Tag Archives: Pain

Open Label Placebos … again

An article in Big Think entitled People are knowingly taking placebos—and its working starts to untangle some of the theories about the functionality of ‘open label’ placebos – which describes the engagement of a placebo effect even when people know they’re taking a placebo. 

“Even though they were told that what they were taking was placebo and contained nothing of therapeutic value, those patients who received the placebo reported a 30% reduction in usual pain and maximum pain and a 29% drop in their disability. Incredibly, the placebo worked better than the real pain medication. Participants who took the pain pills reported feeling 9% less usual pain, and 16% less maximum pain. Furthermore, patients taking the real medication reported no change in their level of disability.”

Placebos and pain

Pain is a subjective state – that’s why practitioners typically ask us to ‘scale’ our experience of it, from a ‘1’ (slight) to a ’10’ (unbearable). And while it’s easy to see why the experience of pain is useful in an evolutionary sense (‘keep your hand out of the fire!’) it’s difficult to account for what mechanism is responsible for this experience. Different analgesics may have different effects (and affects) for different people, and some don’t seem to contraindicate – it seems you can ingest an opioid at the same time as paracetemol.

Enter the placebo effect! Here’s a recent research paper on placebos and pain. And also a fascinating article on ‘leveraging the Placebo Effect to Reduce Opioid Requirements’.

So you have a placebo-friendly brain and personality?

It seems there may be characteristics which not only how receptive you are to benefiting from the placebo effect, but also the degree with which it effects you.

In a study published in Nature Communications, two factors seems to influence results:

  • Brain anatomy (such as asymmetry in areas of the brain that control emotion and reward, including the amygdala, accumbens and hippocampus), and
  • ‘Personality’ – especially mindsets “emotionally self-aware, attuned to the body and mindful of one’s surroundings”

At Universal Placebos we’ve always known that awareness and mindfulness are part of the therapeutic value of placebos, of course, which is why our product comes bundled with instructions for mindful and meaningful administration.

“Down the line, the clinician could give five or six questions to the patient and decide whether they should just prescribe a sugar pill to them,” say the researchers. “The higher they score on this personality questionnaire, the bigger their placebo response will be.”

How the Iceman Resists Extreme Cold

Finland’s Arctic circle might not seem like a great place to run a marathon barefoot and in shorts—unless you’re Wim Hof. Hof, better known as “The Iceman,” has attained roughly two dozen world records by completing marvellous feats of physical endurance in conditions that would kill others. Yet even he was understandably nervous the night before his 26-mile jaunt at -4 degrees Fahrenheit.

“What did I get myself into?” he recalls thinking. But from the moment his bare toes hit the snow, he began to feel “surprisingly good.”

MRI scans reveal that Wim Hof artificially induces a stress response in his brain. “By accident or by luck he found a hack into the physiological system,” they say.

How? Well, you know what we think. The placebo effect in action once more!

Patients may be experiencing placebo effect, but it’s still an effect: “Placebo is active treatment”

 

In Respect the Needle in OA (osteoarthritis),  a rheumatologist says:

“… Dealing with osteoarthritis, both patients and their physicians often have a hard time understanding what to make of novel “cures” such as platelet-rich plasma (PRP), stem cell treatments, and so-called prolotherapy.

Although these are typically marketed as halting or reversing joint degeneration in OA, there is virtually no evidence that they actually do. Yet it’s impossible to discount the countless reports from patients that the treatments helped them in terms of pain and function.

The explanation may very well lie in the placebo effect, said Joel Block, MD, a well-known osteoarthritis specialist at Rush University, speaking at the American College of Rheumatology’s 2018 State of the Art Symposium.

But the thrust of Block’s 30-minute talk can be summed up in two words: So what?

The placebo effect is still an effect and a very important one, he argued repeatedly in addressing current knowledge about therapies, largely unregulated, now marketed nationwide in newspapers and online as “disease-modifying.”

It’s “extraordinarily strong” in osteoarthritis, Block said, for reasons that aren’t entirely clear. The experience from randomized trials is that one normally expects a 40% response rate with placebo with large effect sizes. Moreover, the improvements in patient-reported pain do not quickly disappear: the trial data indicates that placebo responses last beyond a year, he said.

“Placebo is active treatment,” Block said.

The placebo’s evil twin

The placebo effect is one of the most mystifying phenomena in medicine. When we expect a pill to make us feel better, it does. If we see others get better while using a medicine, we will too.

