Optimizing Treatment Strategies for Diabetes - Episode 11
Addressing fears surrounding insulin injections through education may positively impact treatment adherence.
Jerry Meece, RPh, CDCES, FACA, FADCES: With you and I being in the diabetes field for so long, we always address how to overcome fear of injection. How do you overcome our patients being scared to inject? What do you do to teach that? What has been your experience over the years about fear of injections? What role does it play in insulin? How do you help patients overcome it in your practice?
Jennifer D. Goldman, RPh, PharmD, CDCES, BC-ADM, FCCP: There are a lot of data that show that it’s a provider bias. Patients can certainly be afraid of injection, but a lot of it is a bias of providers assuming patients will be afraid of injections. I had probably 2 people in 25 years who had such a significant fear. Interestingly, one of my patients who was afraid was a physician who didn’t refuse to inject.
One thing that I do is feel them out when I’m talking with them, and I’ll anticipate that fear. If I feel that they’re afraid based on what they said, I don’t call it a pen needle. I call it a pen tip. If I don’t call it a needle, they aren’t thinking about needles. But I also make sure patients understand how delicate they are. They’re very thin. You can’t feel them. I usually say that anyone over 40 can’t even see them without reading glasses. That’s how thin and small they are.
I remind people when they inject that they have to be gentle. Don’t dart it in. Don’t stab it. Be gentle. That will help. Remember, people are thinking about that flu shot that they got and giving themselves an IM [intramuscular] injection, taking from someone else giving them an injection, and this isn’t the same. I prepare them ahead of time that this isn’t like a flu shot. You need to be very gentle. You insert, push the button on the pen, or push in the syringe. Some people are afraid. It’s visual. If you can’t see it, you can’t feel it. They make an Autocover insulin pen needle, in which you never see the actual needle. If I had a patient with such a fear that way, I would use the AutoShield needles instead, and then they don’t see it.
Jerry Meece, RPh, CDCES, FACA, FADCES: With all the new injectables, with the GLP-1’s [glucagon-like peptide-1’s] and everything out there, what we learned is that it wasn’t needle fear. Sometimes it was insulin fear. They’ve heard so many things about insulin. In approaching people’s fears of insulin and separating it from the needle, has there been any way in which you’ve talked to people about insulin itself? When they’re put on insulin, how do you approach that?
Jennifer D. Goldman, RPh, PharmD, CDCES, BC-ADM, FCCP: Take away the patient’s sense of guilt and sense of failure, and make sure you ask them the right questions. What’s your fear? What have you heard about insulin? What do you think about insulin? Every once in a while, you hear stories like “My grandmother had insulin and she lost her legs,” or “As soon as this one went on insulin, this happened.” This is really people’s feelings and what they might think of it. We understand that Grandma lost a toe because she should have had insulin 20 years earlier.
We need to have the insulin conversation early, even when they don’t need insulin. When it’s time for insulin, make sure it isn’t fear or punishment. It’s that you’re missing a hormone that you need. Nobody has a problem taking their thyroid hormone. We have to put it into the same perspective with them. We’re replacing the hormone that you need, and you’re going to feel better because we’re replacing it. We’re going to try to prevent those microvascular and macrovascular complications. The earlier we do this, the better. The key is education to remove the fear of all those bad things, the complications.
One thing to be afraid of with insulin is hypoglycemia. That could happen now. Obviously, insulin didn’t cause the amputation, but hypoglycemia is a real thing. That brings us back to education. We have to teach patients how to prevent it. We need to make sure they can recognize the symptoms of it, and that they can treat it and manage it. Make sure they have glucagon. If somebody has hypoglycemia, and it happens more than rarely, then they need an adjustment on their insulin dose because their insulin dose is too high. That’s another place to make an intervention.
Jerry Meece, RPh, CDCES, FACA, FADCES: You hit the nail on the head of what we do in our practice. There are 2 questions I always ask when someone is starting on insulin. What do you know about insulin? What do you think about insulin? Listen to what they’re telling you, because you can get all of that out of the way and then you’re ready to talk about injection technique and how to do things. But if you don’t get that out of the way, they aren’t hearing what you’re saying. We probably have a lot of identical thoughts in mind, that insulin is just hormone replacement therapy. You’re lacking insulin hormone and we’re going to replace it. It’s a common, everyday thing. Once you get that out and get the patient to understand that, we can move on to other things. Thank you.
Transcript edited for clarity.