© 1997-2014 Jerry Emanuelson
The Needle Phobia Page
A starting point for overcoming an important, but widely-ignored condition.
Needle phobia is a defined* medical condition that affects between 20 and 23 percent of the population to such an extent that it causes them to avoid needed medical care. Many cases of what is called needle phobia go far beyond a simple fear of needles. On this page, you will learn the many aspects of needle phobia.
Between 4 and 10 percent of the population has a form of needle phobia that is biological in origin, and that is unrelated to classic phobias. (In medical environments, the percentage of patients suffering from this genetic type of needle phobia is 3 to 5 percent, but at least twice that number with this genetic condition will never seek medical care under any circumstances.) Needle phobia is a medical condition that deserves treatment just as much as any other medical condition. You shouldn't be ashamed of having needle phobia any more than you should be ashamed of having a headache. Whether your particular needle phobia is biological or psychological in origin, or both, in medical journals it is still called needle phobia (and there is an ICD-10 medical insurance code for it).
The medical profession pays inadequate attention to needle phobia, in part, because those with needle phobia tend to avoid contact with the medical profession. Few physicians have any idea about the magnitude of this problem. Many people would rather die than have a needle procedure, and countless thousands of people actually do die for that reason.
I urge you to read this page very carefully, and to read it more than once. If you have this condition, it is very important that you do everything possible to overcome it.
The vast majority of patients who suffer from needle phobia are much too passive in their dealings with the medical profession; and many actually avoid the medical profession completely, even when they have a serious or potentially fatal condition.
Needle Phobia is used to describe one of several conditions that are often interrelated. The term Needle Phobia is commonly used, even among medical professionals, to describe several very different conditions. Some of these conditions are classic phobias, and some are not. This makes needle phobia a very complex condition.
A significant fraction of the cases of needle phobia are actually a medical condition, probably with specific genetic origins, and not a traditional phobia at all. This is discussed further in Dr. Hamilton's 1995 medical journal article described below, and it has been discussed in other recent medical journal articles. In many cases, any perceived fear is actually directed mostly toward the involuntary physical reaction of one's body to needle procedures (rather than the needle procedure itself). Resistance to the idea that many cases of needle phobia are a part of a genetic-physical disorder is a significant barrier to needle phobia treatment.
For many people, the needle is only a source of fear to the extent that a needle is a necessary part of the procedure that provokes a terrifying involuntary reaction of one's body.
For some sufferers of Needle Phobia who have thought about the nature and origin of their condition, they actually have no fear of needles at all, but may have a extreme fear of suffering the physical effects of a needle phobia reaction.
Needle Phobia is also unique among so-called phobias with respect to the fact that it is a direct cause of death in many documented cases -- and as an undocumented cause of countless millions of deaths throughout the world among those who avoid all medical and dental care because of the condition. The undocumented deaths, due to the avoidance of medical care, undoubtedly would put Needle Phobia among the world's leading causes of premature death.
There are, however, a large (and very rapidly-growing) fraction of the cases of needle phobia that are simply the fear of needles resulting from one or more traumatic experiences. The number of these human-caused "classic" phobias has been increasing dramatically over the past two decades, and has become the majority of needle phobics since this web page was started in 1997. For many needle phobics, though, the first traumatic experience was the unexpected and involuntary reaction of their body to a needle procedure rather than the needle procedure itself. It can often be very difficult to separate the simple exaggerated fear of needles from the terrifying purely biological reaction that some people experience. This is complicated by the fact that some people experience both kinds of needle phobia.
A few doctors tell those who are suffering from needle phobia to "Just get over it!" This is an extremely common complaint that I read in my email. It is also completely inexcusable in every respect. This is like telling a patient with clinical depression to "Just cheer up!" This, in fact, is becoming a major cause of new cases of needle phobia itself. This problem is especially bad in the United Kingdom.
A rude "Just cheer up!" command to a patient suffering from clinical depression would now be considered as serious medical malpractice. If those who suffer from needle phobia ever become active in educating the medical profession about their condition, the "Just get over it!" command to a needle phobic will also someday be considered to be serious medical malpractice. For now, it is up to those who suffer from needle phobia to educate the medical profession about the seriousness and the magnitude of this problem.
For a physican to tell someone with needle phobia to "Just get over it!" or to "Just grow up!" is equivalent to beating a headache patient over the head with a rubber mallet. It is certainly not going to make the situation any better, and it is likely to make it very much worse, possibly with results that could later become life-threatening. Any medical professional who behaves in this manner should be stripped of all medical credentials.
An important note about email to me: My email volume very frequently exceeds my capability to respond to it all. I do read all of my incoming email. In many cases, especially during weeks when the volume is especially high, I simply cannot think of a good and useful response to some emails that really do deserve a response.
My email address is shown near the bottom of this page.
Please don't get discouraged if I don't respond to your email. I am only one person. Maintaining this Needle Phobia Page consumes a lot of my time, and I may not be able to maintain this page much longer. I know that some cases of needle phobia may seem hopeless, and I wish that there were enough hours in the day for me to offer individual suggestions and encouragement to everyone who writes to me.
Please just know that it is never hopeless; and that in spite of all of the difficulties, needle phobia can be overcome.
Because needle phobia is a complex condition with many causes, the same treatments will not work for everyone. Here is a quick summary of the most effective treatments for needle phobia that are detailed below on this page:
The most important needle phobia treatment is a topical anesthetic or device that will prevent the sensation of the needle penetration. In some cases, the topical anesthetic needs to be combined with a prescription oral sedative. The most effective of the topical anesthetics is the Synera patch (known in Europe as the Rapydan patch). There are anesthetic creams that are messy to use and that have a much lesser degree of effectiveness, but which may be sufficient for some people. A device known as the Buzzy is available without a prescription, and it can typically eliminate about half of the needle sensation.
