One of the first articles I ran on this blog addressed the placebo effect. The topic wasn’t one I would normally have chosen. When people are in pain, they don’t need to be given a pill and sent on their merry way. They need help.
Shortly after I re-published that article earlier this year, I came across another article on the placebo effect. The author, Brian Resnick, presented several more points and more recent research that merit consideration, particularly in a society where access to medicine and health care is diminishing. I highly recommend reading his article; the address to it is provided below. However, what we really need to know can be summarized as follows:
Reviews of pain-drug clinical trials over the past 25 years have shown that the placebo response is growing, especially in the US. (The researchers didn’t offer any explanation why. Maybe Americans are all going soft in the head.) They are also finding that the placebo effect isn’t just increasing in pain medicine, but also with antidepressants and anti-psychotics.
For thousands of years, healers of various stripes the world over have employed the placebo effect. Whether in the form of sugar pills, talismans, and/or rituals, all recognized that many patients made improvements with their “treatments”. Of this phenomenon, Thomas Jefferson wrote to Dr. Caspar Wistar: “One of the most successful physicians I have ever known, has assured me, that he used more bread pills, drops of colored water, powders of hickory ashes than of all other medicines put together. It was certainly a pious fraud.”
That pious
fraud, an act of innocent deceit technically using the methods of a fraudster
but for an honest, honorable purpose, definitely has a place in treating our
family members when there is no doctor available. The placebo effect is real, it works, and we
really ought to become familiar with how to use it to our best advantage.
First off, we need to keep in mind that the placebo effect isn’t just a single phenomenon. There are several different elements involved, from simple to complex.
Regression to the mean is one that parents around the world use all the time. I’d hardly call it a placebo. It’s basically “time heals all wounds.” While that may not be quite correct, the idea is that in the natural course of an illness, the symptoms eventually resolve on their own. A child in pain seeks his mother out for comfort. She gives him a kiss, perhaps cuddles a bit in more serious situations, and then shortly the child is off playing again. When people seek medical care, the symptoms are usually bad (hence the reason for the doctor visit). Often, the patients improve without drugs or a placebo. They just needed some time. Interestingly, clinical research on depression has shown that about a third of patients improve without any drugs or placebo.
Confirmation bias occurs because a patient hopes to improve under treatment, so he changes his focus. He pays more attention to signs that he’s becoming better and ignores signs indicating that he’s getting worse.
Awareness and perception contribute to pain relief. Post-operative patients needed twice as much morphine to achieve the same pain relief when the drug was administered by a hidden robot pump as when it was injected by a caring nurse they could see. Knowing that you’re being given a pain reliever impacts the perception of its efficacy.
We’ve all seen examples of the above aspects of the placebo effect throughout our lives and hardly consider them placebos. They are just normal life and normal human behavior. The following phenomena, however, are a bit more intriguing and may certainly come to play a significant role in a society where licensed medical care is limited or non-existent.
Pharmacological conditioning. In clinical studies on Parkinson’s patients, Dr. Luana Colloca has switched the Parkinson’s medication after several days to usage to a placebo. On the fifth day, the placebo apparently triggers a response in the brain similar to the real drug. The same thing can happen with opioids. The researchers note that this pharmacological conditioning only works when the drug/placebo is acting on a process that the brain can do naturally. They liken the phenomenon to Pavlov’s dogs; as the dogs learned to associate the sound of the bell with food and would begin to salivate, the human brain learns to associate taking a pill with relief, and the brain starts producing the chemicals to initiate that relief.
