#Project Syndicate RSS Feed Friday, January 3, 2014 * Facebook * Twitter * LinkedIn * Google plus * rss Menu Back to the Homepage * Register * Sign In Back to the homepage * Home * Columnists * Sections * Syndication * About Us * Search… * ____________________ Submit See all Columnists International Economics * Michael J. Boskin * J. Bradford DeLong * Barry Eichengreen * Jeffrey Frankel * Daniel Gros * Koichi Hamada * Lee Jong-Wha * Stephen S. Roach * Kenneth Rogoff * Nouriel Roubini * Andrew Sheng * Hans-Werner Sinn * Joseph E. Stiglitz * Laura Tyson * Yu Yongding Strategic Spotlight * Shlomo Ben-Ami * Jorge G. Castañeda * Gareth Evans * Joschka Fischer * Richard N. Haass * Christopher R. Hill * Yuriko Koike * Dominique Moisi * Joseph S. Nye * Ana Palacio * Michel Rocard * Jaswant Singh * Anne-Marie Slaughter * Javier Solana * Shashi Tharoor Global Finance * Howard Davies * Mohamed A. El-Erian * Martin Feldstein * Simon Johnson * Zhang Jun * Robert J. Shiller Economics of Development * Kemal Derviş * Ricardo Hausmann * Dani Rodrik * Jeffrey D. Sachs * Michael Spence * Andrés Velasco Economic and Regulatory Policy * Jean Pisani-Ferry * Raghuram Rajan * Mark Roe Economic History * Harold James * Robert Skidelsky Public Intellectuals * Ian Buruma * Esther Dyson * Bjørn Lomborg * Peter Singer * Naomi Wolf * Economics * World Affairs * Culture & Society * Politics * Global Health & Development * Environment & Sustainability * Business & Finance * Innovation & Technology * Education Innovation & Technology Environment & Sustainability Culture & Society Photo of Ted J. Kaptchuk Ted J. Kaptchuk Ted J. Kaptchuk is Professor of Medicine at Harvard Medical School and Director of the Program in Placebo Studies at Beth Israel Deaconess Medical Center in Boston. read more Photo of John M. Kelley John M. Kelley John M. Kelley, a professor of psychology at Endicott College and an instructor at Harvard Medical School, is Deputy Director of the Program in Placebo Studies at Beth Israel Deaconess Medical Center in Boston. read more Exit from comment view mode. Click to hide this space * English + Arabic + Chinese + French + German + Spanish * Mail to friendMail to friend * PrintPrint OCT 18, 2013 1 Inside the Placebo Effect * * * * * * BOSTON – For many medical researchers and followers of science, few things are more unsettling than the placebo effect. How can an inert sugar pill have therapeutic value? The answer requires understanding the context that surrounds medical treatment – a setting in which the symbols and rituals of health care combine with the charged emotional reactions that arise when patients encounter healers. The importance of trust, empathy, hope, fear, trepidation, and uncertainty in the therapeutic encounter should not be disregarded. By using sugar pills, saline injections, or even sham surgery, placebo research isolates provision of care from the direct effects of genuine medications or procedures. Recent research on the placebo effect has demonstrated that the clinical encounter alone – without the provision of any “real” medicine – can alleviate pain, improve sleep, relieve depression, and ameliorate the symptoms of a wide variety of conditions, including irritable bowel syndrome, asthma, Parkinson’s disease, heart ailments, and migraine. Placebos mainly influence patient self-appraisal. They cannot shrink tumors; but they can help patients experience less of the fatigue, nausea, pain, and anxiety that are associated with cancer and its treatment. They cannot lower cholesterol or reduce high blood pressure, but they may alter mood or pain sufficiently to promote more healthful behaviors. Placebos can behave like drugs; and the placebo effect can also make drugs more effective. Research shows that various components of the placebo effect – for example, the paraphernalia of care (pills and syringes) and the patient-provider relationship – can be added incrementally in a manner analogous to dose dependence (the higher the dose, the greater the effect). Indeed, these components have been shown to boost the efficacy of many powerful medications. For example, when morphine is administered by injection in full view of the patient, it is significantly stronger than when it is given through an intravenous line without the patient’s knowledge. Many psychosocial mechanisms have been implicated in placebo responses. Increased hope, positive expectations, and reduced anxiety can all modify “mindsets” that guide how patients respond to noxious sensations. Evidence strongly suggests that the support and empathy of a thoughtful and attentive physician can improve clinical outcomes. Indeed, it has been demonstrated that non-conscious environmental cues and symbols – the white coat or the diploma on the wall – can “prime” a patient to experience improvement. Until recently, it was assumed that the effects of placebo pills depended on concealment or deception. The patient had to believe that the treatment was “real” for placebos to work. But new research indicates the potential for significant clinical improvement even if patients are told that they are ingesting an inactive substance. This suggests that the simple enactment of a treatment ritual may, like conscious expectations, have a powerful impact. In fact, the power of imagination, it seems, has a basis in neurobiology. Recent evidence shows that when placebos have salubrious effects, they engage the same neurological pathways as active medications. For example, when patients experience pain relief from placebos, the brain releases endogenous opioids and/or CB1 cannabinoids – the