June 6, 2017

The placebo effect is stranger—and more powerful—than you think

Daily Briefing

    Harvard Medical School professor Ted Kaptchuk researches the effects of giving patients "open-label placebos"—that is, sugar pills that the patient knows are sugar pills—and his findings may lead to a new understanding of exactly how medicine works.

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    Vox's Brian Resnick sat down with Kaptchuk to discuss his unexpected findings on placebo pills, which some in the medical community still seem a bit hesitant to accept.

    What is the placebo effect?

    The exact meaning of the "placebo effect" can be tough to pin down, but Kaptchuk describes it as "a surrogate marker for everything that surrounds a pill." Essentially, the placebo effect describes how a patient is affected by factors other than an actual medication.

    One example: "Morphine given without a person knowing—surreptitiously, in a[n] IV drip—is 50 percent less effective than when it is given in front of them," Kaptchuk explained.  "That's the placebo effect."

    The placebo effect doesn't mean the brain is actually getting rid of a disease. Rather, it reflects the brain's response to the disease. "Placebos only affect what the brain can modulate," Kaptchuk said. "It's not going to shrink a tumor. It's not going to deal with malaria. But it will deal with pain, fatigue, and nausea. Or will deal with feeling malaise."

    Placebo research

    Up until now, placebos have been best known for their role in trials of new drugs. One set of patients will receive a new drug; another set of patients will receive a sugar pill; neither the patients nor doctors are told which group received which pill—and if the patients on the "real" drug show greater improvement, that's taken as evidence that the drug works.

    But doctors have long known that even the patients who receive placebo pills often show remarkable improvement. So Kaptchuk decided to push the limits of the placebo effect: "Let's just try to see if we can be honest, transparent," he said. "Is it possible that (the placebo effect) would work giving a placebo pill and telling people the truth?"

    His first study was on irritable bowel syndrome (IBS), and his findings were eye-opening. Patients in his study who received no treatment got around 30 percent better—but patients who were given an open-label placebo got 60 percent better. That effect, according to Kaptchuk, is just as good as any IBS drug on the market.

    "All illnesses have a psychosomatic component," said Kaptchuk. "IBS, like many illnesses, has a large brain-gut connection. It has a clear physical component, including bowel disturbances. But medicine cannot find an underlying pathophysiology"—suggesting a large mental component that the placebo effect could potentially treat.

    Why do open-label placebos work?

    This research, Kaptchuk believes, shows that the "intangibles" of medicine are important. The ritual of going to the doctor, being around caregivers, forming connections with them—these are all factors that help people handle their symptoms.

    Kaptchuk admitted that the research is in its early stages, but he believes it shows a real effect. "We do know with double-blind studies with placebo … that (neuro)chemicals are activated, regions of the brain are engaged that are specific and relevant—there's something going on," he said. "And I don't think it's belief."

    How could open-label placebos be implemented?

    Kaptchuk believes that the placebo effect could be used as a tool for treating symptoms when normal drugs don't work. For example, a doctor who's treating a patient for back pain might tell a patient, "'We've tried everything. Let's see if the placebo effect can work for you. Try it out for three weeks.' That's one scenario," Kaptchuk said.

    Kaptchuk also noted that, at times, doctors feel pressured to give their patients some kind of medication, even knowing it will likely be ineffective, so that patients don't feel they're walking away empty-handed. This, too, might be an instance where placebos could play a role.

    Kaptchuk said that he needs to do more research on open-label placeboes, but for reasons that are as yet not fully understood, they seem to work relatively well. "Our patients tell us it's nuts and crazy. The doctors think it's nuts. And we just do it. And we've been getting good results," he said (Resnick, Vox, 6/2).

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