Taking a break from my monthly blog post about the fantastic Natural History Museum, I have decided to discuss one of my favourite and perhaps more controversial biological topics – the placebo effect. I am a massive fan of mental strength over physical prowess (I’m not the most athletic shall we say, so it works for me) and the placebo effect demonstrates just how strong the human mind can be. As perhaps one of the more complex of all of our organs, I’m going to talk about the brain and its role in numbing pain, reducing physical symptoms, and sometimes even curing disease.
This is one of the more obvious uses of placebos, as everyone has heard of someone withstanding cutting off a limb without anaesthesia in order to save their life; there has even been a film in which a man becomes trapped for 127 hours, only being released after cutting off his own hand. However, the more interesting side to this story is how we could potentially harness this effect in order to treat those with addictions to painkillers.
The statistics are shocking, with nearly 7,000 visits to A&E and 44 deaths each day caused by prescription painkiller addictions in America in a single year. Pain clinics and monitoring prescription patterns are struggling to reduce this, so what if a solution could be found in a more unconventional place? Prescription painkillers have been put to the test, and some studies have shown that they do not work as well in bland, non-branded packaging , and also that their effects are reduced when the patient is unaware that they are taking them . Additionally, the placebo effect can also have the opposite outcome – where no drugs are administered, placebo painkillers have been seen to affect the pain-related areas of the brain, and even stimulate the release of endorphins (which are pain relieving chemicals that the body produces).
Expectations play a great role in this effect. This is where ‘mind over matter’ plays a more prominent role. During a study, three groups of patients were given a placebo. One group had no expectation of analgesia (pain relief), another group had a positive expectation of analgesia, and the third had a negative expectation of analgesia (in the sense that they expected the pain to worsen). When the patients were asked to rate their pain, the patients expecting a positive result experienced twice the analgesic effect than the patients with no expectation of pain relief. Also, the patients expecting a negative result experienced no pain relief at all . And this leads me quite nicely onto my next point for discussion.
Placebos rely quite heavily on the art of pomp and ceremony, and this is quite clear to see when the placebo ‘form’ is examined in more detail.
As aforementioned, the packaging of a placebo makes a huge difference in the level of expectation and therefore the experience of the enclosed pill. On reading “Bad Science” by Ben Goldacre, I was interested (but perhaps not surprised) to read that patients responded better to placebos found in bright and flashy, branded packaging as opposed to bland, neutral boxes. An even greater effect was seen when patients were given aspirin in differing packaging.
However, external packaging is not all that matters when packaging a placebo. The colour of the pill itself has been found to play a role in this ever so fascinating and developing effect. For a drug called Oxazepam, its effects differed when the tablets were differently coloured. In a green tablet form it was better at treating anxiety, whereas the same drug was found to be more beneficial at treating depression when yellow. Colours have been assigned meanings by society, and these societal norms are influencing the way we perceive the world. Blue for sedatives, pink for stimulants. This was seen to be the case when a group of college students were given a placebo, told to be either a sedative or a stimulant. Those given pink pills experienced higher maintained concentration levels than those given blue pills. Two pills were also observed to have a greater effect than one (side effects included) .
This explains the pomp, but what about the ceremony? Well, again, this relates back to what we perceive to be ‘more effective’. The best example of this is the vaccine. In three separate experiments, pills have been out done by the salt-water injection. Not because sugar pills have any less of a biological effect than salt-water, but purely because it was seen as a more dramatic treatment. Much the same was seen when a sugar pill was put up against an acupuncture style ‘ritual’ treatment . Ceremony wins.
This is perhaps the more controversial side of any placebo discussion. Is it ethical to supply a patient in pain, or with a disease, a placebo knowing that it has no active ingredient to treat the ailment? The answer is no. At least if you don’t discuss it with them first.
In a recent meeting of the school’s vets and medics society, we discussed in some detail the ethics behind full disclosure and some scenarios in which it was difficult, from an ethical stand point, to determine what exactly was the best way and thing to tell your patient. I was very much on Team Full Disclosure and my opinion hasn’t changed. When it comes to a patient’s health, they have a right to know exactly what is going on, which is why my whole viewpoint on the placebo effect changed when I discovered this next fact.
The placebo effect will have a very limited real life application if the patient must remain in the dark about the contents of the mysterious looking pill sat in front of them in order to feel its effects. It’s unethical. However, the placebo does not just work because the brain is tricked into thinking it has received a drug. Patients have been fully aware that they are taking a placebo and have still experienced the same effects as if they had been unaware. In a study, 80 patients suffering from irritable bowel syndrome (IBS) were split into two groups. One group was given no treatment, and the other given a placebo. The placebo group were told that they were being given a placebo, and that meant that all the pills would contain was sugar. To avoid confusion, ‘placebo’ was even printed on the bottle. Defying all expectation, the placebo group doubled the average rate of improvement to that expected from the most powerful IBS medications . Presumably, this has something to do with the ritual of taking a pill, whether it contains medication or not, and the mind being deceived by the mere action. However, the sheer size of the effect experienced was somewhat incredible.
The placebo effect is a wonderful demonstration of the power of the human mind, which I have always been deeply fascinated by. The social perceptions of colour and packaging, along with the ritualistic ceremony linked to how our brains not only receive medicine but also see the world is brilliantly clever, but also a little terrifying – perhaps the role of society in our lives is not as small as we once thought! I hope you have found this little insight into the placebo effect as interesting as I have, and I hope you now realise how truly amazing your brain is.
 MARCHANT, J. (2016) A Placebo Treatment for Pain. [Online] Available from: https://www.nytimes.com/2016/01/10/opinion/sunday/a-placebo-treatment-for-pain.html?_r=0 [Accessed: 30th January 2017]
 GOLDACRE, B. (2010) Bad Science. 1st ed. New York: Faber and Faber.
 NOVELLA, S. (2011) Placebo Effect for Pain. [Online] Available from: https://sciencebasedmedicine.org/placebo-effect-for-pain/ [Accessed: 30th January 2017]
 JHA, A. (2010) Placebo effect works even if patients know they’re getting a sham drug. [Online] Available from: https://www.theguardian.com/science/2010/dec/22/placebo-effect-patients-sham-drug [Accessed: 30th January 2017]