia exists in about 1% of patients (J. Psychsom. Res. 2001;51:665–72).
If these issues are not properly addressed, they can lead to skipped doses and poor glycemic control, according to Dr. Mary Korytkowski, of the division of endocrinology and metabolism at the University of Pittsburgh, and director of its center for diabetes and endocrinology.
“I've had people tell me it takes them an hour to give the shot,” Dr. Korytkowski said in an interview. “They break out in a cold sweat, they just can't face it, and they have to work themselves up to giving it.”
“For someone with diabetes to have needle fear, and then have to take four shots a day, that's a little bit of an overwhelming request,” commented Dr. H. Peter Chase, professor of pediatrics at the University of Colorado, Denver, and clinical director emeritus of the Barbara Davis Center for Childhood Diabetes, Aurora. “I've had kids [who were] ready to go to college, and the parents were still giving the shot because the kids were so scared of it.”
According to Dr. Korytkowski, needle anxiety can arise not only in first-time insulin users, but also in experienced patients in whom the injection routine has become well established.
Although some patients are clearly focused on their fear of pain or injury, others have psychological issues that are more complex. “Sometimes it is an emotional response to going on insulin,” she said. “Now that we have other injectable medications that are not insulin, I find that some people will accept them more readily. There's something specific about the insulin.”
The psychological implications of reaching insulin dependency may not figure as prominently in needle fear among children or adolescents, whose primary concerns focus more on pain—both physical and social, Dr. Chase said in an interview.
“Only about a third of teenagers are currently in the range recommended by the ADA [American Diabetes Association] for good glycemic control,” he said. There are lots of reasons for this, and fear of needles is one of them.
In fact, Dr. Chase's group recently completed a study looking at the effect of reducing needle pain by fitting pediatric diabetes patients (aged 5–7 years) with a subcutaneous injection port (presented at the 2006 ADA annual meeting). EMLA cream was used for placement of the port, which could then stay in place for 3–5 days. Patients' multiple daily needles (mean, 4.5) were then administered through the port's catheter without piercing the skin. After 6 months, compared with 22 patients in both a control group and a second group who received regular dose-reminder alarms, the 17 patients fitted with the injection ports reported a reduction in pain, which was reflected in significantly improved glycemic control. “The injection port improved pain and/or convenience,” he said.
All patients in the study used pen injection devices, which, like insulin pumps, can help alleviate needle anxiety for several reasons. “Some people just don't like to see the needle, or they're not sure how far they should inject,” Dr. Korytkowski explained. “Sometimes with pen devices you don't really see the needle. And it's all a contained system [which controls insertion depth] so patients don't have to manipulate much.” Jet injectors, which use air to drive an insulin dose through the skin without a needle, also are worth considering.
Devices such as pens and pumps also improve the discreetness of injecting, which is helpful for people whose needle anxiety is rooted in embarrassment, Dr. Korytkowski said. “Individuals with diabetes may be particularly conscious of self-injection in public places, as they fear the judgment of others and stigmatization as a 'sick person,' a 'dependent,' or even a 'drug user,'” she wrote in a review on addressing issues of confidence and convenience in insulin delivery (Clin. Ther. 2005;27[suppl. B]:S89–S100).
Although she has never referred a patient for psychological counseling because of needle anxiety per se, she has referred patients because they have a certain “disconnect” with their condition. “That's a different group. They'll do what has to be done, but they're not happy and they don't connect to it somehow. That takes a while to work through,” she said.
Although some patients who are transitioning to insulin may be extremely vocal about their fear of self-injection, patients' needle anxiety may not always be obvious. Physicians should consider this possibility in patients who are not achieving good glycemic control, Dr. Korytkowski said. “If you have just one visit with a person, you may not find much out, but as you get to know these people—and diabetes is a chronic disease, so you usually get to know them—they will eventually tell you.”