It is rare for any kind of psychological treatment alone to eliminate needle phobia, and it is almost never helpful for those who experience the vasovagal (fainting) type of needle phobia. For a significant minority of needle phobics, though, psychotherapy or hypnotherapy may be a necessary first step in eliminating needle phobia. Because discussions of needle procedures may cause some needle phobics to experience loss of consciousness with convulsions and potentially other serious medical problems, all psychotherapy or hypnotherapy should either be conducted directly by a psychiatrist (who is also a medical doctor) or in an environment where advanced medical treatment is rapidly available (such as by a psychotherapist or hypnotherapist whose office is in the same building as, and in very close proximity to, the offices of well-equipped medical doctors).
Although hypnotherapy may be a useful first step for many people, after more than 17 years of maintaining this Needle Phobia Page, I have yet to encounter a single case where hypnotherapy alone worked satisfactorily. That may change, though, since the percentage of the population who experience needle phobia as a classic phobia has roughly tripled since I started this page.
For those who experience the vasovagal (fainting) type of needle phobia, there are other techniques, such as Applied Tension, that can prevent loss of consciousness during or after needle procedures. There are very large differences in various evaluations of the effectiveness of Applied Tension, but it is a technique that is worth very serious consideration.
I have a separate web page with details about the prevalence of needle phobia. This is an early version of the "Prevalence" page, and I will be adding more relevant information later, especially as more studies are done.
When I started the original version of this page in early 1997, I did a Medline search of the medical literature since 1985. At that time, the search turned up only 16 articles in response to a keyword search for needle phobia. One would expect that any disorder affecting more than 10 percent of the population would generate thousands of medical journal articles. For example, a keyword search in the same database at that same time in 1997 on diabetes listed 66,190 articles.
Things have gotten somewhat better in the intervening years. A search for the phrase "needle phobia" in the same database in early July of 2013, turned up 88 medical journal articles. By March of 2014, the number had grown to 98.
The initiative for treating needle phobia must come from the patient.
This adds to the difficulty of the problem since the fear tends to paralyze most needle phobics, making it difficult for them to take the initiative with the medical professionals that they encounter.
Many needle phobics feel rather beaten down by the medical profession. Nearly everyone can remember unpleasant experiences with the medical profession with respect to needle procedures during childhood. Despite all of the potential difficulties, needle phobia can be overcome.
Overcoming needle phobia is one of the most important things that you can do for your health.
The following statement is so widely and consistently ignored that I must repeat it again:
The initiative for treating needle phobia must come from the patient.
A very important warning: Of the needle phobics that I hear from, many of them have waited until they have what I call end-stage needle phobia, meaning that they have a treatable condition that has become very serious or life-threatening. Needle phobia can be overcome at any stage, but this end-stage needle phobia presents special difficulties because of all of the other issues that a person is facing. Overcoming needle phobia is much easier when you are otherwise in a healthy condition.
If your doctor does not take your needle phobia seriously, it is critically important that you find another doctor. If you don't make a considerable effort to find a doctor who is at least somewhat understanding toward needle phobics, then you may become one of those unfortunate individuals with end-stage needle phobia.
There are more products on the market for treating needle phobia now than ever before. Unfortunately, most of the products are marketed in such a way that they are often extremely difficult for the needle phobic patient to obtain. I have been trying to overcome this inexcusable condition, which leaves millions of needle phobics without medical care while relatively inexpensive products are available that could help them to overcome needle phobia.
There are a number of psychological techniques that are very effective in overcoming most phobias that fail completely in most cases of needle phobia. Some of these techniques can even be very risky for needle phobics with the vasovagal type of needle phobia, as discussed below.
Cases of needle phobia that are a sub-type of blood-injury-injection phobia are recognized by medical scientists who have studied this issue as being intrinsically different from other phobias in very important and fundamental ways.
It is not unusual for those with the blood-injury-injection phobia to experience either fainting or near-fainting when merely discussing needle procedures, or when listening to a discussion of needle procedures, or while watching someone else (even a pet) undergo a needle procedure. (For this reason, I try to be very careful of what I write on this page. It is also the reason that this page consists of mostly text, with few images.)
There is only one comprehensive review of needle phobia that has been published in the medical journals. That review is an excellent and comprehensive article: Needle Phobia: A Neglected Diagnosis by James G. Hamilton, M.D. in the August, 1995 issue of The Journal of Family Practice. [Vol. 41, No.2, pp. 169-175]
Dr. Hamilton's review does have 56 references, dating back as far as 1939, to other medical journal articles -- although many of the references are to single case histories, or to topics only secondarily related to needle phobia.
There are large differences among individuals with needle phobia. Those who have studied needle phobia express the categories of needle phobia differently. For purposes of this page, needle phobia can be put into four broad categories:
(1) The type of needle phobia described in Dr. Hamilton's article is characterized by the vasovagal reflex reaction, a frightening reaction which includes plunging blood pressure and (often) loss of consciousness and (sometimes) convulsions. This reaction generally occurs only after the onset of puberty, and is more common in men than women. Most estimates have been that 3.5 to 5 percent of the population suffers from this condition. It is likely that the percentage is far higher since vasovagal needle phobics tend to avoid all contact with the medical profession more than any other type of needle phobic, even when faced with death. Therefore, there is little opportunity for an accurate count of vasovagal needle phobics.
(2) It is very common for young children to be afraid of needles. Many children will simply "outgrow" their fear, but others will become adult needle phobics. Children who are needle phobic can be administered topical EMLA cream or iontophoresis or the Synera/Rapydan patch (see below). The Buzzy device, described below, is also extremely helpful for children, especially for routine injections. Forcing needle phobic children to undergo needle procedures without the treatments described below will greatly increase the chances that they will become severe needle phobics and avoid medical care as adults. There is evidence that the prevalence of needle phobia is growing dramatically as more vaccines are available for important diseases, but these vaccines continue to be administered to children without any kind of pain mitigation. Children have a much greater sensitivity to needle pain than adults.
