They say you never forget your first. I know I won’t.
I was 19 and nervous — and a little embarrassed about being so nervous. As I stood there, shaking and sweating, the questions piled up: Would it hurt? Is it safe? How quickly do I pull it out? But I wasn’t going to let mislabeled peanut butter cookies be my downfall, so I held my breath, hoped for the best and went for it.
I’ve been extremely allergic to peanuts since birth. If I ingest anything laced with the legume, my lips swell up and my throat constricts almost instantly. As a result, I keep an EpiPen within arms reach at all times. EpiPens are the best-known brand of epinephrine auto-injectors, prescription-only medical devices that deliver concentrated shots of adrenaline into the bloodstream to counteract severe allergic reactions, most often to food. Other brands include Auvi-Q, Adrenaclick and Impax, and they all basically work the same way.
Allergies — especially to food — are becoming more common because of environmental changes, new genetic variations and potentially even insufficient exposure to germs (the “hygiene hypothesis”). That means more and more EpiPens will be used to save lives in the future. That is, if they’re used correctly. While they’re becoming easier to use (some even talk you through the procedure), the prospect of willingly stabbing yourself in the leg is daunting. It’s also necessary.
My first injection was both harrowing and comical: I was asphyxiating in my college apartment, acutely aware of what I needed to do (jam an inch-long, spring-loaded needle into my thigh with gusto, ASAP), but unsure if I could actually do it. I felt like a Civil War soldier mustering the courage to amputate his own arm. Finally, with Blink-182 blasting in the background, I did it. The needle pierced my thigh. I yelped. My best friend, a witness to the madness, and I waited briefly to see what would happen. Then we called my mom.
“Get to the hospital,” she commanded. “Right now.”
On the way, I started feeling better — my throat loosened up and I began breathing normally again. The EpiPen had saved my life, and I was grateful to have it. But I didn’t know anything about how it worked or how often I’d need to reach for it. And I had to wonder: Why couldn’t Big Pharma come up with a less terrifying way to halt allergic reactions, like an Epi-pill or Epi-inhaler?
Nineteen years later, I’m a lot more informed about EpiPens and a lot less nervous when the situation demands whipping one out.
The allergen diaries
My complicated relationship with allergies started long before I got an EpiPen. I’m allergic to numerous things, but my peanut allergy is the most severe. Eight major food allergens are thought to account for 90% percent of food allergies: milk, eggs, fish, crustacean shellfish, tree nuts, peanuts, wheat and soybeans. These are called the “Big 8” in the allergy community; the FDA requires food manufacturers to list them as ingredients on product labels. The list isn’t necessarily fixed, though — there’s federal legislation pending to make sesame No. 9.
Growing up, I was the only one of my friends with a Big 8 allergy. Now, it seems like every kid’s a member of the club. Indeed, data indicates food allergies are more prevalent than they used to be. For example, according to the National Center for Health Statistics, the percentage of children under 17 with a food allergy increased from 7.4% to 12.5% between 1997 and 2011. This isn’t because our bodies have gone soft. Instead, greater allergy awareness and advanced diagnostic tools have led to earlier, more widespread allergy testing in kids, according to Dr. John Panuto, an allergist and immunologist.
Allergies aren’t necessarily with you for life. The list of things I’m allergic to is a lot shorter than it used to be. I overcame allergies to dogs, cats, pollen, dust and mold with help from weekly allergy shots, which I received until I was 18. I also overcame allergies to certain foods, including shellfish and eggs, by avoiding them entirely.
“If you [successfully avoid the foods that harm you] long enough, you can down-regulate the memory cells to the point where they actually disappear,” Panuto says. “It doesn’t work for everyone, but when it does, it’s basically the body forgetting that you’re allergic to something.”
While my peanut allergy has stuck with me, I’m grateful that nothing else has emerged, since food allergies can also develop during adulthood. Research suggests this is the case for about half of food-allergic adults.
War against the reaction
A chemical called histamine is responsible for many allergy symptoms. Histamine lives in mast cells, a type of white blood cell found in connective tissue. Coming into contact with an allergen activates mast cells and releases histamine. If the roof of your mouth itches after eating pineapple, or you sneeze when a cat’s nearby, that’s histamine in action.
“Compromised mast cells near the surface of the skin can cause hives and irritation, while histamine released in the lungs or throat can cause bronchoconstriction, narrow airways, wheezing, and respiratory compromise,” says Dr. Schuman Tam, an allergy, asthma and immunology specialist in San Francisco.
