Grace Gawler Writes About the Placebo Effect in Healing and Cancer Part One

What is a Placebo? The Placebo effect (Latin placebo, “I shall please”), also known as non-specific effects and the subject-expectancy effect, is the phenomenon that a patient’s symptoms can be alleviated by an otherwise ineffective treatment, since the individual expects or believes that it will work. Some people consider this to be a remarkable aspect of human physiology; others consider it to be an illusion arising from the way medical experiments were conducted.

What is Nocebo effect: In the opposite effect, a patient who disbelieves in a treatment may experience a worsening of symptoms. This nocebo effect (nocebo translates from Latin as “I shall harm”) can be measured in the same way as the placebo effect, e.g., when members of a control group receiving an inert substance report a worsening of symptoms. The recipients of the inert substance may nullify the placebo effect intended by simply having a negative attitude towards the effectiveness of the substance prescribed, which often leads to a nocebo effect, which is not caused by the substance itself, but more the patient’s mentality towards her or his ability to get well. (source Wiki Psychology)

Doctor-Patient Relationship and Placebo:

ABC TV Australia 26 May 2011 broadcast – This was a most useful and interesting segment and gave a terrific layman’s explanation of this complex area of healing.

The power of vodoo and hex or… in other words placebo (I shall please) and nocebo (I shall harm) is  discussed in these two short videos copied from ABC’s Catalyst website. If you missed the program or even if you watched it; I suggest you take another look. The PET scan images at the end of the video titiled Vodoo –  provide some tangible explanations as to why some people are susceptible to placebo and power of suggestion than others. The outcome of a pain test reveals that subjects who are susceptible to the placebo effect produce significant amounts of opioids and the outcome of reduced pain. In fact these subjects can produce in their brain the equivalent of 10 mg or more of morphine! Others in the experiment for whom placebo did not work (15%) –  experienced a nocebo effect –  a decrease of opioids and therefore increased pain. Select video link below.

PET and MRI brain scans were combined to make these images, illustrating activity in the brain’s mu opioid system. On top, study participants were experiencing pain. On the bottom, they thought they were receiving an injection of painkiller medicine that was actually a placebo. Image Courtesy of University of Michigan

 Why are some people susceptible to Placebo and others not?
 It is thought that those who are susceptible to placebo response have 2 copies in their brain of the gene that creates seratonin!  It has been known for some time that in social anxiety disorder (SAD) an inherited variant of the gene for tryptophan hydroxylase 2 (enzyme that synthesizes the neurotransmitter serotonin) is linked to reduced amygdala activity and greater susceptibility to the placebo effect. Select video link below.

Placebo in psychology of pills
Because placebos are dependent upon perception and expectation, various factors which change perception can increase the magnitude of the placebo response. For example, studies have found that the color and size of the placebo pill makes a difference, with “hot-colored” pills working better as stimulants while “cool” colored pills work better as depressants. Capsules rather than tablets seem to be more effective, and size can make a difference. One researcher has found that big pills increase the effect while another has argued that the effect is dependent upon cultural background. More pills, branding, past experience,and high price increase the effect of placebo pills. Injections and acupuncture have larger effect than pills. Proper adherence to placebos is associated with decreased mortality

Doctor-patient relationship – A study of Danish general practitioners found that 48% had prescribed a placebo at least 10 times in the past year. The most frequently prescribed placebos were antibiotics for viral infections, and vitamins for fatigue. Specialists and hospital-based physicians reported much lower rates of placebo use. A 2004 study in the British Medical Journal of physicians in Israel found that 60% used placebos in their medical practice, most commonly to “fend off” requests for unjustified medications or to calm a patient. The accompanying editorial concluded, “We cannot afford to dispense with any treatment that works, even if we are not certain how it does.” Other researches have argued that open provision of placebos for treating ADHD in children can be effective in maintaining ADHD children on lower stimulant doses in the short term.

Critics of the practice responded that it is unethical to prescribe treatments that don’t work, and that telling a patient (as opposed to a research test subject) that a placebo is a real medication is deceptive and harms the doctor-patient relationship in the long run. Critics also argued that using placebos can delay the proper diagnosis and treatment of serious medical conditions.

Roughly only 30% of the population seems susceptible to placebo effects, and it is not possible to determine ahead of time whether a placebo will work or not. (However the placebo effect is zero in studies of blood poisoning and up to 80% in studies of wound on the duodenum).
Patients rightfully want immediate relief or improvement from their illness or symptoms. A non-placebo can often provide that, while a placebo might not.
Legitimate doctors and pharmacists could open themselves up to charges of fraud since sugar pills would cost pennies or cents for a bottle, but the price for a “real” medication would have to be charged to avoid making the patient suspicious.
About 25% of physicians in both the Danish and Israeli studies used placebos as a diagnostic tool to determine if a patient’s symptoms were real, or if the patient was malingering. Both the critics and defenders of the medical use of placebos agreed that this was unethical. The British Medical Journal editorial said, “That a patient gets pain relief from a placebo does not imply that the pain is not real or organic in origin…the use of the placebo for ‘diagnosis’ of whether or not pain is real is misguided.”

The placebo administration may prove to be a useful treatment in some specific cases where recommended drugs cannot be used. For example, burn patients who are experiencing respiratory problems cannot often be prescribed opioid (morphine) or opioid derivatives (pethidine), as these can cause further respiratory depression. In such cases placebo injections (normal saline, etc.) are of use in providing real pain relief to burn patients if those not in delirium are told they are being given a powerful dose of painkiller.

 The implications of studying placebo effects are far reaching – but how does placebo relate to positive thinking…especially in relation to life challenging illness such as cancer? We will explore this question and my clinical experience in this arena in my next blog.