(3) Some needle phobics have an acute sensitivity to pain. Needle procedures that are painless to most people cause considerable physical pain to these needle phobics, especially when a needle enters their vein. The use of one of the iontophoresis units described below may greatly improve the lives of these individuals (although most patients find the currently-available general-purpose iontophoresis units very difficult to use for this purpose). It is very unfortunate that the special purpose iontophoresis units that were designed for needle phobia are no longer available. The Synera/Rapydan patch may be very useful to some individuals in this category, especially since most of these individuals experience great pain during intravenous procedures. Intravenous procedures are an area where the Synera/Rapydan patch is most effective.
(4) The type of needle phobia that most people think that they have (but which, until recently, was suffered by only a small minority of needle phobics) is a classic phobia that results from a specific early traumatic experience (or multiple experiences). Many people with needle phobia remember an early experience which they believe triggered their needle phobia. Most of the time, though, these people are simply remembering their first needle phobia reaction. The traumatic experience that is described is usually a routine needle procedure that occurred without any significant problem other than the physical needle phobia reaction itself. Some cases of needle phobia involve combativeness and active physical resistance that is, on rare occasions, quite violent. Although little, if any, research has been done into the sources of this combativeness, it is generally believed that this is the result of the unfortunate common practice of physically restraining children (often using more than one adult) in order to forcibly administer needle procedures. Unless a child is literally in danger of imminent death or long-lasting disability, such forcible restraint is clearly child abuse unless it is accompanied by sincere and effective efforts to comfort the child and minimize the pain.
Many needle phobics fit into more than one of these categories, and there may be other categories that are not listed here. Needle phobia is a subject that has received very little formal study for a disorder that affects such a large fraction of the population. Whatever form your needle phobia takes, some of the treatments listed below on this page are likely to be useful.
About 80 percent of vasovagal (fainting) needle phobics have a first-degree relative (parent, child or sibling) with needle phobia. This is evidence that this type of needle phobia has a genetic component. Vasovagal needle phobia is a genetic trait that had survival value for humans prior to the 20th century. Before modern medicine, an individual with an inordinate fear of being stuck with a fang, a thorn or a knife was less likely to die in accidents or in encounters with hostile animals or men. Prior to the 20th century, even an otherwise non-fatal puncture wound had a reasonable chance of causing a fatal infection. This trait that had positive survival value prior to the 20th century now has a negative survival value since it shuts its victims off from many of the benefits of 21st-century medicine.
An episode of needle phobia of the vasovagal type can be frightening not only for the needle phobic, but for others present as well. When needle phobia results in loss of consciousness, it is not uncommon for it to be accompanied by convulsions or respiratory distress. There are, in fact, at least 23 documented cases of death due to needle phobia. One of those deaths was the father of Dr. Hamilton, who wrote the review article mentioned above.
Of much greater concern than the very rare cases of death directly due to needle phobia are the countless thousands of premature deaths caused by the avoidance of medical care due to all types of needle phobia. The avoidance of medical care due to needle phobia causes an amount of human suffering that is on a scale with many major well-known diseases. I know of no way to get solid data on the number of deaths caused by needle phobics avoiding medical care, but it is likely that avoidance of medical care due to needle phobia is among the top ten causes of death in the industrialized world. I have a separate page about the estimates of the prevalence of needle phobia. I will be expanding that page later.)
Most physicians tend to greatly aggravate the needle phobia problem by the way that they treat children who require needle procedures. Commonly, two techniques are employed with children. One technique is that the children are forcibly held down by adults while a medical professional sticks needles in the child. The second technique is to resort to one of many kinds of deception, threats and trickery in order to administer the needle procedure. Either technique will help to guarantee that the child will develop a lifelong distrust of any kind of medical professional.
Distraction of children during needle procedures is a good thing, but trickery is not.
All forms of needle phobia can be overcome, though. In fact, even though I am a lifelong needle phobic, I wrote the first draft for this page in 1997 sitting with a needle in my left arm, undergoing an elective 3-hour intravenous therapy as part of my personal program of preventive medicine. The first draft of this page was written during the 2nd of 10 such sessions. I decided to begin this web page after suffering a vasovagal reflex reaction and losing consciousness and suffering convulsions shortly after beginning the first of these 3-hour I.V. treatments a week earlier. That was my first needle phobia reaction in many years, even though it had been a constant problem for me up through my early twenties. I have not had a needle phobia problem since August 2001.
Overcoming needle phobia does present special difficulties, and it does not usually respond well at all to traditional techniques for overcoming phobias. Nearly half of the cases of so-called needle phobia are a distinct physiological reaction that is, to some extent, hard-wired into the human brain.
Quite often, even after a person has lost his conscious fear of needles, the patient may retain anxiety about the physiological needle-phobia reaction. For many needle phobics, the physiological needle-phobia reaction is much more unpleasant and anxiety-provoking than the needle stick itself. (I have pretty much lost all conscious fear of needles myself, and I can even give myself injections; but I still am in danger of having a vasovagal reflex reaction occasionally if I'm not careful, and I find the vasovagal reflex reaction to be a truly terrifying experience. Fortunately, I have had only one vasovagal reflex reaction since beginning this page more than 16 years ago. In that 2001 event, I was talking with the nurse about needle phobia and the Needle Phobia Page during the needle procedure. I inadverently gave a demonstration of the vasovagal needle phobia reaction when I passed out less than a minute after the needle procedure was finished. Being a well-known needle phobic to everyone in the office, no one was taken by surprise when I suddenly collapsed on the floor.)
See Accurso, V.; et al. (August 2001). Predisposition to Vasovagal Syncope in Subjects With Blood/Injury Phobia. Circulation. Volume 104. Issue 8. pages 903-907.