Originally, Tam explains, our bodies released histamine to ward off dangerous parasitic infections like malaria. But in our industrialized world, our bodies now primarily use it to flag allergens. Antihistamines are the class of drugs that block the effects of histamine; they include Benadryl (diphenhydramine), Claritin (loratadine) and Zyrtec (cetirizine).
While antihistamines are a good tool against minor or moderate allergy symptoms, they aren’t strong enough to combat anaphylaxis, an extreme and potentially life-threatening allergic reaction that causes blood pressure to plummet and affects multiple areas of the body at the same time. Symptoms include wheezing, hives and swelling, and trouble breathing and swallowing. Food allergies are the most common cause of anaphylaxis, but other possible triggers include allergies to insect venom and certain medications.
A standard EpiPen delivers 0.3mg of the hormone epinephrine, also known as adrenaline. (The adorably named “EpiPen Jr.” halves that dose for users under 66 lbs.) An epinephrine injection reverses anaphylaxis by blocking the release of additional histamine, increasing heart rate and blood pressure, and relaxing muscles in the airway and around the lungs. Experts recommend injecting the pen into the back-side of your thigh, specifically, because it offers a large, muscular surface area that’s ideal for drug absorption.
Unfortunately, there’s no way to eliminate needles from the equation. A pill can’t be absorbed quickly enough to stop a massive allergic reaction, says Tam. “The drug would be broken down too substantially, and food in your stomach would prevent it from being absorbed rapidly,” he says. “In order for epinephrine to potentially save your life, it must be absorbed into your bloodstream almost immediately. That’s why the thigh makes the best injection site — it’s full of blood supply.”
Sealing the deal
EpiPens are recommended for generally healthy adults and children with truly severe allergies who don’t have underlying heart disease. Older adults and people with minor or moderate allergies aren’t good candidates, Panuto says.
“If a patient says, ‘Hey, can I have an EpiPen? When I get stung by a yellow jacket I get a little swelling in my hand,’ that’s not a valid reason,”‘ Panuto says. “Or if you’re an 85-year-old with cardiovascular disease and hypertension, an EpiPen isn’t the best idea. But if you’re relatively healthy, you’re better off being aggressive in an emergency situation.”
Still, it’s possible that more adults should be carrying around EpiPens. Research suggests they’re prescribed to as little as one-quarter of adults with food allergies.
While there’s no official rule, most allergists say kids with diagnosed food, insect or medication allergies should “self-carry” auto-injectors — and be prepared to use them in an emergency — starting at 12 to 14 years old. I got my first EpiPen in middle school; I just never had to use it until college. Since my inaugural shot, I’ve stabbed myself seven times. Who knows what my lifetime total will be. There will always be the chance of unknowingly scarfing down pecan-laced strawberry pie at a family gathering (stab No. 3). Or confusing the red-colored granola bar wrapper (chocolate) and the orange-colored one (peanut butter) during a chaotic morning (stab No. 7).
EpiPen pro tips
Over the years, I’ve gotten a lot better at wielding an EpiPen. Based on my own experiences, here are some tips to help you get the hang of it:
- Check expiration dates, regularly. Epinephrine injectors have varied shelf-lives, maxing out at 24 months. If you’ve been lucky enough to go two years without using an EpiPen, the one you’re carrying around is expired. Still, Dr. Tam says, it’s better than nothing: “If you’re in danger, and it’s your only option, don’t hesitate to use an expired EpiPen,” he says. “The drug will be less potent, but it could still save your life.”
- Hold and tap. Pre-stabbing nerves are very real. My trick (adopted during stab No. 4, another family gathering) is to place the business end of the EpiPen on my thigh, and tap the butt end to activate the needle. It’s less aggressive and, honestly, less terrifying than winding up and slamming down like you’re trying to ring a carnival bell with a giant hammer.
- Tell someone beforehand. Just in case something happens and you don’t complete the mission. By notifying a coworker, family member or whoever you happen to be texting with at the moment, they can keep potentially life-saving tabs on you until you complete the injection. And, they can always lend moral (or even physical) support if you have trouble doing the deed. “It’s good to familiarize your family or friends with how these devices work and why you need them,” says Dr. Tam. “They may have to administer the infection if, for some reason, you become incapacitated.”
- Immediately follow up with a hospital visit or call to a doctor. Because I’m an Epi-veteran, I know how my body responds to injections, and what needs to happen for me to be safe. A medical professional can guide you through the post-injection process so you learn how to monitor your allergy health.
- Keep your eyes open. It can be tempting to wince, look away or squint when you swing the EpiPen toward your thigh. But don’t close your eyes. You might whiff completely, or inject yourself in a less-than-ideal part of your thigh.