So, can this pharmacological conditioning be employed to extend a patient’s drug supply? In a Finnish study in 2012, researchers used a sweetened drink to condition an immune response to a placebo. Healthy volunteers were given a flavored drink and an immunosuppressant drug for several days. Then, without the volunteer’s knowledge, the immunosuppressant was replaced with a placebo on one of the days. Their bodies still exhibited a diminished immune response.[1]
Social learning occurs when patients see other patients achieve relief from a placebo.[2]
A caring caregiver, one of the most important elements to creating a successful placebo effect, was the focus of the previous Prep School Daily blog article on the placebo effect. Basically, it’s not just about the pills. A warm, caring doctor or nurse or other provider fulfills much the same role as the medicine man of old. Those rituals of care may be absolutely essential to the patient’s well-being.
Placebos seem to be most effective with symptoms that fall between the physical and psychological. A 2010 review of over 200 drug trials showed that placebos were more effective with pain, nausea, asthma, and phobias.[3] Research published in the New England Journal of Medicine focused on four groups of asthma patients.
- Group 1 received an inhaler with albuterol, a drug that dilates the airway.
- Group 2 received an inhaler with a placebo.
- Group 3 received sham acupuncture (needles withdrawn before touching the skin).
- Group 4 received nothing.
Lung function was evaluated based on the patients’ self-report and by an objective measure of lung functioning. According to the self-report (what the patients reported), the albuterol inhaler, placebo inhaler, and sham acupuncture were all about equally effective (45-50% improvement). However, objective measure of lung function using spirometry showed that only the albuterol inhaler actually improved airflow.
The placebo effect only works with symptoms that can be controlled by the brain. The asthma patients didn’t actually have improved lung function. They only thought they did. Sometimes that is enough. An asthma patient who under stress about not having an inhaler is going to experience worsening symptoms simply due to the stress. If that same patient thinks a placebo is working, he experiences less stress, and symptoms don’t worsen. When there are no other options for treatment, that may be worth something. It may be enough.
A placebo isn’t going to work when an antibiotic is needed to kill the bacteria. It might work to alleviate pain due to the infection somewhat.
As noted in the previous blogpost on the placebo effect, patients don’t even have to anticipate that the placebo will work. So many have already been to a dozen doctors without achieving any relief. And yet, the placebo can still be effective. Dr. Colloca hypothesizes that there is a difference between belief and expectation; patients may not believe a treatment will work, but they still subconsciously expect that it will. She suggests that patients still have a conditioned memory for taking medication and being in a physician’s care. It’s that memory that elicits the analgesic effect in the brain.
In conclusion, as Dr. Cynthia Koelker writes in Armageddon Medicine: “Doing anything at all is nearly always better than doing nothing. Placebos, which have no physical basis for helping, still do so about a third of the time. Hope is a natural narcotic, and people will try a multitude of peculiar and likely ineffective therapies on the basis of hope alone. This is also how so many crackpot therapies work their way into the health care field. Anything, even a sugar pill, will help somebody…. As a physician I struggle with the need to be honest with my patients versus the desire not to deprive them of the placebo effect. Modern medicine prides itself on “truth.” But for anyone who believes in a certain therapy, even one proven by medical science to be ineffective, for that individual the relief is real. After an Armageddon event, the placebo effect may be a doctor’s strongest ally. A placebo may be a pill, a procedure, an activity, or a dressing. Whatever you do, choose your placebos wisely and first, do no harm.”
Links to related posts:
References
https://getpocket.com/explore/item/the-weird-power-of-the-placebo-effect-explained
https://memory.loc.gov/service/mss/mtj/mtj1/038/038_0687_0692.pdf
[1] Antje Albring, et al., Placebo effects on the immune response in humans: the role of learning and expectation, PLoS One, 2012, Vol 7 No 11, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3504052/ (accessed 27 October 2021).
[2] L. Colloca, et al., Placebo analgesia induced by social observational learning, Pain, July 2009, Vol 144 No1-2), https://pubmed.ncbi.nlm.nih.gov/19278785/ (accessed 27 October 2021).
[3] Asbjorn Hrobjartsson, et al., Placebo interventions for all clinical conditions, Cochrane Library, 20 January 2010, https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD003974.pub3/abstract (accessed 27 October 2021).