very same mechanisms that mediate pain relief derived from pharmaceutical treatments. Likewise, neuroimaging studies show that placebo treatment activates specific brain structures such as the prefrontal cortex and the rostral anterior cingulate cortex. Experiments on patients with Parkinson’s disease have shown that placebo treatment releases endogenous dopamine in the striatum region of the brain. Moreover, intriguing pilot research suggests that there may be genetic factors that predispose one to have greater placebo responses. The effects of placebos are not always beneficial. The placebo effect has a dark twin called the nocebo effect. Although placebos are biologically inert, as many as 26% of placebo-treated patients drop out of clinical trials after suffering intolerable side effects, which are usually the same as the possible side effects of the drug being tested. For example, in a trial of anti-migraine medication, if the active ingredient is an anticonvulsant, the nocebo effect (the placebo’s side effect) will disproportionally relate to anorexia or memory; but if the active ingredient is a non-steroidal anti-inflammatory drug, the nocebo effect will more likely be gastrointestinal symptoms and thirst. This underscores the importance of placebo effects in the development of new drugs. To approve new pharmaceuticals, the US Food and Drug Administration requires two well-designed randomized controlled trials in which the drug demonstrates superiority over placebo treatment. However, evidence suggests that for some illnesses, placebo effects have grown progressively larger over the last several decades. This “placebo drift” poses significant challenges to detecting drug-placebo differences. And that highlights a more fundamental point: In our rush to embrace high-tech medicine, we tend to forget the enormous potential for healing that can arise from a good therapeutic relationship. Placebo research has demonstrated that the context within which treatment takes place and the patient-clinician relationship have huge potential to improve health outcomes. We need to learn more about the placebo effect’s power and limitations. We also need to learn how to translate this scientific knowledge into ethical and effective methods that physicians can use to improve medical outcomes. And we need to know more about the placebo effect in clinical trials. In short, we need to stop thinking in terms of the “art of medicine” and start exploring a new science of healing. * Contact us to secure rights * Previous Winning the Fight Against Killer Diseases Jeffrey D. Sachs * Next Measure for Mismeasure Esther Dyson Exit from comment view mode. Click to hide this space Hide Comments Hide Comments Read Comments (1) Please login or register to post a comment * Sign in * Register * [X] Experts * [X] Users 1. + Reply + Vote down + Vote up CommentedZsolt Hermann NOV 7, 2013 Thank you for this intriguing article. I agree with everything the article describes, as a surgeon myself, and I am sure other health professionals can testify "intrinsic" factors are crucial, we could even say most important in healing, acquiring illness and health in general. I would suggest that while modern medicine looks at illness and healing as an external process, illness happening due to external causes, pathogens, environmental factors, and healing also have to come "from the outside" from overwhelming pharmaceutical agents, improving technology and surgical miracles and of course expensive implants, true illness/healing is a completely internal matter. Although Indian or Chinese traditional medicine has several thousands of years experience with this viewpoint, by today even in their original countries very few people remember, let alone practice this notion. All medicine should be doing is facilitating, initiating a healthy protective, healing response from the body and the body then heals itself. And beyond medicine the whole human environment should function in such natural, self supporting way as any other interconnected natural, living system providing healthy, sustainable living, strong inner protection to all the individuals and the whole. Featured Photo of George Soros EconomicsJAN 2, 2014 5 The World Economy’s Shifting Challenges George Soros maps the terrain of a global economy that is increasingly shaped by China. Photo of J. Bradford DeLong EconomicsDEC 31, 2013 15 The Strange Case of American Inequality J. Bradford DeLong asks why Americans are not clamoring for polices that would leave 90% of them better off. Photo of Naomi Wolf Business & FinanceDEC 31, 2013 2 The Girl Can’t Help It Naomi Wolf decodes the sexist media coverage of Mary Barra's appointment as CEO of GM. * * * * * * * Mail to friendMail to friend * PrintPrint Menu back to home * Columnists * Sections + Economics + World Affairs + Culture & Society + Politics + Global Health & Development + Environment & Sustainability + Business & Finance + Innovation & Technology + Education * Blogs * Syndication * About * ____________________ Submit * Register * Sign In Quantcast Email this Article Your Name ____________________ Your Email ____________________ Friend’s Name ____________________ Friend’s Email ____________________ Message ____________________________________________________________ ____________________________________________________________ Incorrect please try again Enter the words above Enter the numbers you hear ____________________ Captcha is not valid Get another captcha Get an audio captcha Get an image captcha Help Thank you. 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