Monday, November 12, 2012

Placebos and Nocebos

     I don't have a problem with placebos.  They don't seem like lies or hoaxes, so much as useful adjuncts in the practice of medicine.  It's difficult, in fact, to know when a "real" treatment is working, and when it's the placebo that's effecting the cure--that's how "real" placebos are.
      Placebos may be pills that contain no "active" ingredients--the snake oils of the nineteenth century-- or they may do their deed in the guise of therapies like EDTA chelation, colonics, high-dose vitamin C, colloidal silver, craniosacral therapy, anthroposophical medicine, homeopathy, and hundreds more.
     Nor is it necessary to "trick" patients into taking placebos.  Believing in a therapy is important, but believing that it is science-based is not a big deal.  The placebo effect is in full force even when patients are told they are being given a placebo, and that it may work.  This was proven by medical researcher and acupuncturist, Ted Kaptchuk, who showed in a study on irritable-bowel syndrome that participants reported relief from their symptoms when they were told they were being given placebos. Was it simply the fact that they were being taken seriously, and the long conversation about the placebo-effect that led to these surprising results?  Or are such results only surprising in an era so hoodwinked by the absolutism of science that we can't entertain any other ideas about how the world works?
     When I opted for acupuncture treatment last year--and again this month--I "knew" that it was not scientific and has never been proven to work.  In a way, I was purchasing a placebo, with full understanding of what it was, namely, nothing at all.  Nevertheless, the acupuncture treatments worked--and for some reason this makes perfect sense to me.
     MRI's and PET scans have shed a little light on the biological underpinnings of placebos by demonstrating alterations in brain metabolism similar to those induced by "real" medicine.  We are beginning to understand that beneficial chemicals are secreted by the nervous system, and affects the brain, when a good treatment is administered, regardless of the actual components of that treatment.  In fact, what makes any treatment good is that it works.  It is even likely that so-called incurable diseases might be cured via the mysterious handiwork of placebos.
     Many years ago I read a book with the irresistible title, Remarkable Recovery.  It chronicled in rather haphazard form the astounding cures experienced by a motley group of patients--people who bore no relationto one another, except that they were in extremis, far gone with illness.  They were emaciated, had widely metastatic cancers or debilitated hearts, and were sometimes days away from death.  Doctors had given up on most of them.
     Then, in a reversal that could only be termed miraculous, they were cured--sometimes overnight.  The explanations offered by the patients themselves followed no pattern and simply could not be accepted by the medical community.  Some said they prayed, or did meditation;  some followed macrobiotic or raw diets, or introduced strange foods;  some quit smoking, others started;  some went on a pilgrimage or made peace with loved ones, while others started conflicts; and many chose unconventional treatments.  There was no consistency in the illness-cure connection, so the cases were sort of forgotten in the annals of medicine.   It was as though, in the absence of logical elucidation, theses cases had to be banished to the sidelines of western medicine.  They could not be believed.  
     The author, Marc Barasch,  gathered them up, however, like breadcrusts dropped by Hansel in the darkening woods, in the hope, perhaps, of following their path to the cottage of the hag who surely was responsible for such aberrant results.  The hag has yet to reveal her truth.
     Barasch concluded that while extraordinary healings might give us clues about how the human organism repairs itself, and why some people get well and others don't, he could not say what exactly those clues were, or what they might mean.
     While doctors might be skeptical about the power of placebos, they are fully aware of the "nocebo effect."  

      Placebo:  A non-medicine which, when administered along with a suggestion that it will have a positive or curative effect, and taken by a person with specific symptoms, results in significant improvement in those symptoms.

     Nocebo:  A non-medicine which, when administered to a person along with the suggestion that it may have side effects, results in that person experiencing those particular side effects.

     The Power of Suggestion:  An effect on brain chemistry--especially involving endorphins, but probably many substances--resulting from powerful messages conveyed by an interaction of one person with another person, or by reading, hoping, fearing, hearing or thinking about the possibility of such an effect.

     The advertising industry has harmed medicine by listing in harrowing detail all the possible side effects of the pharmaceuticals being promoted--especially on television, where the "fine print" is audible, and therefore inescapable.  While I am not opposed to giving patients a heads-up about common repercussions of treatment, putting them in context within a caring relationship goes a long way toward calming the disquietude of  "too much information," and the nocebo effect that may ensue.
     The placebo effect does not work with patients who have Alzheimer's.  Neither does it wwork, we presume, in animals.  When I recommend MSM to patients who have arthritis--telling them that lame horses sometimes walk as though they are not in pain after a few doses of the white crystalline veterinary version--it's a way of "proving" that MSM is better than a placebo.  But there's no way to separate the effects in humans or placebos and real medicine.  Even in double-blind placebo-controlled studies the participants wonder whether they're getting the real stuff or the placebo, and their suspicion has to have an effect, too.
     If you expect to undergo a treatment, it starts to work even before you receive it.  Alzheimer's patients don't get the beneficial surge of brain hormones triggered by expectation, and neither do horses.
     Kaptchuk, the world's expert on placebos, is quoted in the December 12, 2011 New Yorker article, "The Power of Nothing"--

          "Anything that gets people away from the conveyor belts that move from the pharmaceutical houses to doctors and on to patients is worth considering.  Anything.  We need to stop pretending it's all about molecular biology.  Serious illnesses are affected by aesthetics, by art, and by the moral questions that are negotiated between practitioners and patients.  Chiropractors never say that your pain is all in your head.  But orthopedists do it all the time.  What a fucking way to try and help someone heal.  Do you know how evil that is?"

     I could propose a psychological theory that explains the placebo effect, and it would be as good as any other theory so far.  Even if alterations in brain chemistry are deemed the "real" explanation for the effects of medicines and placebos, we haven't yet figured out how to measure expectation.
     But we all know when we feel an expectation, and how it's full of possibility.  In the weeks leading up to my call to the acupuncturist, I was already expecting to be cured of my symptoms.  Once I made the appointment the expectation was ramped up a few notches.  By the time I got there, whatever the acupuncturist did was bound to effect a cure.  And, it was worth paying for.


Michael Specter wrote a terrific article about placebos, "The Power of Nothing," published in the December 12, 2011 issue of The New Yorker.

1 comment:

  1. Get all the best alcoholic drinks on Duty Free Depot!

    All the highest quality brand name drinks for unbeatable discounted prices.