The differences between needle phobia and other common phobias cannot be over-emphasized. Psychologists and counselors should be warned against attempting to treat needle phobics in a non-medical environment. (Conventional treatments for phobias have a very poor track record against needle phobia, even in cases where the phobia is acquired from a traumatic event.) Conjuring up images of needle procedures can evoke a full needle-phobic reaction, including vasovagal shock and possible cardiovascular problems. Although permanent injury is very rare, no one should risk evoking the physiological needle-phobic reaction without emergency oxygen and the presence of medical personnel skilled in cardiovascular resuscitation.
See Accurso, V.; et al. (August 2001). Predisposition to Vasovagal Syncope in Subjects With Blood/Injury Phobia. Circulation. Volume 104. Issue 8. pages 903-907.
Hypnotherapy alone also has a extremely poor track record in the treatment of needle phobia, although (as stated earlier) there are likely to be many cases where hypnotherapy combined with other treatments may be necessary for the effective treatment of needle phobia.
The rare fatal reactions to needle phobia should not deter anyone from getting needed medical attention, or even preventive medical procedures. Even a needle phobic with a weak heart is more likely to die in a traffic accident on the way to the doctor's office than of a needle phobia reaction. Every needle phobic is far more likely to die from avoiding medical care than from a needle phobia reaction. Even though there is no solid data on the subject, nearly everyone who looks seriously at the needle phobia problem will conclude that needle phobics suffer premature deaths in extremely large numbers as a result of avoiding medical care.
A modern physician's office is well-equipped to deal with a typical needle phobia reaction and has several people present who are well-trained in cardiovascular resuscitation in the rare event that it should become necessary.
Many needle phobics who were born prior to the mid-1960s had their needle phobia reinforced in childhood by poor quality control in needle manufacture which resulted in occasional dull or poorly-beveled needles. Also, many medicines, such as penicillin, that were given in earlier days were highly viscous liquids that required large gauge needles. Most substances given by injection today use very thin and very sharp needles that can hardly be felt by most adults. Quality control in needle manufacture is far superior to what it was forty or more years ago.
Needle Phobia in Dentistry:
The main mistake that people make with respect to dental needle phobia is going only to a familiar, or arbitrarily chosen, dentist without regard to any knowledge that the chosen dentist might have about needle phobia. There are many dentists who do understand needle and dental phobias, but you have to actively search and find them. They won't just knock on your door one day.
There are dentists, in many countries where this Needle Phobia Page is read, who do specialize in either sleep dentistry or sedation dentistry. Most of those dentists have their own informative web sites because of the somewhat specialized work that they do.
With sleep dentistry, the patient is completely asleep while the dental work is being done. With sedation dentistry, the patient is not asleep, but is so deeply sedated that he usually forgets completely about the fear of needles for a while.
The major problem is that all sleep dentistry and most (but not all) sedation dentistry requires the use of a needle in the arm to put the patient to sleep or to sedate the patient. Some sedation dentistry uses only oral sedation (taking a strong tranquilizer pill in the dentist office an hour or so before the dental procedure). Both sleep dentistry and sedation dentistry often use nitrous oxide before administering the sedative or anesthetic when it is given with a needle in the arm.
Like all needle phobias, the particular procedure has to be individualized to accommodate the particular fears of the patient. When it comes to dental needle phobias, individual differences tend to be quite unique to the individual. It is a good idea to have brief telephone conversation with the dentist before making the appointment to make sure that your particular needle phobia can be accommodated.
Although the great majority of dentists will do nothing to help needle phobics (except possibly offering nitrous oxide, which can be very useful in many cases), sleep dentistry and sedation dentistry are becoming increasingly popular among a very small percentage of dentists. You just need to make the effort to find the best dentists, and the specific dentist who is the most appropriate for your individual situation.
I have been contacted by one dentist who specializes in needle phobia and other dental phobias. You can contact him at the Dental Phobia Page.
Another useful dental phobia site (based in the U.K.) is Dental Fear Central. Although that site makes the very dangerous unqualified suggestion that needle phobics work with a psychologist, the web site otherwise contains a lot of very useful information.
This page was started on February 14, 1997. This Needle Phobia Page has been on the internet continuously for 17 years, and it is still updated frequently. It will continue to have frequent additions and modifications as often as possible, and as I acquire new information.
This page originated because of my strong personal interest in preventive medicine. Preventive medicine may have remarkably beneficial effects that are indicated clearly on blood tests, but those benefits may remain invisible for years without the necessary lab tests. Since effective preventive medicine can be expensive and time-consuming, if the benefits are invisible in the short-term, motivation may be lost; and the unfortunate result may be that a very effective program of preventive medicine is discontinued.
There are a number of methods that can be used to cause the human brain to avoid the needle phobia reaction. Because of the number of different kinds of needle phobia, and the variations in the intensity of needle phobia, some of these techniques are likely to be useless for any specific case of needle phobia. You will have to read each one carefully to decide which one may be right for you. Overcoming needle phobia is usually very difficult, but with the correct individualized plan of action, needle phobia can be overcome. If you happen to choose the right individual plan of action quickly, though, sometimes even a very severe case of needle phobia can be overcome with amazing speed.
Many of the marketing materials for the most effective treatments for needle phobia would tend to cause a person to believe that they are only effective for avoiding pain from needle procedures in children. Many of these products are quite effective in adults who experience extreme discomfort, but not pain, during needle procedures. Many people pass over effective treatments for needle phobia because they were designed for children. You need to evaluate the specific treatment, and not judge the treatment on whether you are now a child or are just someone who was a child a long time ago.
Since modern sharp needles produce a needle stick that is usually painless for most people, topical anesthetics are rarely used. But this completely misses the point of using anesthesia in needle phobics (although part of the needle phobia reaction is often a great amplification of any pain that does occur). The reason for topical anesthesia is to totally eliminate the sensation of being stuck by a needle. It is necessary to temporarily block the site of the needle procedure from sending the needle puncture signals to the brain.
