Running Head: The Placebo: A Highly Beneficial and Side-Effect-Free Kickstart
The Placebo: A Highly Beneficial and Side-Effect-Free Kickstart Therapy
Ben Rosen
Missouri State University
THE PLACEBO: A HIGHLY BENEFICIAL AND SIDE-EFFECT-FREE
Abstract
This literature delves into the primary psychological and physiological effects of a
placebo when kickstarted by a primary care physician before medication is considered.
For something to kickstart or jumpstart, this entails that the placebo will only be a
temporary act to be used before medication. However, if the placebo does prove effective
for treating mild pain, mild social anxiety, and or mild depression, there may be no real
medication needed after a two-week placebo trial. Furthermore, this paper examines the
ways in which human expectations and beliefs interact with a patients belief system and
expectancies for taking a pill, whether the capsule contains real or fake chemicals. For
there to be an effective placebo response, which is the way a patient responds to a sugar
pill, there must be a strong doctor patient relationship. This relationship is built off trust
in addition to the doctor checking up on the patient daily through the phone to ensure
their mental state and current well-being. (Haas, Anderson, & Filkowski, 2015). The daily
contact should be maintained for the duration of the two-week placebo administration. A
placebo should be used in the treatment of mental and physical disorders before
administering real medication because it has reduced side effects, costs less money, and
can eliminate the need for using potentially addictive drugs.
The placebo effect is not a physical entity. For the purpose of this researched argument,
the placebo effect is a mental belief system that a doctor should conform to when he or
she is briefing a client about a medication (placebo) they should take. A placebo can be a
cost effective and alternative option for pain pills and other drugs, while also providing
similar pain relief. (Price, Petersen, & Vase, 2014) The trick to this whole system is
THE PLACEBO: A HIGHLY BENEFICIAL AND SIDE-EFFECT-FREE
simple yet complex. The doctor should inform the patient that they may or may not
receive a placebo. Uncertainty is what creates a specialized response in the patient that
yields a possible what if scenario and also either enhances the doctor patient bond, or
hinders it. Trust is the main factor in building this placebo response and getting effective
results. A fake/sham study below will further explain a similar real life scenario.
Imagine a stroll into the doctor's clinic where patient A is given a medicine that
will alleviate their lower back pain. Physician A, who writes out the prescription, (Rx)
happens to have a PhD, and well respected and is always asked for first by clients. After
handing the prescription to the patient, the doctor smiles, beaming with confidence and
says, "This pill, whether it is the real deal or not, will put a stop to all of the mild pain
experienced through your lower back, I will help you to conquer this internal
psychological struggle. You will see that that your deliberate focus on the pain is the
deciding culprit for your agony."
Now it's patient B's turn to enter a similar building. This individual also suffers from
chronic lower back pain and is looking for a drug to help diminish the agonizing aches.
Patient B is handed an Rx from physician B, who has similar experience and credentials
as physician A. However, with physician B, the doctor is dressed up in blue jeans and an
AC/DC shirt instead of a white lab coat. The doctor is also poorly groomed and hasn't
showered in what seems like a week. The doctor then groans noticeably toward the
patient and states, "This drug may or may not be a placebo, it's intent is to change your
body, call me in two weeks and let me know if anything happens. Oh and it is also my job
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to inform you that there may be some terrible side effects that go along with this possible
placebo."
Two weeks later both patients return to their primary care physicians. Patient A enters the
office with a slap happy grin on his face exclaiming proudly that the back pain has been
significantly reduced as a result of the medication. Patient B arrives with little energy and
feels that his/her back feels no different as a result of the not-so-magical drug. The
doctors were instructed to give sugar pills to both subjects as part of an experiment
conducted in regards to the defining factors of a placebo response. The only difference
between the two experiences was the way the doctor interacted with the patient. Doctor A
had positive expectations and had a firm belief that nothing would stop patient A from
experiencing total relief. Doctor B on the other hand had a lowered credibility because of
the way he/she dressed and presented him/herself to the client. This made it so the patient
was less likely to believe that the doctor knew what he/she was doing, this in turn
lowered their expectations for the effectiveness of the placebo, which in turn caused
patient B to receive little to no relief. This all goes back to the time of young Siddhartha
and the practice of early meditation, when the Buddha himself said, "We are what we
think. All that we are arises with our thoughts. With our thoughts, we make the world."
