Eric Barker
It all started with a Persian rug. The patient brought it as a gift for
Ted Kaptchuk because he had “cured” her. Ted accepted it gracefully…
despite not believing a word she said. He wasn’t a surgeon or an
oncologist, he wasn’t even an MD. Ted dispensed herbs and acupuncture.
Ted’s a sincere and reasonable guy. He believed his work had some
ability to make his patients feel better; that’s why he did it. But
this woman was saying he had cured a problem with her ovaries that
required surgery. As he told The New Yorker, “There was no way
needles or herbs did anything for that woman’s ovaries. It had to be
some kind of placebo, but I had never given the idea of a placebo effect
much attention.”
Years later he was invited to visit Harvard Medical School. Researchers
were exploring potential new therapies based on alternative medicine and
wanted his insight. And this is where he first got some formal exposure
to the placebo effect. Often, the effect was so strong that it was more
powerful than the drug being tested. This made doctors angry because it
got in the way. Ted was confused. We’re trying to relieve pain and this relieves pain. Why would you hate it?
And that’s when Ted knew what he would spend the rest of his career
doing. He wanted to help patients by understanding this “nuisance” that
brought so many people relief. Ted would remark, “We were struggling to
increase drug effects while no one was trying to increase the placebo
effect.” He thought we were ignoring one of the most powerful tools in
medicine. So Ted devoted himself to showing doctors the error they had
been making.
And that was not going to be easy. He was going to have to prove this
scientifically, or no one would listen to him. He didn’t have an MD or a
PhD. He knew nothing about conducting clinical studies or the
statistical methods necessary for research. So he would have to learn...
CUE THE ROCKY THEME
Ted asked the top medical statisticians at Harvard to take him under
their wing and teach him. It was absurdly difficult to go from herbs and
acupuncture needles to rigorous math, but he was dedicated. Ted worked
hard. And that hard work paid off when he was able to start leading
studies—and especially once he started seeing the results. He wasn’t
crazy. The placebo effect couldn’t kill viruses or excise tumors, but it
had incredible power to make “real” medicine even better.
He split migraine patients into three groups. The first received a
placebo in an envelope labeled “Maxalt” (an FDA-approved migraine drug).
The second got real Maxalt in an envelope labeled “placebo.” The third
got Maxalt in an envelope labeled “Maxalt.” What was the result? Thirty
percent of those receiving the placebo labeled “Maxalt” felt better. And
38 percent of the ones who got the real drug labeled “placebo” got
relief. Statistically, the results were indistinguishable. The placebo
was as powerful as the drug in relieving pain. But that wasn’t the most
important insight. The ones who got Maxalt labeled “Maxalt” felt better
62 percent of the time. That’s 24 percent better than the same exact medication when it’s labeled differently. To get maximum effectiveness, you needed to maximize the placebo effect.
And he even learned how his previous work had helped people. Ted took
two groups of patients and gave one real acupuncture and the second
“sham” acupuncture (seems the same to subjects but the needles don’t
penetrate the body). Both reported similar improvements. So Ted’s
acupuncture didn’t “really” provide any relief—but the placebo effect
did.
Of course, Ted’s research met with resistance. But now he could hit back
with rigorous research. He made it very clear he wasn’t saying the
placebo effect was going to cure cancer or fix broken bones. But Ted
could now prove placebos had legit physiological effects on patients
when it came to pain and anxiety, and boosting the results of “real”
treatments.
Ted showed it wasn’t magic and it wasn’t fake. Naloxone is a drug that
blocks opiate receptors, usually used to counteract heroin overdoses.
But Naloxone also blocks the body’s natural opiates, endorphins. Guess
what else happens when you give Naloxone to people? The placebo effect stops working. So placebos aren’t multidimensional-quantum-crystal-healing-magic:
they’re a normal process that leverages the body’s natural painkillers
in some way that modern medicine did not yet understand. And that effect
could be profound. Eight milligrams of morphine is a lot. But patients
who receive it and patients who are merely told they received it
experience the same amount of relief. You have to up the dosage by 50
percent to get the drug’s effect to surpass that of a placebo.
It wasn’t long before the no-MD guy with a degree from a Macao Chinese
medicine program was receiving grants from the NIH to further his
research. But what was troubling Ted now was though he knew the placebo
effect was real and useful, he wasn’t sure just how and why it worked.