For most needle phobics, this temporary disconnection of the needle procedure site from the brain is critically important. Topical lidocaine has been tried for this, but topical lidocaine alone will anesthetize skin only to a depth of 2 or 3 mm.
With the Synera and Rapydan patches, we enter the realm of really effective needle phobia products. The same patch is sold in the United States under the brand name Synera and in Europe under the brand name Rapydan. The patch was developed by ZARS Pharmaceuticals in Utah. The marketing of this product has been a true comedy of errors by people with absolutely no understanding of needle phobia. After several companies managed to keep this product a virtual secret for the first 8 years following its initial approval, the United States rights to the Synera patch have been sold to the U.S. division of Galen Pharmaceuticals. Galen is a United Kingdom company which obtained the rights to Synera in July 2013. This gives Synera a real chance for a fresh start. Galen seems to be taking advantage of this fresh start, although things happen slowly in the area.
Published medical studies have shown this patch to be much more effective than other anesthetic creams and patches for needle procedures. It is also much faster-acting than most anesthetic creams, although the Synera/Rapydan patch still requires 20 minutes or more to achieve full effectiveness. Those of us who have been fortunate enough to be able to obtain and use the Synera/Rapydan patch have generally found it to be far more convenient, and far more effective, than the other alternatives. In addition, the the dual action of the warming effect of the patch plus the vasodilation of the tetracaine component makes veins much easier to access during needle procedures.
Although the Synera/Rapydan patch has been approved for several years, like most products for needle phobics, in the past it has been marketed exclusively to the people who believe that it is unnecessary. The Synera/Rapydan patch went practically without any effective marketing during the first 8 years after its FDA approval in the United States, but there is some indication that this product may become more easily available to needle phobic patients in the future. In the United States, the Synera patch is currently available by prescription (but not yet easily available). Although very few doctors know about Synera (and only a few hospital and specialty pharmacies have Synera patches in stock), any United States licensed physician may purchase the Synera patch or write a prescription for their patient to use the Synera patch. Synera patches are nearly always a special order item from a conventional pharmacy, and it can be a one or two week process to obtain it from a local pharmacy. It is not yet clear how Galen eventually plans to sell and distribute the Synera patch. So far, they have, at least, greatly expanded the ineffective practice of selling Synera only to physicians directly. Physicians can now also prescribe Synera for delivery directly to the patient's home.
The manufacturer of the patch had been somewhat constrained by the FDA-approved labeling which required that it be used only in a medical setting; but in June of 2014, the U.S. Food and Drug Administration approved Synera for home use. In Europe, where the patch is marketed as Rapydan, the marketing has in recent years been done by EuroCept, and the availability may vary greatly from country to country, although the Rapydan patch has been approved for use in the United Kingdom and throughout the European Union. It is not clear how the purchase of U.S. rights to the Synera/Rapydan patch by a company based in the United Kingdom will affect its availability in the United Kingdom and the European Union.
Nuvo Research, which was a former owner of Synera and which still owns many of the rights to Synera, entered into marketing contracts for Synera with a distributor in Canada and has applied to the Canadian government authorities to license the Synera patch for sale in Canada. It is very clear, however, that Nuvo Research still does not understand what an important and revolutionary product that they have had.
Published reports on the Synera/Rapydan patch indicate that this may be an extremely valuable product for those suffering from needle phobia (and I have personally found it much better than anything else that I have used).
The Synera/Rapydan patch could be a revolutionary development for needle phobics because of its ease of use and for its ability to, in effect, temporarily disconnect the brain from the part of the body undergoing the needle procedure. Unfortunately, it doesn't matter how good the product is if patients cannot obtain it. Fortunately, Galen-USA is finally making it easier for United States residents to obtain this patch. See the Synera web site. This patch is still very difficult or impossible to obtain in many other countries.
For an example of a medical journal report comparing the Synera/Rapydan patch with EMLA cream, see:
J. Sawyer, et al. Heated lidocaine/tetracaine patch compared with lidocaine/prilocaine cream for topical anaesthesia before vascular access. British Journal of Anaesthesia. February 2009. Vol. 102, issue 2: pages 210-215. PDF version
One of its uses listed on the FDA-approved labeling of EMLA is for "intravenous cannulation and venipuncture." It was one of the first and oldest medicines used for this purpose. EMLA is a mixture of lidocaine and prilocaine that is a liquid at room temperature, even though both lidocaine and prilocaine are room-temperature solids. (This is what is meant by eutectic. Another common eutectic mixture is solder, which has a lower melting point that its constituent metals.) The liquid penetrates much more deeply than ordinary anesthetic solutions. The anesthetic doesn't penetrate as deeply as it does with the Synera/Rapydan patch or the iontophoresis units mentioned below, nor does it act nearly as fast; but EMLA has the advantage of being much more readily available, and less expensive for most people. EMLA is rather messy and must be applied at least one hour before the needle procedure. Any pharmacy can get EMLA easily, but most United States pharmacies (except for hospital pharmacies) do not keep it in stock. Although EMLA is available without a prescription in Canada, Canadian pharmacies now require a prescription from United States residents ordering by mail order or on the web. EMLA cream should be applied one hour before the needle procedure. Some individuals may require more time, and many people find the process to be rather troublesome and messy, and many find it to be not very effective. The effectiveness of EMLA cream varies greatly from individual to individual. EMLA works fairly well for many people whose needle phobia reaction is triggered by the sensation of the needle going in. EMLA does not work well for most people whose primary problem is an acute sensitivity to pain. An EMLA patch is also available in many countries.
EMLA is one of the older and less effective solutions for needle phobia. Its main advantage is that, since it has been around longer, more doctors know about it, and it is generally easier to obtain that other options that are likely to be much more effective.
A disadvantage of EMLA is the vasoconstriction it causes, which can make your veins more difficult to access. In this regard, tetracaine and (especially) the Synera / Rapydan patch are much better.
For more information about EMLA, in the United States, visit the USA EMLA web site.