But the placebo effect has an evil twin: the nocebo. It can kick in when negative expectations steer our experience of symptoms and create side effects where none should occur.

This means, incredibly, that you can get side effects from a sugar pill. And sometimes these side effects are so severe that patients drop out of clinical trials. More info here.

Recent evidence suggests that the muscle aches might be a big nocebo.

More Research on ‘Open Label’ Placebos

Whether you know you’re taking a placebo pill or not, it will still have a beneficial effect, new research has revealed (Is the rationale more important than deception? A randomized controlled trial of open-label placebo analgesia.)

Scientists from Harvard University and the University of Basel prescribed a group of minor burn victims with a “treatment” cream, telling only some of them that it was a placebo.

After the cream was applied, both groups reported benefits, despite the placebo cream containing no medicine.

Read the full article here

On the subject of Open Label Placebos, here’s a link to research on their efficacy in chronic lower-back pain.

Who is More Likely to Experience a Strong Placebo Effect?

A new study finds that people who have a better handle on their negative emotions may be more likely to experience a stronger placebo effect. Researchers at the University of Luxembourg found that participants who were better at interpreting negative events in a positive light felt more relief from a placebo pain-relieving cream.

The placebo effect has traditionally been viewed in a negative light; however, within the last decade, researchers have investigated the placebo effect itself and found that placebos can trigger real biological changes in the body, including the brain.

In a related article:

“All participants reported less pain: the placebo effect was working. Interestingly, those with a higher capacity to control their negative feelings showed the largest responses to the placebo cream in the brain. Their activity in those brain regions that process pain was most reduced. This suggests that your ability to regulate emotions affects how strong your response to a placebo will be.”

PLACEBO AND FAKE SURGERY

Two thought-provoking articles relating the placebo effect to ‘sham surgery’, which has been canvassed in these pages previously.

In this meta-study, the authors point out that ” the literature is not chock full of studies comparing a surgical procedure to placebo. While the study of a drug versus placebo is standard practice, the picture changes radically when the placebo is a sham operation involving incisions and anesthesia …  Of about 3000 articles, 53 full-text articles were selected. They represented randomized controlled studies, with both an active intervention and a placebo arm involving a sham procedure. The authors defined a surgical outcome based on three elements:

•    The critical surgical component – the anatomic changes felt to result in a therapeutic effect

•    Placebo component – the patient’s expectations

•    Non-specific effects – changes in the natural history of an illness that might impact the outcome, the experience of being in a hospital, interactions with staff – the multitude of other factors.

In this study, the author admits that sham (placebo) srugery already occurs. Because it can work.

How?

“How can sham surgeries work? Bigness. In the same way that placebo pills and other modalities make people get better, the clinical evaluation, workup, stress and travel of surgery day, surgical prep, etc. all make for an almost unbeatable set of placebo-instituting conditions. And with some of the data which exist, sham surgeries perform better in the patients’ minds than a drug treatment that’s a comparator for the same condition.

Placebos and acupuncture

Here’s a link to a fascinating meta-analysis of the effectiveness of acupuncture in the treatment of chronic pain, controlling for some of the dodgy and unscientific ‘studies’ out there.

In this article, the outcomes of the study are listed and discussed, and it’s good news for acupuncturists.

‘When comparing legit acupuncture to standard care, there was a statistically significant benefit to acupuncture … “We saw a measurable effect there,” he explains. “If acupuncture were a drug, we’d say the drug works.”’

…and later, in relation to the placebo effect:

‘Many people equate placebo effects with scams. “The term placebo has always had this very negative connotation,” says Vitaly Napadow, director of the Center for Integrative Pain Neuroimaging at Harvard Medical School. But Napadow says our poor opinion of placebo needs revising. The human body has built-in systems for stoking or calming pain and other subjective sensations. “If a placebo can target and modulate these endogenous systems, that’s a good and a real thing,” he says.’

Meanwhile, in two comprehensive studies into the value of acupuncture treatment in treating women’s health issues, we see mixed results.

‘These studies shed new light on when and when not to consider using acupuncture,” Dr. Josephine Briggs and David Shurtleff, of the U.S. National Center for Complementary and Integrative Health, wrote in an editorial to accompany the studies.

The research done to date on acupuncture has shown that, generally, its benefits are limited to outcomes that are subjective, such as pain, Briggs and Shurtleff wrote. People’s positive expectations and the reassurance they feel from the procedure likely contribute to the benefits. “Clearly these ancient practices are helping reveal the complexity of the links between the mind and the body,” the editorial said.’