In fact, the fact that you go to the doctor itself has a therapeutic effect.
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The so-called placebo, as the name suggests, is usually a sugar tablet or salt water that has no actual effect, and will be "comforted" after taking it. In 1955, Henry K. Beecher of Harvard Medical School proposed the "placebo effect", which can also be understood as a subject expectation effect - comfort brings expectations, and people who expect to get better will get better faster. Stories about the placebo effect seemed like a "deception" in the past. In the 1950s, this effect was also known as the pseudo-drug effect, the pseudo-drug effect, and the proxy effect, that is, when a patient unknowingly received ineffective treatment, because of a strong belief in the treatment drug, the symptoms were eventually alleviated.
In the past, it was thought that this effect could only work without the patient's knowledge; today, studies have found that even if the patient knows, it has the same effect.
On February 12 of this year, the Ted Kaptchuk team at Harvard Medical School published an article in the journal PAIN titled "Open-label placebo vs double-blind placebo for irritable bowel syndrome".[1]. Studies comparing the effects of open-label placebo with double-blind placebo in the treatment of irritable bowel syndrome (IBS) found that both were effective.
Professor Kaptchuk said: "Over the past decade, one experiment after another has shown that publicly informing patients that they are using a placebo can make them feel better. Specifically, Kaptchuk found that placebo not only relieves pain, but also anxiety and fatigue.
With this result, the "placebo is a lie" statement is self-defeating, and a series of new problems have emerged. Since placebo is also effective, can it be part of standard medical practice? Will patients be willing to take it? Strategically, can it be used to reduce consumption of addictive opioid painkillers? The answers to these questions may change the way we usually think about medicine, but one of the most important problems is that researchers aren't entirely sure how placebos work.
Awkward placebo: can only be used in secret
Kaptchuk recalls: "When it came to the first thought of giving a patient a sugar pill and telling them it was a placebo, colleagues thought it was a very stupid thing to do because placebo usually needed to be kept secret from the patient to work. ”
For years, Kaptchuk has been trying to find ways to make the placebo effect stronger, especially in the treatment of irritable bowel syndrome, a very painful chronic condition. But all the research on placebos was painful for Kaptchuk because they were based on concealment and deception.
If placebos can only be used in secret, it will never become part of mainstream medical practice. In the context of a clinical trial, patients may be able to accept deception, but in the real world, doctors cannot offer this option.
The deception made Kaptchuk uneasy. To analyze how patients feel cheated, he and his colleagues conducted an anthropological survey of patients involved in clinical trials of irritable bowel syndrome [2], which found that many were concerned about being given a placebo. The patient said, "If I'm well on a placebo, what does my condition mean?" Was the whole thing made up by me? ”
Irritable bowel syndrome is a common functional gastrointestinal disorder characterized by recurrent abdominal pain and abdominal discomfort, often accompanied by constipation and diarrhea. Although normal function is impaired, structural abnormalities are not seen on endoscopic, x-rays, or blood tests.
Public use of placebo has also been effective
Since using a placebo in the dark will worry them, why not just tell them that it is a placebo? Kaptchuk felt he could tell patients that if they got better after taking a placebo, it was a sign of healing, not a nonsense.
In 2010, Kaptchuk et al. published a study of placebo treatment in 80 patients with irritable bowel syndrome [3]. He openly gave placebo treatment to half of his patients, while the other half did not give any treatment. It turned out that patients who used open placebos were in better health than those who did not receive any treatment!
Since then, publicly given placebo has also been shown to relieve symptoms of other diseases, such as chronic pain, fatigue, arthritis, anxiety, depression, etc. The researchers also followed up patients who were openly placebo for up to five years [4], and the results also showed a gradual improvement in the health of such patients.
Based on these studies, Kaptchuk reinterpreted the placebo effect. He believes that in the clinical context, the confidence of patients to recover is mainly based on the way and method of drug delivery. When a person falls ill and goes to the doctor, the act itself is a potential form of treatment, which can be called "the drama of medicine." In this "drama", the pill is only a prop in it, and the doctor is the key role in it, and a doctor with a warm, friendly personality can often produce a stronger placebo effect.
How powerful is "drama"?
To answer this question, Kaptchuk and his collaborators conducted scaled replication of the initial 80-person IBS patient trial[1], the recently published study mentioned at the beginning of this article. This time, they compared three situations: an open placebo (both doctors and patients were well aware that a placebo was used), a double-blind placebo (neither the doctor nor the patient themselves knew whether to use a placebo or a drug), and an untreated control group.
The results found that in the placebo group (the first two cases), 70% of patients had at least a 50-point reduction in symptom severity (graded on a 500-point scale, the higher the score, the more severe the symptoms), compared with only 54% of patients in the untreated control group.
In addition, about 30 percent of patients who publicly used placebo reported a 150-point reduction in symptoms, compared with only 12 percent in the no-treatment group.
The results also showed no significant difference between the open placebo group and the double-blind placebo group in terms of the IBS severity score. That is, whatever benefit people derive from a double-blind placebo, they can also get it from a publicly available placebo.
Why does it work? Two psychological explanations
Why is the use of placebo openly effective in some cases? At present, researchers mainly explain from the two aspects of "expectation" and "conditioned reflex".