In the U.K., visit the U.K. EMLA web site. (Site is temporarily under construction as of February 2014.)
In Australia, visit the Australian EMLA web site.
Although a prescription is required for United States residents purchasing EMLA, there is no reason for a doctor to be reluctant to write you a prescription for this unless you are one of the rare people with an allergy to one of the ingredients. If your doctor doesn't take your needle phobia seriously, find another doctor. For most people, the 30 gram tubes of EMLA cream offer the most convenience and flexibility. Use caution about where tubes of EMLA cream are stored. There have been cases of people (especially young children) confusing EMLA cream with toothpaste, sometimes with serious results.
The most important thing about EMLA is its relative ease of availability outside of the United States.
Tetracaine is also known as amethocaine, and is sold under a number of brand names in various countries. Tetracaine has the additional advantage over EMLA that it will dilate veins, making them easier to access. This is in contrast to EMLA, which contains prilocaine, which is a vasoconstrictor, and can therefore make access to veins more difficult. A topical 4 percent tetracaine gel sold under the brand name Ametop is available in many countries, but not in the United States. Ametop generally takes from 30 to 60 minutes after application to achieve effectiveness for needle procedures.
L-M-X 4 is not specifically approved for needle procedures, but some test reports have indicated that it is nearly as effective as EMLA. Most reports indicate that L-M-X 4 is much more effective than other forms of topical lidocaine. For reasons that I don't understand, most needle phobics are unwilling to even try L-M-X 4. They may have the mistaken impression that it is not as effective as EMLA because it doesn't require a prescription in the United States.
A company called Echo Therapeutics has made a device that appears to make L-M-X 4 dramatically more effective. Echo Therapeutics has entered into an agreement with the makers of L-M-X 4 to develop the product combination. Much will depend upon FDA regulatory approval and whether Echo Therapeutic follows a rational marketing policy, or whether they will decide instead to follow other companies into the graveyard of companies that have produced effective products that were kept forever out of the reach of needle phobics.
WARNING: All of the anesthetic creams mentioned above should only be applied to a small area where the needle procedure is to be done. They all need to be applied in a rather thick layer, and they must be left on for 30 to 60 minutes. For most people, these creams will not produce total numbing, but will usually be quite helpful. If you don't already know, find out (in advance) on what part of your body the needle procedure will be done. There have been some people who have suffered severe adverse effects from using these creams over a very large area of their body. Also, keep these creams out of reach of the unsupervised use by children. There have been severe adverse effects from young children mistaking these anesthetic creams for other products such as toothpaste. The anesthetic creams are very helpful for most people, but do not reduce sensation as much as the newer products such as the Synera patch.
I have moved my information about iontophoresis to a separate Iontophoresis for Needle Phobia page because the lidocaine-based iontophoresis units are no longer available because of extremely poor marketing practices by the manufacturers. This is very unfortunate because, at one time, these units were the basis of the most effective technique for conquering needle phobia. None of the three major manufacturers of the lidocaine-based iontophoresis units really understood the nature and magnitude of the needle phobia problem, and they all insisted on marketing their products to the very people who considered them to be unnecessary.
Like EMLA, ice works for some people whose reaction is triggered by the sensation of the needle going in, but it does little for acute sensitivity to pain. Ice does not work nearly as well as EMLA or Synera/Rapydan or iontophoresis, but it works well enough for a small minority of people with needle phobia.
A relatively large dose may be needed, depending on the severity of the needle phobia, but eventually the anti-anxiety agent may become unnecessary as the brain learns to avoid the needle phobia reaction.
Do not drive while under the influence of a large dose of an anti-anxiety agent. These anti-anxiety medicines must be used as directed by a physician, but they can be very effective, especially for those whose main problem is fainting (the vasovagal reflex reaction).
Some patients must lie with with legs elevated and their head lowered. The patient must be encouraged to remain lying or sitting until he feels quite comfortable slowly standing up.
There have been a number of scientific tests of beta blockers for vasovagal reflex, but the results have been very inconsistent. Beta blockers do seem to be very useful for some people, though. The older beta blockers, such as propranolol (Inderal) and atenolol (Tenormin) are very inexpensive and very safe (especially when used only occasionally). When used only intermittently in healthy people, they are almost completely free of side effects. Beta blockers are most commonly used as blood pressure medications, but they have many other uses. One big advantage of beta blockers over other medications is that they rarely have any significant effect on thinking and reaction time. So, unlike large doses of tranquilizers or anti-anxiety medications, beta blockers usually don't usually affect your ability to do things like driving. Be careful about standing up too quickly when you are on a large dose of a beta blocker, though. Standing up too quickly can cause "postural hypotension." Postural hypotension can cause you to faint if you aren't careful, but it is not nearly as terrifying as the fainting caused by a vasovagal reaction. If you are considering the use of both lidocaine and a beta blocker, you need to be aware that there have been some rare reports of interactions between these two medicines. In some people, beta blockers can increase the severity of allergic reactions.
Nitrous oxide is probably the safest and most convenient anti-anxiety agent, especially for milder cases of needle phobia. Unfortunately, nitrous oxide is rarely available in doctor's offices. There are reports that a few hospitals are finally beginning to make nitrous oxide available for use during needle procedures, although they are restricting the use of nitrous oxide in hospitals mainly for use in children only.
Relatively inexperienced nurses should gain their experience on non-needle-phobic patients. Also, be aware that problems with any of the apparatus during venipuncture are likely to unduly panic a needle-phobic patient. Such problems may even cause a relapse among patients who have overcome their needle phobia. Consider temporarily aborting the procedure if problems are encountered with any of the equipment during procedures performed on a needle phobic patient.
Needle phobics need to make a conscious attempt to breath deeply and slowly. This cannot be emphasized enough.
Many needle phobics have preferred locations for a needle insertion. During I.V. procedures, certain needle puncture locations make the presence of a needle much less obvious than other locations.
