PLACEBO vs NOCEBO
Posted on October 6, 2020 - No Comments
When we choose allopathic medicine to treat a health issue, there are two things to keep in mind. First, the medical profession is the leading cause of death. It began when death from prescription drugs bypassed traffic fatalities, and now, when one adds up death from prescription medication, hospital and doctor error, and super bugs, the most dangerous thing you can do is walk into a hospital, doctor’s office, or pharmacy. (Source)
The second thing that we should be aware of is the power of the placebo.
I’m sure most of you know what the placebo effect is, but just to reiterate, here is the definition.
In a double-blind, placebo-controlled medical study (the gold standard), a control group is given an inert substance (usually a sugar pill), which gives researchers a baseline with which to compare the effectiveness of the new drug being tested. Subjects in such studies all believe they are getting the real drug, and surprisingly, a good portion of those given the placebo will have an improvement in their symptoms, a result of their belief in the potential power of the medicine they have been given.
The idea of the placebo can be portrayed as amusing, however when it has an effect of benefiting roughly one third of study participants, it is clearly something that deserves more attention. And, as I pointed out in a previous newsletter, the placebo effect is growing stronger.
Over the last two decades, clinical trials seem to be indicating that the placebo effect appears to be increasing in effectiveness. Recently, a study published in the journal Pain discovered that in 1990 pain-relieving drugs worked 27% better than placebo, but by 2013 that gap had narrowed to 9%. (Newsletter)
It is easy, and common, to dismiss the placebo effect as meaningless, something that only applies to the weak-minded or susceptible. That is a nearsighted approach. For one thing if antidepressants are only marginally better than placebo (Source), but have dangerous side effects which can include suicide (and even homicide), perhaps placebo should be examined more closely.
(From a study on the subject published in the British Medical Journal: “The following symptoms, anxiety, agitation, panic attacks, insomnia, irritability, hostility, aggressiveness, impulsivity, akathisia (psychomotor restlessness), hypomania, and mania, have been reported in adult and pediatric patients being treated with antidepressants.”) (Source)
I used to believe that homeopathy may only be based on the placebo effect, and if so, it could count on at least a third of users finding benefit. And, for the rest of the users at least no harm was done, (supposedly the primary tenet of medicine), unlike with actual drugs, which do as much harm as good. However, since discovering that homeopathy studies have shown that homeopathic metals (including arsenic, cadmium, and lead) can cause the body to excrete these heavy metals, I no longer suspect that the benefits of homeopathy are placebo in nature. (I have covered the subject in this newsletter.)
Before I leave the subject of the placebo, I have one last illustration of its powerful potential, an example that is hard to wrap one’s brain around. In this study knee surgery was compared to placebo surgery for the treatment of patients with “degenerative tear of the medial meniscus.”
The study concluded: “In this 2-year follow-up of patients without knee osteoarthritis but with symptoms of a degenerative medial meniscus tear, the outcomes after APM (arthroscopic partial meniscectomy) were no better than those after placebo surgery.” (Study)
And this one regarding osteoporosis.
“A total of 180 patients with osteoarthritis of the knee were randomly assigned to receive arthroscopic debridement, arthroscopic lavage, or placebo surgery. Patients in the placebo group received skin incisions and underwent a simulated debridement without insertion of the arthroscope.” Patients were followed up with for two years.
Conclusion: “In this controlled trial involving patients with osteoarthritis of the knee, the outcomes after arthroscopic lavage or arthroscopic debridement were no better than those after a placebo procedure. (Source)
That is a fascinating concept, but my point is that perhaps our belief in the superiority of Western medicine is more reliant on the belief than the actual form of medicine used. Now let’s look at placebo’s evil twin.
While the placebo effect is well known and well studied, there is another side to that coin, one far less understood, and that is nocebo.
The nocebo effect is simply the opposite of the placebo effect, whereby those taking the sugar pill, instead of having an improvement in symptoms, have negative side effects. In theory, this response is due to their belief that they are getting a real drug, having also been informed at the outset of the study of the pill’s potential side effects.
As with the placebo effect, scientists currently think that the nocebo effect is a result of the “combination of Pavlovian conditioning and a reaction to expectations”.
In 2001, German researchers published a review of the few (31) studies done on the nocebo effect. They set out to examine both the biological mechanisms involved and the problems this effect can have on medical research, and in clinical practices. They concluded that, though not well understood, the nocebo effect nonetheless was not uncommon, and should be taken into account by all levels of medical professionals.
This is what they had to say in summary: “On one hand physicians are obliged to inform the patient about the possible adverse events of a proposed treatment so that he/she can make an informed decision. On the other, it is the physician’s duty to minimize the risks of a medical intervention for the patient, including those entailed by the briefing. However, the studies just cited show that the patient briefing can induce nocebo responses.”
They then went on to suggest some strategies that could be used by medical professionals to mitigate the potential damage that the nocebo effect could cause in susceptible patients. (Study)
Now I’ll take a brief look at some of the studies they examined, just to give us a better idea of how this effect manifests.
In many of the experiments studied in this overview, informing the patients of the potential for pain (some of these were procedures, not just drugs) resulted in statistically significant increases in pain-related side effects among participants.
In one study, 50 subjects suffering from chronic back pain were given a flexibility test, half of the participants being told the test may result in some pain, while half of the group were not given this warning. As you may suspect, the group given the pain warning experienced significantly higher levels of pain than the unwarned group. (Study)
In another study, finasteride was given as a treatment for benign prostatic hyperplasia (BPH), with half the subjects being told it could cause erectile dysfunction (ED), and the other half not receiving this warning. Fifteen percent of the uninformed subjects experienced ED, as compared to the informed group among whom 44% reported experiencing ED. (Study)
Okay, we all know that sexuality is easily influenced by psychology, but can belief be potentially deadly? One case certainly suggests that to be true.
