If you rely on the lifesaving drug epinephrine for severe allergic reactions, the controversy over high-priced auto-injectors probably shouldn't be your only worry.

A recently released report by the American Academy of Pediatrics shows that most people with severe food allergies—the majority of them children—don't carry an auto-injector for epinephrine at all times and wait too long at the onset of an attack to inject themselves.  

Even more alarming, a separate study found that just 16 percent of adults who've been prescribed epinephrine know how to use the auto-injector correctly—including parents who might need to inject their child.

Not having an auto-injector with you, waiting too long to use it, and not knowing how to inject yourself are potentially life-threatening mistakes, says Michael R. Cohen, R.Ph., president of the Institute for Safe Medication Practices. 

That's because if you're having an attack, you might have just a few minutes to get a dose of epinephrine—a form of adrenaline—to prevent a potentially fatal result. The drug works to open up your airways, restoring normal breathing while also tightening blood vessels to bring your blood pressure back to normal.

Here's what causes these mistakes—and what you can do to prevent them.

Not Having the Auto-Injector

While 60 percent of patients or families of patients with food allergies said epinephrine should be carried at all times, only 40 percent reported carrying the medication, according to a 2014 survey by Nationwide Children’s Hospital, in Columbus, Ohio.

The most common reasons given are inconvenience, forgetfulness, the cost of buying the device, and lack of awareness that it was needed at all times.

Though many public facilities such as schools and hospitals stock epinephrine, it's not worth the risk to assume it will be on hand. Make sure to bring it with you.

Waiting Too Long to Inject

The American Academy of Pediatrics report reveals that people wait too long to use EpiPen and other epinephrine auto-injectors because they might not recognize the symptoms of anaphylaxis—which include difficulty breathing, throat swelling, and wheezing—or aren't sure they're having an attack. There's also the fear of needles, injuring oneself, or having a bad reaction to the drug, even though it is safe. 

"Anaphylaxis can progress very quickly, and you certainly don’t want to delay a therapy that could be lifesaving," says Cohen.

Even if you do inject yourself, you’ll still need to get to an emergency room.

Like many drugs, there might be side effects from epinephrine, such as anxiety, dizziness, and sweating, and swelling, pain, or changes in skin color at the injection site because of decreased blood flow to the area. And though rare, people with heart disease might experience chest pain after an injection. 

Still, the benefits of using the auto-injector—even if you're not sure you're having an attack—far outweigh the risks, says Cohen.

Forgetting How the Injector Works

Perhaps the biggest problem, though, is that most people might be using EpiPen and other auto-injectors incorrectly when they have an emergency. 

Most auto-injectors operate in a similar way. After sliding the injector out of its protective tube, take the safety cap off, jab the colored end (orange in the case of EpiPen) into your thigh and hold for about 10 seconds. The needle will go through your clothes, but make sure there are no other obstructions. (See step by step instructions below.)

In a 2015 University of Texas study, only 16 percent of those prescribed an epinephrine auto-injector were able to correctly demonstrate its use when asked to do so. 

Of 102 patients, 86 people made at least one mistake. More than half of those tested made three or more mistakes. 

The most common problems were 1) not holding the auto-injector in place long enough; 2) pressing the wrong end into the thigh; and 3) using too little force to inject into the thigh. All are serious errors that can delay or prevent getting someone the epinephrine necessary to stop a reaction.

Why so many mistakes? One explanation, says Cohen, is that people might forget how to use the injector after having an initial training session but no refresher courses.

People who carry an auto-injector might have learned to use it when it was first prescribed, but "in that moment when they're having an anaphylactic reaction, they get very excited and don't necessarily remember the instructions," Cohen explains. "That’s when they can hold the pen backwards and run into other problems."

Another reason for the errors: People aren't being properly trained at the doctor's office. 

Although doctors should demonstrate proper usage when prescribing an auto-injector, a January 2016 Northwestern University study of 859 families with at least one child with food allergies found that training in auto-injector use is spotty at best. One-third (33 percent) of parents said their allergist or pediatrician had not explained to them how to use epinephrine during an appointment. 

