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Abstract: Difficulties with self-injection, including inability to self-inject, are common for individuals taking home-administered injectable medications. In relapsing-remitting multiple sclerosis (MS), all of the currently available disease-modifying medications are injectables marketed for self-injection. Problems with self-injection pose a barrier to treatment adherence for many patients. Clinicians at the University of California, San Francisco (UCSF) Multiple Sclerosis Center have developed a number of strategies to help patients who experience anxiety associated with self-injection. These strategies have been empirically tested and found to be effective and easily implemented by mental health professionals and nurses. This article offers case examples and discussion of the principles of the techniques developed at UCSF to remediate patients' difficulties with self-injection. Nurses are most often the healthcare providers responsible for training MS patients in self-injection and monitoring their compliance. Nurses who are familiar with these tools have the opportunity to have a significant positive impact on patient comfort, confidence, and, ultimately, successful long-term adherence to disease-modifying medications.
Most patients dislike injections, particularly self-administered injections. Common reactions include anxiety, fear, avoidance, autonomic reaction, and disgust. In some cases, patients' reactions make it extremely difficult or impossible to receive injections. These patients may meet criteria for the Diagnostic and Statistical Manual of Mental Disorders diagnosis Specific Phobia Blood/Injection Type (American Psychiatric Association [APA], 1994). This phobia is fairly common, with an estimated prevalence of 7%-22% in the general population (Agras et al., 1969; APA; Bienvenu & Eaton, 1998; Cartwright et al., 1993; Costello, 1982). The diagnosis is generally more common in pediatric patients. Treatment regimens that require more frequent injections are more likely to be associated with injection anxiety (Mohr, Bondewyn, Likosky, Levine, & Goodkin, 2001). In general, injection anxiety decreases over time, with increased exposure to injections in the course of routine immunization and illness and with increased ability to control the circumstances of medical care as an adult.
Many adults can receive injections administered by others with minimal difficulty and discomfort, but they experience significant levels of anxiety if they are required to self-inject. This anxiety poses a barrier to treatment for multiple sclerosis (MS), because the patient becomes dependent on others to administer injections. Self-injection allows the patient maximum independence and reduces the risk of missed injections or drug...