A young man was taking antidepressants, and when his girlfriend left him he bottomed out, ingesting most of the bottle of pills in an attempt to commit suicide. After doing so he immediately regretted it, and sought medical help. In the hospital he was seriously ill, unable to breathe properly, he experienced hypotension requiring intravenous fluids to maintain an adequate blood pressure, and was virtually near death.
In attempting to define the drug the young man had overdosed on, the doctors discovered that he was part of a study on a new antidepressant, and in fact this fellow was one of those receiving the placebo.
Because his mood had improved, due ironically to the placebo effect, he was convinced that he was receiving the real medication. Thus, when he “overdosed” on what he believed was a real drug, the placebo effect turned into the nocebo effect. However, “once the true nature of the capsules was revealed his adverse symptoms then rapidly abated”. (Study)
The Role Doctors Play
Researchers into the subject of nocebo are suggesting that it is time for doctors to reevaluate the conventional medical beliefs about pain management. For example, doctors currently believe that they are minimizing anxiety by preparing the patient for the worst. So, they might say something to the effect of, “this is going to hurt quite a bit”.
Yet, one study showed that the words used by a doctor before injections affected the amount of pain the patient experienced. “The more frequently the words “sting,” “burn,” “hurt,” “bad” and “pain” were said, the more discomfort felt by patients.” (Source)
In a group of patients receiving treatment for back pain, a stretch test was administered. If the doctors giving the test suggested that it might hurt, patients were more likely to report pain, however if they said nothing about potential pain, the majority of patients reported no pain.
Unfortunately, some doctors consider changing the focus on the negatives to positives, to be at odds with properly informing the patient about procedures, and potential dangers or discomforts that may ensue (“informed consent”).They consider this an “ethical dilemma”: much better to tell the patient they have six months to live, or never will walk again. (And I have met many people who have been told such discouraging things, only to defy such predictions.)
But, the fact of the matter is belief, at the very least, influences the immune system, and giving patients a positive framework to work from, along with hope, are in and of themselves, of healing benefit.
The authors of this study on words used by doctors, suggested that doctors “emphasize positives (re-framing warnings into phrases such as “the majority of patients tolerate this well”) and, in some cases, actually getting permission from patients to keep them in the dark about certain mild side effects”. (Source)
The nocebo effect clearly has the potential to be seriously dangerous, as with the young man referred to above, who almost died from it. And he is not the only example.
Patients who enter into surgery expecting they might die, are more likely to have serious complications, and delayed recovery. In one particular case a man with a tumor was told that it had metastasized and that he only had so many months to live, and he indeed died within that time line. However, his autopsy revealed that the tumor on his liver had not in fact metastasized, so he was in no danger, thus there was no real reason that he died. (Source)
There are few experiments on the nocebo effect as doctors would consider it unethical to try and create an illness in a patient. However, there is a study that has determined the nocebo effect follows a specific pathway in the brain, and it is possible to biochemically block that pathway.
Cholecystokinin (cck) is a hormone found in both the gut and the brain. In the gut cck, and its variants, regulate the release of bile, along with other digestive enzymes. In the brain, however, two variants of cholecystokinin (cck-a and cck-b), when activated, bind to receptors that reduce the amount of dopamine in the brain. This, in turn, increases levels of depression and anxiety in individuals, which makes us aware of pain, and helps us to focus on it (which is an evolutionary survival mechanism).
Happiness and relaxation, on the other hand, reduce pain levels. So, when patients were injected with something that blocked the cck receptors (benzodiazepine diazepam), allowing the dopamine to rise, the nocebo effect lessened, and patients had better outcomes, with less sensations of pain. (Study)
This leads me to think that taking dopamine precursors prior to medical events might help reduce the pain response. (Dopamine precursors include, acetyl-L-carnitine, L-tyrosine, avena sativa, and mucuna pruriens.)
“Bone pointing” is a method of execution used by the Aborigines of Australia, and is highly effective to this day. So much so that Australian medical staff are often trained to deal with illnesses caused by bone pointing. The bone used in this curse may be made from emu, kangaroo, or human bones (or sometimes even just wood).
This form of ritual which causes death is not unique to the Aborigines, but has been found to occur around the world.
“Victims become listless and apathetic, usually refusing food or water with death often occurring within days of being “cursed”. When victims survive, it is assumed that the ritual was faulty in its execution. The phenomenon is recognized as psychosomatic in that death is caused by an emotional response—often fear—to some suggested outside force and is known as “voodoo death”. As this term refers to a specific religion, the medical establishment has suggested that “self-willed death”, or “bone-pointing syndrome” is more appropriate.” (Source)
Perhaps we are not as modern as we like to believe. According to Ronald Wright, in “A Short History of Progress”, “…we are running twenty-first-century software on hardware last upgraded 50,000 years ago or more. This may explain quite a lot of what we see in the news”.
And, when we consider the outcome of placebo knee surgery, perhaps medicine is not the scientific marvel that we have been led to believe it is. (See my newsletter on Dr. Robert Mendleson, and how medicine is the new religion. Also this article, “Altars and Icons – The Surgical Suite as a Sacred Ritual”, which opens with: “The surgeon as priest, shaman, or healer performs sacred rituals every time he or she steps into the operating room.”)
So, perhaps we have more healing potential within us than outside of us, and we need to learn to participate in our own healing, rather than totally depending on others to take care of us.