Doctors might fall short in training patients for several reasons, according to Andrew Murphy, M.D., a board-certified allergist at the Asthma, Allergy and Sinus Center in West Chester, Penn.

"For one, both doctors and patients might underappreciate the potential for errors and, therefore, assume training is unnecessary," says Murphy.

Doctors also might be pressed for time or assume someone else, like a pharmacist, will train the patient. "And sometimes patients insist they already know how to use the auto-injectors," Murphy adds.

"If your doctor doesn’t offer a training session during your appointment, or if you have more questions about how to use your injector, be sure to ask your pharmacist when you pick up your auto-injector prescription," advises Barbara Young, Pharm.D., of the American Society of Health-System Pharmacists.

And because there might be a significant time lapse between when you are trained on an auto-injector and when you need to use it during an emergency, it’s important to practice regularly using an auto-injector "trainer"—a reusable version that’s similar in size and shape to an active auto-injector, but does not contain a needle or medicine. Auvi-Q, EpiPen, and generic EpiPen include a trainer with each prescription; patients using generic Adrenaclick can order a trainer on the manufacturer's website. 

"Every three months or so, take a look at the auto-injector and its instructions again," advises Cohen. "The more that you do that, the more familiar you’ll become with the device, and the more likely you’ll remember how to use it during an emergency."

Steps to Take During an Allergic Reaction

While a training session by your doctor or pharmacist is a critical first step in learning how to use your auto-injector, the manufacturers of generic Adrenaclick, Auvi-Q, and EpiPen and its generic (the auto-injectors currently for sale) also recommend reading the instructions and watching the training video on your injector's website well before you need to use it. (See instructions for Auvi-QEpiPen and generic, and generic Adrenaclick.) 

Family members, caregivers, close friends, teachers, and coworkers must also learn proper usage; they might need to assist you during an emergency.

Keep in mind that the instructions differ slightly for each auto-injector. The recently re-released auto-injector Auvi-Q is currently the only one on the market that features voice instructions to guide its use during an emergency.

The minute you or a child experience symptoms of a severe reaction—difficulty breathing, throat swelling, and wheezing—says Cohen, inject epinephrine into the thigh muscle using the following steps:  

  1. Remove the auto-injector from its protective case.
  2. Remove the safety cap (depending on which auto-injector you use, there might be more than one).
  3. Making sure you’re holding the device with the needle end toward your thigh, press the auto-injector firmly against the middle of the outer thigh until you hear a clicking sound. (The medicine can be injected through your clothing.)
  4. Hold firmly against your thigh for 3 seconds for EpiPen and its generic, 5 seconds for Auvi-Q, or 10 seconds for generic Adrenaclick to deliver the medication.
  5. Remove the device from your thigh and call 911. Epinephrine is safe, but you might need additional medical treatment after an attack.
  6. If, after the first dose of epinephrine, your symptoms continue, or they go away but then return, give yourself—or have someone else give you—the second shot.

Stay Safe in Public Spaces

If you leave home without your auto-injector, finding someone to assist you during a reaction is less fraught than you might expect. 

While it’s common knowledge that hospitals and schools stock epinephrine, twenty-seven states currently have in place what are called "entity stocking laws." The laws require restaurants, sports venues, amusement parks, daycare centers, youth camps, hotels, and shopping malls to stock epinephrine, and for their staff to be trained in administering it.

The Federal Aviation Administration requires that all airline crew members be trained in responding to a passenger experiencing an allergic reaction, including administering epinephrine and oxygen, monitoring breathing, and communicating with the flight deck to arrange medical assistance.  

So, if you start to experience anaphylaxis at a restaurant or on a plane, get your waiter’s or flight attendant’s attention immediately and ask if they have an auto-injector.

Editor's Note: This article and related materials are made possible by a grant from the state Attorney General Consumer and Prescriber Education Grant Program, which is funded by the multistate settlement of consumer-fraud claims regarding the marketing of the prescription drug Neurontin (gabapentin).