Expectations will evoke a placebo response, just like a class of students will be more
likely to listen attentively and believe a speaker who is in a suit and standing, rather than
in a t-shirt and slouched in a chair. Avid researchers and practicing psychologists conduct
studies similar to this pseudo example regularly. A primary goal in these experiments has
been to find out how medications are affected by beliefs and expectations. (Kong,
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Kirsch, Sadler, Spaeth, Cook, Kaptchuk, 2014) & (Kermen, Hickner, Brody, Hasham,
2010)
Literature Review
A prime example of "conditioned expectancy" is seen with patients who suffered
from bleeding ulcers. This placebo study featured two groups. Robbins (1997) explained
that group number one was to be administered a "new drug that would absolutely produce
relief." Group two was advised that they were given an experimental drug. Both groups
were given a sugar pill, yet 70% of group one had "significant relief from their ulcers,"
versus only 25% of group two stating they also had significant relief. Further along,
Robbins mentions a doctor Andrew Weil who states, 'studies conducted...have shown that
the experiences of drugs users correspond almost exactly to their expectations' (p. 47).
In the journal titled, Placebo: From Pain and Analgesia to Preferences and
Products, evaluated the way a person will perceive something and what the reward value
or benefit of that thing will be. It found that a placebo response evokes "unconscious
physiological functions." Particularly, expectations evoke opioid systems. It is then stated
that, "expectation plays an important role in modulation of acute and chronic pain" (p.
395). In experimental settings, it was found that 30-60% of individuals had a placebo
response in regards to pain and analgesia. It was also noted that those who had pain
experienced lower respiratory rates when influenced by a placebo.
Going back to opioid systems, the Journal of Neuroscience published the paper,
Somatotopic Activation of Opioid Systems by Target-Directed Expectations of Analgesia,
and found that there is such a thing as placebo-activated opioids. These endogenous
opioids, endogenous meaning that they result from an internal response elicited from the
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body, are activated when a patient is told that they are receiving a "powerful local
anesthetic," (p. 3639) but are actually being administered a placebo cream. This placebo
cream only evoked the opioid systems in the target area of expectation. Meaning,
"placebo-activated opioids do not act on the entire body but only on the part where
expectancy is directed." (p. 3639)
In the New York Times article, Beware the Nocebo Effect, journalists Paul Enck
and Winfried Hauser described that placebo effect expectations can do as much harm as
they could do good. Paul and Winfried elaborated explaining that doctors need to be more
aware of dangers that result from briefing a patient about treatment complications.
A scholarly paper that was published by the American Psychological Association
in 2014, titled Expectancy and Conditioning in Placebo Analgesia Separate or
Connected Processes? examines the differences between conditioning and expectancy. At
Massachusetts General Hospital, the Harvard Medical school conducted an experiment
on acupuncture to evaluate the placebo effects on conditioning. In order for something to
be conditioned it must be as a result of direct experience. In addition, for something to be
considered an expectation, "it can be produced by verbal information" (p. 52). The
Harvard school under the guidance of Randy Gollub, a group of subjects were given the
same verbal information that the conditioned group was briefed on. This consisted of
informing the group that the acupuncture treatment has pain reducing potential. However
the experience will be surreptitiously lowered pain. There were three studies conducted,
focusing on conditioning, which housed a conditioned and controlled group, both who
had treated and untreated participants. It was found that in the conditioned group, the post
placebo effect was greater and went from -0.2 to 1.6, versus the control group who had a
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post placebo effect that gauged from 0.51 to 0.65. As a result, it was found that the
concepts of conditioning and expectancy run independent of one another. In addition,
when an individual is conditioned and experiences the "analgesic effect in association
with the conditional stimulus, this experience is likely to influence their expectancies for
pain relief" (p. 57). It was also found that when attempting to condition an individual,
verbal information that is previously presented can "block the effect" of conditioning.
This literature showed that when someone experiences relief from pain, their brain will
encode and label this as a pleasurable experience. Meaning, the individual will be more
likely to experience pleasure again from the acupuncture, even if the test is now a sham
experiment that presents no real acupunctural benefit. This is important for doctors and
other medical professionals, because this means there is immense power in demonstrating
the ways an individual can receive pleasure from a drug. This could work in terms of first
telling a patient they will be receiving a certain pain or anti depressant medicine and
instead administering a sugar pill.
The Psychiatric Times reported a study on men with unipolar depression, which is
also referred to as Major Depressive Disorder, and examined changes in brain glucose
metabolism. One group received the Selective Serotonin Reuptake Inhibitor, (SSRI),
Fluoxetine, the next received a placebo. Both groups had their brain activity evaluated
using a positron emission tomography, (PET), which will analyze the functioning of both
tissues and organs. The similarities between the SSRI drug and the placebo were found in
areas of metabolic increase including: the anterior cingulate, premotor, parietal, posterior
insula, posterior cingulate areas, and prefrontal lobes. Other similarities between
Fluoxetine and the placebo were found in areas of metabolic decreases including: the
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subgenual cingulate, parahippocampus, and thalamus. It was also discovered that
"patients who respond to placebo experience brain changes that are similar to but less
extensive than those that occur in response to Fluoxetine." (p. 1)
It may seem evident that a placebo is something that should be implemented in all
doctors offices as a kickstart program for two weeks to see if medication is really needed.