Darwin Guevarra, a researcher at Michigan State University, said: "The expectation is that you believe that something will work. "In many studies, expectations seem to have been set — for those subjects, the researchers would tell them what a placebo effect was and tell them that placebo might also have some effect.
But things are far from simple. When you expect improvement, you may begin to pay attention to various signals from your body, both good and bad. So when you change your expectations, you may selectively block out bad signals coming from your brain and look for signals you feel good instead.
However, expectations do not explain the full extent of public placebo use. Kaptchuk said many people who sign up for clinical trials don't really want a placebo to cure the disease, but rather to alleviate the pain that comes with the disease.
At this point, it is the conditioning that is at work. The theory of classical conditioning derives from the Russian psychologist Pavlov's experiment with dogs: When dogs learn to associate ringtones with eating, they will begin to drool as soon as they hear the bells. For humans, we can associate one thing (taking a placebo) to a positive outcome (feeling better). In this way, even if the drug component in the actual treatment is removed, the act of receiving treatment will make you feel better.
In another study published in PAIN [5], Kaptchuk divided 51 patients undergoing spinal surgery into two groups, one receiving open placebo and taking opioids, and the other taking only opioids.
During the experiment, the patient took an opioid followed by a placebo. Over time, the brain gradually learned to associate placebos with real drugs. Drugs relieve pain by stimulating the brain to release neurotransmitters, so, theoretically, even if you're just taking a placebo, if your brain is in a state of conditioning, it will start releasing those neurotransmitters.
The results also showed that those who took both placebo and opioids had a 30 percent reduction in opioid dependence compared to the conventional treatment group, and also reported a gradual reduction in pain.
Some have questioned this result: Will patients just say what the researchers want to hear? But there have also been studies that have found that the open use of placebo does appear to reduce nerve markers of pain and stress [6].
Overall, researchers still don't know which factors play a major role in the placebo effect. But it's important to figure this out because it will determine how scientists design to use placebos in the clinic. "Conditioned reflex theory" seems to require frequent stimuli, while "expectation theory" can be put in place in one step and seems more attractive.
Placebos have been ignored as drugs, and perhaps this should be changed
Kaptchuk says placebo is not a magic pill, and it may only work for specific groups of people at certain times. Studies have shown that placebo (whether open to patients or not) appears to act primarily on subjective symptoms such as pain. They do not work on objective symptoms, such as fractures.
A placebo won't shrink the tumor, won't improve diabetes, and won't quickly lower your blood pressure. So does this mean that their usefulness is very limited?
Kaptchuk believes that all objective diseases have subjective symptoms. For example, cancer is caused by tumors, but it can also make people feel pain or fatigue; there are also diseases, such as irritable bowel syndrome, which is believed to be the brain's misinterpretation of normal sensations as pain, and the use of placebo may interfere with the brain's interpretation and relieve the pain.
Overall, Kaptchuk's new definition of the placebo effect — "medical drama" — is a radical way of thinking about medicine that not every doctor can identify with. For a long time, mainstream medicine has been dismissive of placebos, even arguing that the placebo effect seems to be an obstacle that needs to be cleared in order to determine what a "real drug" is. But the placebo itself is acting more and more like a drug. The placebo effect is an additional healing power that is used outside the drug or when no good medicine is available.
To this day, we still have many unknown questions about placebo, and more research is needed on whether placebo can become a real drug in the future.
Original link:
https://www.vox.com/unexplainable/22405880/placebo-mystery-open-label-pain-medicine
bibliography
[1] Lembo, A., Kelley, J. M., Nee, J., Ballou, S., Iturrino, J., Cheng, V., Rangan, V., Katon, J., Hirsch, W., Kirsch, I., Hall, K., Davis, R. B., & Kaptchuk, T. J. (2021). Open-label placebo vs double-blind placebo for irritable bowel syndrome: a randomized clinical trial. Pain, 10.1097/j.pain.0000000000002234. Advance online publication.
[2] Kaptchuk, T. J., Shaw, J., Kerr, C. E., Conboy, L. A., Kelley, J. M., Csordas, T. J., Lembo, A. J., & Jacobson, E. E. (2009). "Maybe I made up the whole thing": placebos and patients' experiences in a randomized controlled trial. Culture, medicine and psychiatry, 33(3), 382–411.
[3] Kaptchuk, T. J., Friedlander, E., Kelley, J. M., Sanchez, M. N., Kokkotou, E., Singer, J. P., Kowalczykowski, M., Miller, F. G., Kirsch, I., & Lembo, A. J. (2010). Placebos without deception: a randomized controlled trial in irritable bowel syndrome. PloS one, 5(12), e15591.
[4] Kaptchuk, T. J., & Miller, F. G. (2018). Open label placebo: can honestly prescribed placebos evoke meaningful therapeutic benefits?. Bmj, 363.
[5] Flowers, K. M., Patton, M. E., Hruschak, V. J., Fields, K. G., Schwartz, E., Zeballos, J., Kang, J. D., Edwards, R. R., Kaptchuk, T. J., & Schreiber, K. L. (2021). Conditioned open-label placebo for opioid reduction after spine surgery: a randomized controlled trial. Pain, 162(6), 1828–1839.
[6] Guevarra, D.A., Moser, J.S., Wager, T.D. et al. Placebos without deception reduce self-report and neural measures of emotional distress. Nat Commun 11, 3785 (2020).