Get the injection at a doctor's office. Let the nurse know that you are needle phobic, and get the injection while your are sitting or lying down. Don't get up too quickly. Stay in the doctor's office for fifteen minutes or so after the injection. The physiological needle phobia reaction sometimes doesn't occur until a few minutes after the injection.
"Applied tension" is a technique for tightly contracting certain muscles of the body in order to prevent blood pressure from dropping. Muscles should be contracted over as much of the body as possible, but relaxed in the area of the body receiving the needle procedure. Unfortunately, I have not been able to find a good description of the technique in readily available articles. Most of what has been written about the technique is in medical journal articles that require a significant payment just to read the article online. People who are interested in pursuing this further can do a search for "applied tension" on PubMed.
The Anxiety BC web site has some brief, but extremely useful, descriptions of the applied tension procedure. See:
The two Anxiety BC web pages above are PDF files that are read much more easily using the free Acrobat Reader from Adobe. Open source PDF readers such as the one in the Firefox web browser may not reproduce these files clearly.
In general, it seems that the best things on the market right now for needle phobia are the Synera/Rapydan patch and the Buzzy device. The Buzzy device, on average, only eliminates about half of the needle sensation and pain, but that may be enough to make a very big difference for many people. The Buzzy device is becoming available in other countries besides the United States. For residents of the United Kingdom, there is now a Buzzy web site for the U.K.
There are also now sellers of the Buzzy device in South Africa, Indonesia, Hungary, France, Taiwan and many other countries. See the Buzzy International Orders Page. (Unfortunately, as of March 2014, sales of Buzzy are still not permitted in Canada. The fact that Buzzy is not available in Canada is solely due to regulatory obstruction on the part of Health Canada.)
The Synera patch is available in the United States and is becoming available in most countries in Europe (where it is sold under the name Rapydan). It requires a prescription, but most doctors have never heard of it. This is a good opportunity for patients to educate their doctors about needle phobia and about the things that are available for needle phobics. The Synera/Rapydan patch is currently intended for things like intravenous procedures. The patch may not numb deeply enough for intramuscular injections; but it should help a little, and every little bit helps. Many needle phobics find the Synera patch life-changing for blood tests and other intravenous procedures. The Synera/Rapydan patch is not yet available in Canada or Australia.
In May 2012, a marketing agreement was signed between Nuvo Research and Paladin Labs to allow Paladin Labs to market Synera in Canada upon regulatory approval. The fact that Synera is not available in Canada is solely due to regulatory obstruction on the part of Health Canada.
Applied Tension seems to be a good technique to prevent fainting. Applied Tension is a technique that does require some practice, though. It is a technique that you can practice doing at home, however, when you are not actually facing a needle procedure. Applied Tension may also be useful to those who tend to lose consciousness when watching or listening to descriptions of medical procedures.
In spite of the fact that the physiological vasovagal reflex reaction is rather consistent, there are individual differences in the subjective perceptions of needle phobics; and many needle phobics have other reactions, and do not experience the vasovagal reflex reaction at all. The best techniques to use to prevent a needle phobia reaction vary greatly from individual to individual. These individual differences must be taken into account when choosing a solution.
According to Dr. Hamilton's article, the clinical findings associated with the vasovagal reflex reaction include:
Difficult to access veins:
Many people who would otherwise have mild or moderate needle phobia have their condition made much worse because of having veins that are difficult to access. Many people have smaller or deeper veins than normal, others have veins that tend to "roll" or break during needle procedures. There is no longer any excuse for this to happen to anyone because of the recent development of devices for imaging veins. A number of such devices are available. One of the most sophisticated is the Vein Viewer as shown in this YouTube video animation. There are several YouTube videos of this device, and some of them show actual needle procedures, but the one linked here does not.
The Vein Viewer is made by Christie Digital.
The Vein Viewer is a more sophisticated device that is intended for sale to hospitals and doctor's clinics. There are much less-sophisticated and lower-cost devices available, though. One of the most common is the hand-held Veinlite, which is available to both patients and medical professionals from many medical supply stores. There are several versions of the Veinlite available, with the simplest version available from some sources for less than 200 United States dollars.
Those who wish to learn more about needle phobia are encouraged to read the article by Dr. Hamilton mentioned above. The Journal of Family Practice is available in any medical library. Most cities have at least one hospital with a medical library that is available to the public. Many people have recently been having a very difficult time finding this article since most libraries are no longer keeping older issues on the shelves. Most medical libraries that no longer have 1995 issues on the shelves usually do have these issues available on either computer or microfilm, especially the larger university libraries.
Here is the information about that article once again: Needle Phobia: A Neglected Diagnosis by James G. Hamilton, M.D. in the August, 1995 issue of The Journal of Family Practice. [Vol. 41, No.2, pp. 169-175]
I am not aware of any complete copies of Dr. Hamilton's comprehensive article on needle phobia that are available on the web.
If you have access to a University medical library, you can find the original article using the following citation:
James Hamilton (August 1995). "Needle Phobia - A Neglected Diagnosis".
Journal of Family Practice 41 (2): 169-175
Some hospital medical libraries may also still have access to Dr. Hamilton's article.
Important: Showing a copy of Dr. Hamilton's 1995 article from the Journal of Family Practice to your physician may encourage him to take your needle phobia more seriously. I cannot emphasize the importance of this enough. Often, the only way to convey new medical information to a physician is to show the physician a copy of an article from a respected medical journal. You may be surprised how often this can make a real difference in your treatment. Every time that you successfully educate a medical professional about needle phobia, you will be making life better for yourself and for many other needle phobics, as well.
Another very useful article from the Journal of Family Practice about the medical experiments with needle phobia that were done on Dr. Hamilton is no longer available on the web. During those tests, which were reported in a 1991 article, Dr. Hamilton's blood pressure dropped from 130/90 to a very dangerously low 70/0 after insertion of the needle. That article is available through medical libraries using the following citation:
Ellinwood, E.H.; Hamilton, James G. (April 1991). "Case report of a needle phobia".