However, there are problems to this implementation. Ethics is a main factor that first
comes into consideration. Is it ethical to deceive a patient, and trick him or her into
believing a possibly false statement. For example, when the doctor says that he/she may
or may not give a placebo, it is in the best interest of the patient to give him/her a placebo
every time. This then violates a code of conduct that all medical professionals agree to
when they become licensed. But the deal is this, giving the placebo to the patient may in
fact be the best way to evoke a placebo response. A quote from the Guardian in the article
Placebo effect works even if patients know they're getting a sham drug touches on this,
"finding effective means of harnessing placebo responses in clinical practice without
deception is a high priority." This article also brought to light some interesting knowledge
through a small pilot study conducted on conditioning. In the study, researchers found
that patients benefited from taking a sugar pill, even when they are told that a sugar pill is
exactly what they are taking. It was simply the act of taking a pill that caused them to feel
relief. Another paper written by Ben Goldacre of the Guardian looks at the how a placebo
effect will almost always have side effects. This may go against the title of the paper, but
that is because this concerns a different type of side effect. What Ben described is that
this is not a side effect that is caused by medication, but rather expectancy. He found that
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"every single placebo-controlled trial ever conducted on a migraine" had similar side
effects to patients who took the real headache medicine.
All the literature provided is to help the reader understand the urgency of first using a
placebo. It is intended that doctors read these studies and delve further into the positive
outcomes of proper placebo use. A plan to use the placebo will impact not only the
doctors office, but will go far into the world of business and advertising in general
(Borsook & Becerra, 2005). It may sound far fetched that there would eventually be a
company that specializes in the mass distribution of sugar pills, but this could be the case,
come the year 2025. It would be a miracle to live in a world that doesn't rely on
pharmaceuticals to cure their every concern. It would be liberating to see people who
weren't hindered by the side effects of medication. For me, I rely on Attention Deficit
Disorder meds to help me function. I understand personally, that a simple placebo can
cure not all disorders. However, there was an interesting event that occurred with me only
a couple weeks back. I left for class and assumed that I had already taken my medicine.
However, the pills were still lying on the table and I had gulped some water but forgot to
take the pills in addition. Turns out, I still felt the power of the medicine while I was in
class. It wasn't as strong as an effect and about 35 minutes into the lecture I felt that
something was off. None the less, my body was conditioned to feeling a certain response
at a certain time of day, and because of this, my body took it upon itself to generate
dopamine and increase my attention, simply because I thought I took my medicine at
first. This was the power of expectations witnessed first hand. And I have to say, there is
nothing quite like it.
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References
Benedetti, F., Arduino, C., & Amanzio, M. (1999). Somatotopic Activation of Opioid
Systems by Target-Directed Expectations of Analgesia. The Journal of
Neuroscience, 19(9), 3639-3648.
Borsook, D., & Becerra, L. (2005). Placebo: From Pain and Analgesia to Preferences
and Products. Journal of Marketing Research, 42(4), 394-398.
Enck, P., & Hauser, W. (2012) Beware the Nocebo Effect. The New York Times. SR(4)
Frisaldi, E., Piedimonte, A., & Benedetti, F. (2015). Placebo and nocebo effects: A
complex interplay between psychological factors and neurochemical networks.
American Journal Of Clinical Hypnosis, 57(3), 267-284.
doi:10.1080/00029157.2014.976785
Goldacre, Ben. (2009) Homeopathy and the nocebo effect. The Guardian.
Haas, B. W., Anderson, I. W., & Filkowski, M. M. (2015). Interpersonal Reactivity
and the Attribution of Emotional Reactions. Emotion,
doi:10.1037/emo0000053
Jha, Alok. (2010) Placebo effect works even if patients know they're getting a sham drug.
The Guardian.
Kermen, R., Hickner, J., Brody, H., & Hasham, I. (2010). Family Physicians
Believe the Placebo Effect Is Therapeutic But Often Use Real Drugs as
Placebos. Family Medicine, 636-641.
Kirsch, I., Kong, J., Sadler, P., Spaeth, R., Cook, A., Kaptchuk, T. J., & Gollub, R.
(2014). Expectancy and conditioning in placebo analgesia: Separate or
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connected processes?. Psychology Of Consciousness: Theory, Research,
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And
Practice, 1(1), 51-59. doi:10.1037/cns0000007
Vase, L., Skyt, I., Laue Petersen, G., & Price, D. D. (2014). Placebo and nocebo
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in chronic pain patients: How expectations and emotional feelings contribute to
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