A number of months ago we reported that some 45% of Chicago internists (among those who responded to a survey) said they offered placebos to their patients from time to time. The report got people around the country talking – and maybe even wondering about their own prescription history.
Clearly, physicians recognize the impact of placebos, and research has time and again shown their efficacy. So, how does it really work? And who seems to benefit the most from the placebo effect? Is there anyone who can’t be “taken in”? In light of this recent NY Times article about a company that sells cherry-flavored sugar pills to be administered by parents to their unsuspecting children as a placebo we thought we’d investigate.
The placebo effect encompasses a person’s psychological and physiological response to some inactive treatment or procedure. The relief or improvement resulting from the placebo effect is highly dependent on the patient’s expectations, the nature of their condition, and other physical and personality-based aspects. Additional factors, such as the patient’s perception of the care provider and even the color and cost of a placebo pill, can influence the resulting relief or lack thereof. Subjects receiving what they were told were higher cost placebos reported pain reduction in higher numbers than those who received “lower priced” placebo medication. Placebo effect has been shown to have both short-term and long-term impact.
Although it might be easy to chalk it up to mere psychological phenomenon, researchers have identified biological bases of the placebo effect. A study out of the University of Michigan used brain scans to measure activity as subjects were told they were receiving pain-relieving substances to curb the discomfort induced by concentrated salt water injections in their jaws. (Fun, eh?) The scans as well as subjective self-reports showed that subjects did indeed experience physical relief from the “suggested” medication dose. Scans showed increased activity in parts of the brain known to be integral to the processing of pain. The scans also revealed activation of the subjects’ mu opioid endorphin system. Researchers chose to use healthy young men for subjects in order to rule out any impact of medical conditions or pre-existing pain on test results. Researchers say further study will determine if similar results can be found in women and older adults.
In terms of what people may be “high placebo responders,” research suggests that a person’s response may be related to the amount of activity in the nucleus accumbens, a part of the brain with a large number of receptors for endorphins and dopamine. Some of us, apparently, anticipate more benefit than others, and our brain activity and hormonal release follows suit regardless of whether a treatment is fake or the real deal.
Other research shows that people with widely fluctuating as opposed to chronic pain respond better to placebo. And those with chronic fatigue do not seem to respond as well to placebo.
Research also suggests that placebo treatments can offer relief not just from physical pain but from psychological distress. As subjects viewed disturbing photos on the first day of a study, researchers administered legitimate anti-anxiety medication and a short time later an antidote to the drug. Subjects were told what they were receiving and the general impact each medication should have on their experience. On the second day, the researchers repeated the same procedure but administered placebos in place of the drugs. Researchers measured the subjects’ experience through their self-report and through functional magnetic resonance imaging. Subjects reported similar relief on the second day, and scans indicated increased brain activity in the part of the brain associated with pain relief even on the day of placebo administration.
When it comes to harnessing the power of the placebo, those of us on the other side of the prescription pad may have varying responses. Clearly for most of us, the use of placebos in research studies falls into a different category. Subjects know ahead of time that they may receive a placebo rather than an active therapy. But when it comes to the assignment of placebo as presumed legitimate treatment, the picture isn’t so clear. Some question the ethics of placebo use in these situations, particularly the pretense that accompanies it. Others applaud placebos as a safe and reasonably effective means to many positive ends.
Dr. Howard Brody, a professor and medical ethicist at Michigan State University, criticizes the use of physical placebo treatments but offers an alternative view of harnessing the power of “mind-body interaction” in medical care: “Doctors may never prescribe placebos – dummy pills – but can make use of the placebo effect every time they see a patient.” By recognizing and maximizing the power of the physician-patient interaction itself, a patient can experience relief from the knowledge and thoughtful attention his/her doctor conveys. Dr. Brody explains, “Features of the healing environment usually include a physician or healer that listens carefully to what you say and gives you a realistic and sound explanation of what is happening to you. … People express care and compassion for your fears and suffering, and you leave feeling more in control of your life and your illness.” Dr. Brody’s perspective offers a view of the placebo effect that, he believes, isn’t dependent on the physical placebo itself.
And so we turn the questions over to you. Is the deception of placebo worth its potential positives? How can physicians and other care medical providers (indeed, the set-up of our medical system itself) further harness the power of the placebo as Dr. Brody suggests? Tell us your thoughts on the ethics of placebo pretense and the power of suggestion in health.
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