Journal of Family Practice 32 (4): 420-422.
The only way that any progress is going to be made against needle phobia is if those who suffer from this condition educate the medical profession about this condition. Do not sit back and wait for a course in Needle Phobia to suddenly be taught at the Harvard Medical School. This just isn't how things happen. This isn't the way that medical professionals find out about the conditions that they are currently ignoring. Information about needle phobia will only come to the medical profession from those who are suffering from the medical condition and from their loved ones.
Doctors and other medical professionals need to be politely educated about the nature of needle phobia and its treatments. Unfortunately, it is up to patients with needle phobia to educate themselves about this condition, and then to convey that information to their physicians. I keep repeating this over and over for a very good reason, but few hear me. Those who suffer from needle phobia need to learn from those who have suffered from conditions such as breast cancer and AIDS. The recognition of the importance of an ignored major medical condition usually begins with the patients, not with the medical profession.
This important fact deserves repeating again: The recognition of the importance of an ignored major medical condition usually begins with the patients, not with the medical profession.
Among the large amount of email that I receive, a very small percentage come from needle phobics who have developed a high level of anger toward the medical profession. This anger, although often entirely understandable, is extremely counterproductive in our efforts to politely educate the medical professionals about needle phobia. If you are one of these individuals, please try to find a way to overcome your anger before you become a Needle Phobia activist.
If you have developed hostility and anger toward the medical profession, you may find it very useful to have several sessions talking this over with a psychiatrist. A psychiatrist is a medical doctor who is trained to discuss and to help you to understand these types of problems. Considering the brutal way that many very young children are treated during needle procedures, it is not surprising that many people develop this hostility. Someday, though, you are likely to reach a point where your health, and possibly your life, depends upon these medical professionals. So if you feel this hostility, please take steps to overcome it before you develop a serious medical problem where you desperately need medical professionals. You must learn to deal with medical professionals assertively, without being aggressive.
*Needle Phobia is a defined medical condition according to the standard reference work on the subject, the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV). It is a sub-type of blood-injury-injection phobia, which is sometimes called B-I-I phobia. It is also listed in DSM-5 (the fifth edition). It is very briefly discussed on pages 198 and 199 of DSM-5. The standard ICD-10 medical insurance code for injection and transfusion phobia is F40.231. (ICD-10 medical insurance codes are in use in much of the world, but have been repeatedly delayed in the United States.)
This page contains a considerable amount of information in a small amount of space. If you are suffering from needle phobia, it is a good idea to re-read this information carefully.
I read all of my email, and I try to answer as much as possible, but at least half of the email that I receive asks me questions that are answered on this web page. Many people are understandably very emotional when they are reading about this subject. Please re-read this page until you can absorb all of the information calmly. I know that this is a very long page, and it can be difficult, at first, to sort out which parts of this page apply to you.
Unfortunately, I do not know of any physicians offering help or treatment for this condition. I would very much like to develop a list of physicians who treat needle phobia; but that list does not yet exist, and I doubt that it will at anytime in the foreseeable future. Physicians who make special provisions for needle phobic patients are desperately needed. I am asking doctors who are interested to contact me. I do keep this site updated frequently; and after more than 17 years, there are still no practicing physicians who specialize in helping patients with needle phobia. I have to spend time each week answering email to tell people that this paragraph means exactly what it says.
Needle phobics who are unable to find a cooperative physician to write prescriptions for things like anti-anxiety medications or the Synera/Rapydan patch may consider consulting a psychiatrist for help with this. Unlike a psychologist, a psychiatrist is a medical doctor who can prescribe medicines like Valium and anesthetic skin patches like Synera. Psychiatrists are generally much more comfortable prescribing such medicines, and they are much more knowledgeable about the use of anti-anxiety medicines than other physicians.
I have heard from psychologists who claim to be able to treat needle phobia successfully, but nearly all needle phobics who report going to a psychologist report negative results. The number of needle phobics who have emailed me reporting unsatisfactory results from sessions with psychologists is extremely large. I am particularly concerned about what might happen in a non-medical setting if someone experiences a severe vasovagal reflex reaction (as many people do when talking about needle procedures).
Dr. Hamilton is not in private practice. In past years, he has seriously considered writing a book on needle phobia. Other matters have stood in the way of completing such a book.
Some companies have, or are developing, products with the potential to dramatically improve the lives of millions of needle phobics. Echo Therapeutics has developed products for needle-free glucose monitoring and drug delivery that are not yet on the market. It remains to be seen whether either of these companies will market their products in such a way that they will ever become easily available to needle phobic individuals. Most companies still insist upon marketing their products exclusively to the people who believe that such products are unnecessary in spite of the millions of dollars that have already been tragically wasted on such efforts.
(A few needle phobia sufferers want to know the Greek name for needle phobia. Some people argue over the correct Greek term for the disorder. I am not a Greek scholar, and neither are the scientists who have studied needle phobia. The Greek terms for most phobias cannot be found in most medical databases. The correct medical term for needle phobia in all English-speaking countries is needle phobia.)
For those who are curious, there is a separate page about odd names for needle phobia.
Copies of this page may be made for any non-commercial use as long as the copyright notice is included. It may be especially useful for patients to take a copy of this page to their physicians. I STRONGLY encourage patients to inform their physicians about this subject. The only way that needle phobia is ever going to be taken seriously by the medical profession is if needle phobics take charge of the situation and insist that provisions are made for their needle phobia.
This page is for informational purposes only. It is not intended to provide any specific medical advice. This Needle Phobia Page is maintained by Jerry Emanuelson of Futurescience, LLC, who is a science writer and not a physician. Futurescience, LLC is a one-person company that is trying to educate people about critical areas of science and medicine that have all too often been overlooked.
Jerry Emanuelson's email address is firstname.lastname@example.org
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