And he was finding some strange results in the data that told him the
rabbit hole went even deeper than he thought...
Four placebo pills a day work better than two. Blue placebo pills are
superior at improving sleep; you’ll want green placebo pills for
reducing anxiety. But placebo capsules beat placebo pills—and placebo
injections were even better. Oh, and expensive, brand-name placebos beat
cheap generic ones. Huh? Why would the method of
administration make such a difference when the (inactive) substance
delivered was always the same? And the craziest result of all? Placebos
even worked when they were “open label” placebos—yes, you could tell
people that the fake medication was fake and they’d still feel better.
And that’s when he realized why he had been such a good healer even when
dispensing alternative medicine treatments. The placebo effect was
about the ritual. It was about the patient’s belief that they would get
better. Injections look more serious than pills, so they increase the
placebo effect. Brand-names and big price tags scream legitimacy, ergo,
more placebo effect. But it wasn’t all about deception. More empathy,
more attention, and more concern from a doctor conveyed the same power.
One of his studies showed that 28 percent of patients given no treatment
had symptomatic relief after three weeks. They got better on their own.
But 44 percent of patients given sham acupuncture with a doctor who was
“business-like” improved. The ritual and attention had a positive
effect. But what happened when the sham acupuncture was combined with a
doctor who really showed concern? When the physicians were instructed to
have a forty-five-minute conversation with the patient? Sixty-two
percent of the patients felt better. Caring had a dose-dependent effect.
Again, this isn’t going to kill the Ebola virus or replace bypass
surgery. But then again, how often are we going to the doctor for those
serious things versus little stuff where we just want less discomfort?
And “real” medicine works even better with the placebo effect. But what
that means is “real” medicine works better when someone shows us they
care.
Ted Kaptchuk proved that while we have certainly gained enormously from
improvements in technology, we also lost something along the way by
ignoring the power of compassion. Rushed doctor visits reduce the
placebo effect and reduce patient recovery. We pay lip service to
bedside manner, but it has real effects on patients. Of course, we want
real drugs and real surgery with “real” effects. But they work so much
better—scientifically better—with the human element that delivers those “fake” placebo effects.
Ted Kaptchuk hasn’t practiced acupuncture in over twenty years. But he
has been applying the lessons he learned back in those days in his new
role. In 2013 Ted was appointed to full professor of medicine at Harvard
Medical School. He still doesn’t have an MD or PhD. He leads the
Program in Placebo Studies and the Therapeutic Encounter at Harvard.
It’s the only program in existence dedicated to the placebo effect, the
human side of medical science.
So that’s Ted’s story...
But we’re not done yet. We still haven’t explained why the placebo effect works. Yeah, yeah, doctor-relationship-heals-you-blah-blah
is nice and poetic and pretty perfect for my book, but we’re not here
just for feel-good stories. If our body can just turn off the pain, why
doesn’t it? What’s the evolutionary logic behind why those warm feelings
can sometimes matter as much as “real” treatment?
Think of pain not as a direct effect of injury but more like the “NEEDS
SERVICE” light on your car dashboard. It tells you something is wrong
and needs addressing. Your body is saying: You need to stop what you’re doing and take care of this.
Care. As we saw, it’s central to the placebo effect. It’s why placebos
work even when we know they’re placebos. When someone cares for us, the
more attention they give us, the more competent they seem, the better
tools they use, the more time they spend with us, the more our bodies
notice. And then your body can tell you a new story: Someone is caring for us. I don’t need to shout at you with pain anymore. We’re safe now. And it turns the “NEEDS SERVICE” light off.
Loneliness heightens our attention to negative emotions because you’re
not safe, you have no one looking out for you, and your body knows that
historically this has been mucho bad for us. The placebo
effect is the reverse. It says, Someone is looking out for us. Backup has arrived. We are safe now.
Up to 66 percent of therapy clients say they felt better before they
even had their first appointment, just as a result of an intake
interview. Help is on the way. I can turn the light off. Caring
can heal you. Usually when I hear fluffy sentences like that, my eyes
start to uncontrollably roll upward, but it’s true, scientifically.
It turns out placebos do have an active ingredient: human beings caring for one another.
