Needle-Phobia and Jet Injection Technology A viewpoint by Elemer K Zsigmond,MD DSc FCP Department of Anesthesiology, University of Illinois, Chicago, Illinois, USA Guest Commentary* The paper of D Cox and D.C. Mohr entitled:” Managing Difficulties with Adherence to Injectable Medication Due to Blood, Injection & Injury Phobia and Self-injection Anxiety” that is published in this issue of the American Journal of Drug Delivery initiated this editorial. The authors have made a great contribution to current drug delivery practices by calling attention to the existence of needle-phobia and, therefore, to the lack of adherence of the patients to the drug therapy, that may lead to hundreds of thousands of totally preventable death worldwide. Needle-phobia alone may result in death, as I observed during a half a century of medical practice. I can recall dozens of patients who died as a direct result of needle-phobia, which led to cardiac arrhythmias, probably from abnormally elevated catecholamines. When we evaluated a new outpatient anesthesia technique in young female patients who underwent laparascopic tubal ligation or reconstruction and determined the circulatory state, cardiac output measurements revealed an abnormally elevated output and catecholamine levels. In 5 out of the 40 patients studied, the plasma catecholamine levels were as high as in phaeochromocytoma patients, therefore, we carried out screening for this abnormality with negative results. These patients reported a fear of needles because of the pain, it caused. Since no premedication was ordered by the surgeons, a high level of anxiety was observed in these patients. Blood pressure and pulse rate measurements did not indicate this stress. Tranquilization by midazolam reduced cardiac output and the high catecholamines were normalized (1). As an anesthesiologist, I have also encountered sudden, unexplained death, in patients scheduled for surgery, upon anesthetic induction, especially with the two notorious catecholamine stimulant inhalational anesthetics- ether and cyclopropane. In a number of publications we have emphasized the importance of sedation before operations of any kind(2). For further information, interested readers can search the Medline as numerous articles have been published on hormonal and circulatory effects of anaesthetics over the last 30 years by our research group. Painful self-injection of patients, particularly by the im route definitely a major obstacle to patient compliance. Based on three decades of experience with inoculations, we have realized that intramuscular injections given by jet-injectors are not painful at all. Therefore, the conventional needle/syringe ought to be replaced by jet injection. Some injectors, such as the Biojector that is safe not only for the subcutaneous but also for the intramuscular route. In the USA, this technology is approved by the FDA for both routes of administration. Regrettably, as judged from this article, there is little awareness of the wide availability of various jet injection devices without needles. Of these, the Med-E-Jet injector has been used for over two decades in diabetic patients who require daily multiple injections of insulin. Tissue reactions to jet injections were absent in several studies in contrast to the development of subcutaneous nodules when the insulin injections were given by a #27g needle and insulin syringe. The studies on blood glucose and insulin showed the efficacy, safety and superiority of this approach over the conventional needle/syringe. The high initial cost of the Med-E-Jet injector prevented its widespread use. Its successor, the Biojector injector cost about half as much, but disposable syringes have to be used with the added cost. Recently, self-contained needle-free, disposable, jet-syringes became available such as the J-tip Needle-free Injection System, which require no injector at all. During the last year, another jet-injector with spring loading, the Injex became available that utilizes syringes at even a lower cost, but approved only for subcutaneous injections. With the ongoing fierce competition among jet-injector manufacturers, it is likely that all kind of injectors and syringes will be available at a lower cost. In 1995, I set up a project: “The UIC Hospital is the first Needle-free, Infection-free and Pain-free Hospital in the World”. The Administration approved this project to eliminate the conventional needle /syringe system and replace it with jet-injection technology. We already converted about 80% of the practice. During the past two years all injections in the Surgicenter were given by jet-injection, as a result no needle-stick injuries occurred and 99.9% of the patients reported Zero pain scores on a 0-10 rating scale. Hopefully in a short time all injections for all patients in the whole hospital will be given solely by jet injections. The anticipated great cost increase was compensated by a reduction of the cost of the jet syringes and injectors. The cost of the ji technology almost matches the cost of so-called new “safety needle/syringes”, that ought to be used in the place of conventional needle/syringes mandated by US Federal Law. Two additional bonuses are: the complete elimination of needle-stick injuries/death and the reduction of pain scores on injections to Zero both in compliance with the current strict Occupational Safety and Health Administration (OSHA) and Joint Comission on Accreditation of Health Organizations (JCAHO) mandates in the USA. In conclusion, the solution of the problems presented in this excellent review is the routine and exclusive use of jet injection technology! References: 1. Zsigmond EK, Vieira ZEG, Dadhaboy Z: High catecholamine levels and cardiac output in unsedated patients scheduled for outpatient surgery. X. World Congr. Anesth., The Hague, The Netherlands, June 12-19,1992. Excerp. Med. ISBN 90-800899-1-3:A883. 2. Zsigmond EK, Hirota K: The Autonomic Nervous System: Sympathetic and Parasympathetic Pharmacology. In: Prys-Roberts, Ed., ”Cardiovascular Pharmacology”, Current Opinions in Anesthesiology; Philadelphia/London; Publ:Current Sciences.Ltd. Vol. 6:1993:197-207. * Am J. Drug Deliv; 1:223-224,2003.