A placebo, medically speaking, is nothing more than a little white lie. It's not really medicine. You're just supposed to think it is.
So what would happen, Ted Kaptchuk and his team of Harvard researchers wondered, if doctors let people in on the lie? Let them know that the little pill they're taking for, say, chronic back pain is actually a placebo, with no more medicine in it than an M&M?
How would that change things?
As it turns out, it changed just about everything. Though not in the way many would have guessed.
The fake pill that everyone knew was fake actually eased their pain. For real.
"The pill does nothing," says Kaptchuk, a professor at Harvard Medical School and the director of the Program in Placebo Studies and Therapeutic Encounter at the Beth Israel Deaconess Medical Center in Boston, "but it somehow or another tells the brain that the pain is being modulated in a way that the brain turns down the pain."
Harnessing the Placebo Effect
For years, researchers have played sneaky with placebos, often using them to determine the effectiveness of real drugs. It's standard operating procedure among the lab coat set: You give some of your subjects real medicine, you give others a placebo. You don't let either group know what's the good stuff and what's not. You measure the differences.
Outside the lab, doctors will give patients placebos, too, though the ethics of pulling a fast one on a patient are muddier. Still, for some people, the mere belief that they're taking real medicine is beneficial. That's the "placebo effect."
A few years ago, Kaptchuk and colleagues decided to take placebos "out of the trash bag of biomedicine" for a study on irritable bowel syndrome. They were upfront from the start, letting their subjects know placebos were being used. And the researchers found that, somehow, these so-called "open-label placebos" (OLPs) helped in some cases. Even though everyone knew they were fake pills.
The team's latest work advances the concept. It is the first study, the researchers write in the journal Pain, that shows "potential clinically significant benefits of OLP treatment ..." on subjects with chronic lower back pain, the most common cause of job-related disability in the U.S. The results of the randomized, controlled trial surprised everyone, including Kaptchuk.
Those who knowingly took a placebo with traditional treatment reported a huge improvement in pain over those who were going through the traditional treatment alone.
What the Study Found
Kaptchuk's colleagues at the Instituto Superior de Psicologia Aplicada in Lisbon, Portugal, studied 97 patients with chronic lower back pain. The researchers explained the placebo effect, then split the subjects into two groups; the treatment as usual group (TAU) and the OLP group.
For three weeks, both groups were allowed to continue taking pills they already were taking. (Some 88 percent were popping nonsteroidal anti-inflammatory drugs such as ibuprofen.) The OLP group added the placebo pills, too, knowing exactly what they were. Or weren't.
After the three weeks, the OLP group reported a 30 percent reduction in both regular lower back pain and maximum pain. The TAU group reported a 9 percent decrease in usual pain, and a 16 percent drop in max pain.
The OLP group also had a 29 percent improvement in pain-related disability. The TAU group: no improvement.
Some people respond positively to the idea of taking medicine, even when they know it's not medicine. They respond to going to a doctor, to following a doctor's orders, to talking with a nurse or sitting in a waiting room. To the routine of taking two pills a day with water.
For these patients, it's not just the pill. It's the pill as part of a larger, intricate health care solution that they trust will help ease their pain.
"I think our evidence is reasonable — it's certainly plausible — that this is not, 'You think you're going to get better and you get better,'" Kaptchuk says. "This is embodied cognition [a theory that suggests the brain is not the only source that generates how we feel or think or act]. It includes a warm doctor-patient relationship. It includes elements of trust, it includes elements of novelty. It includes elements of uncertainty. It's really the entire dynamic of the patient-clinician attraction that goes into that pill."
Kaptchuk says that out-in-the-open placebos won't always work. They won't be useful for something like controlling cancer or lowering cholesterol. They're more likely to be effective for conditions that the brain dictates, things like pain, hunger or fatigue. Even depression.
"If the brain can modulate the symptoms, then placebos can modulate the symptoms," Kaptchuk says. "People are put on medications when they go to a doctor, but there are certain situations — like chronic lower back pain, fatigue, whatever — where there's no underlying biology maybe.
"I think this OLP may have a value for watching weight. 'Hey, you want to try something interesting. Let's try to take a placebo for three weeks. See what happens. If it doesn't work, we'll put you on a drug. But there's a chance that it might work.' That's where I see the value of this stuff."