What is the placebo effect(link is external)?

While attending the recent conference of the Committee of Scientific Inquiry(link is

external) in Nashville, TN, another compelling talk was given by Dr. Steven
Novella(link is external), director of General Neurology at Yale Universitys School of
Medicine. Along with being a fellow of the Committee of Scientific Inquiry and a
popular blogger and podcaster, Dr. Novella is also a well-known media figure who
become one of the leaders in the skeptical movement with a focus on debunking
alternative medicine claims.
In his talk on the placebo effect, Dr. Novella began by mentioning the ambiguity over
exactly what the placebo effect is. For many years, the placebo effect was
considered to be a nuisance effect that needed to be controlled in clinical trials, Dr.
Novella stated. More recently, the placebo effect has been redefined as the key
to understanding the healing that arises from the medical ritual in the context of the
patient\provider relationship and the power of imagination, trust and hope.
While the medical community recognizes that medically inert substances such as the
basic sugar pill can often produce positive medical benefits when patients are
deceived about their medical value, this placebo effect has always been
controversial (placebo comes from the Latin I shall please). Should medical
doctors rely on deception to avoid using potentially more dangerous medications?
And how effective or reliable is the placebo effect anyway?
Dr. Novella pointed out that advocates of alternative medicine have begun using the
placebo effect as a way of marketing their products by stressing that the mind can
heal the body in way that medical science cannot understand.

In the context of a

clinical trial, the placebo effect is everything other than a physiological response to
an active intervention, Dr. Novella said. Medical research involves controlling for
all possible variables in addition to the actual clinical treatment. The logic of the
placebo-controlled trial is to control for as many variables as possible. The problem
comes when you start shifting the definition of the placebo around. Most medical
research studies arent designed to determine what a placebo is exactly.
Which is not to say that medical researchers have been unable to reach some
conclusions about placebos and how they might work. Pharmaceutical companies
often base their own products on certain placebo characteristics that appear to
influence how patients respond to them. The more expensive the placebo, the
longer the placebo effect lasts for patients. Colour of the pill can be important too.
For whatever reason, bluesleeping pills are more likely to benefit patients than pills

of another colour. Medication to reduce pain are often sold in red pills or capsules
since marketing studies showed these to be more effective, etc.
Even when it comes to treatment compliance(link is external) (a notorious problem
with most pharmaceutical medications), patients who take placebos regularly do
better than patients who are not compliant with their treatment, regardless of the fact
that placebos have no real health benefit. When placebo medications are hard to
obtain, more expensive, or otherwise stressed to be valuable to the patient, the
placebo effect becomes even stronger.
But how real is the placebo effect? While psychological manipulation can change
how patients feel, is there an actual physical effect? Along with the actual treatment
effect itself, there is also the reassurance that health professionals can provide to
their patient. Simply seeing a health practitioner and being reassured that everything
possible was being done can leave a patient feeling hopeful that their condition might
improve.
Physicians are very much aware of the fact that we examine patients, we touch
them, and that in and of itself has a physical effect, Dr. Novella continued. Being
touched in a safe context relaxes and reassures the patient. There are also nonspecific effects in making patients the centre of attention. Bringing them into the
doctors office and asking questions about their symptoms can make them feel as if
they are part of the medicalteam dealing with the health problem. Different nonspecific effects can all contribute to what is regarded as the placebo effect.
Is feeling better the same as actually improving? For fuzzy symptoms such
as chronic pain, patients are often able to convince themselves that placebos are as
effective as actual pain medications. Although the human body continues actual
physiological mechanisms to control pain, such as generating endorphins(link is
external), this is not as reliable as actual pain medication (which is why chronic pain
medication is most commonly prescribed by physicians worldwide(link is external)).
Research looking at the placebo effect usually involves having patients reporting on
their own subjective perception of how they are feeling and comparing it to a more
objective measure of actual improvement.

Intriguingly, Dr. Novella also described a

recent study showing that people with high dopamine levels in the brain are more
likely to experience placebo effects. Although this result only applies to pain and
has still not been replicated, the study does suggest that there is a genetic factor
that might be at work with the placebo effect.

As Dr. Novella also mentioned, it is important to look at how diseases can fluctuate
over time. Every chronic disease goes through cycles with periods when pain or
other distress is most severe and periods of remission when patients are feeling
better. When testing a placebos value in relieving pain, giving that placebo to a
patient when the pain is at its worst will almost certainly lead to pain relief since the
pain would have deceased anyway. This regression to the mean effect is huge,
he said. And its part of the placebo effect too. Its purely an illusion.
And the placebo effect varies from disease to disease. Since subjective ratings of
pain,depression, or any other symptom being measured cannot be directly
compared. It also means that the placebo effect cannot be linked to any particular
physical process at work in the body.
Over the past ten years, research comparing actual medical treatments to placebo
treatments for various ailments where objective measures of medical improvement
were available (such as with asthma) has shown no difference between placebo and
no-treatment conditions.

