The Placebo Effect

  

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.