When compared to subjective measures however,

patients receiving placebos often reported that they felt better regardless of actual
improvement.
Thats hardly a surprising finding since most diseases where a placebo effect has
been observed, such as pain, asthma, and Irritable Bowel Syndrome (IBS), are also
especially vulnerable to psychological factors like stress and anxiety. But even when
psychological effects are taken into consideration, the evidence that the placebo
effect is actually working seems limited. Whatever relief the placebo provides is
usually short-lived and the benefit is purely psychological, not physiological.
There is also the ethical question surrounding placebos. Are medical doctors
ethically permitted to deceive patients into believing they are receiving actual
treatment instead of a placebo? Even if the medical doctor believes that the patient
will benefit? Actually, Dr. Novella argues that deception is not always necessary
and some placebo studies with IBS patients showed that placebo effects still relieved
symptoms even when the patient knew about the placebo (though this result is
controversial).
The real controversy surrounding placebos deals with what the placebo effect
actually is what what is means about the human capacity for self-healing. While
alternative medicine advocates use the placebo effect as evidence that the brain has
the ability to heal physical illness in ways that medicine cannot understand, Dr.
Novella points out that this is often exaggerated. He also states that complementary
medicine proponents are feverishly trying to re-brand their products as placebo

effects.

In other words, since research has consistently shown that homeopathy,

acupuncture etc. tend to be no more effective than the placebo effect, stressing that
the placebo effect as a legitimate medical treatment in itself has become a new
marketing approach.
In various humorous examples that Dr. Novella provides, the placebo effect is
described as amazing and mind-boggling. One breathless news release
described the placebo effect as proof that God exists due to its
mysterious nature.

Other news releases stress that alternative medicine can have

a better placebo effect than regular medicine (which is presumably a good thing).
So, what is the harm of all this? By exploiting the placebo effect in pushing various
forms of alternative medicine, patients develop an unrealistic idea of the kinds of
benefit this type of treatment can produce. Simply because placebo effects can
relieve pain does not mean that the body is capable of curing serious diseases such
as cancer (even though many alternative medicine treatments make this claim very
quietly).
There have certainly been cases of patients delaying or even rejecting potentially
lifesaving medical treatments in favour of alternative medicine. Even in the case of
Steve Jobs, at least one medical expert has suggested(link is external) that Jobs
skepticism of conventional medicine led and his use of alternative medicine in
treating his neuroendocrine tumour may have contributed to his death.
As Dr. Novella stated in concluding his talk, the harm is instilling bizarre, unscientific
beliefs in patients because of exploiting the confusion over the nature of the placebo
effect.

That these unsupported beliefs are still leading to very real suffering and

even death in patients is something that cannot be ignored.

The Placebo Prescribing Controversy

In 2006, the American Medical Association created a policy concerning placebos. It

states that "physicians may use placebos for diagnosis or treatment only if the
patient is informed of and agrees to its use" [source: AMA]. This is the biggest issue
that critics raise: Doctors are essentially lying to their patients when they prescribe
something that they know isn't proven to work for the patient's particular condition.
What if doctors strictly follow the AMA's guidelines? They would have to tell their
patients that what they're being given doesn't actually contain medicine or isn't
known to work for them. Some researchers believe that this would negate the
placebo effect because of the psychological component. Others, especially those
who believe that placebos work through classical conditioning, think that disclosing
that the medication is really a placebo doesn't necessarily mean that it won't work.
Very few doctors are this open about prescribing placebos, but most of them don't
outright lie to their patients, either. In general, doctors who prescribe placebos often
say that they have something that they believe can help, but they don't know exactly
how it will work, either. Supporters of the use of placebos point out that this isn't
lying; placebos are known to be beneficial in some cases. The AMA policy suggests
that doctors could explain the placebo effect to their patients and receive consent to
prescribe them in the course of treating any illness. This way, the patients don't know
exactly when they might be prescribed a placebo and they could still benefit from the
placebo effect.
Another problem inherent in prescribing placebos is the fact that they haven't been
shown to work on more than half of the population. If a doctor prescribes a placebo
and it doesn't work, both doctor and patient are essentially back where they started
in terms of trying to find a treatment. If the doctor continues to prescribe placebos, it
may undermine the patient's trust and potentially diminish the therapeutic effect of
any medication he prescribes in the future. In addition, the placebo effect is usually
short-term -- placebos don't usually work for chronic conditions.
There's also a very real danger in prescribing drugs like sedatives and antibiotics as
placebos. A sugar pill, avitamin or an aspirin isn't generally likely to cause any
problems. But drugs like sedatives and antibiotics could be doing more harm than
good. Many sedatives are habit-forming, so the patient could develop a dependency
on a drug that wasn't even supposed to work on his or her particular condition to
begin with. Doctors who prescribe antibiotics when they're not absolutely necessary
may also be contributing to the rise in strains of antibiotic-resistant bacteria such
as MRSA.

The debate will continue to rage on concerning not only what constitutes a placebo,
but whether doctors and researchers should continue to use them. Even some
supporters of placebo use claim that it's such a loaded word that perhaps we should
start using terms like "mind-body medicine" or "integrated healing" instead. But as
long as many people believe that the placebo effect works, they're not likely to go
away anytime soon.