Placebo effect: NPR

SHOW: MORNING EDITION (10:00 AM ET)

June 29, 1999, Tuesday

LENGTH: 1436 words

HEADLINE: HISTORY OF PLACEBO DRUGS AND WHAT IS KNOWN AS THE PLACEBO EFFECT

ANCHORS: BOB EDWARDS

REPORTERS: ALISON RICHARDS

BODY: BOB EDWARDS, host:

This is NPR's MORNING EDITION. I'm Bob Edwards.

Placebos have been called bogus treatments, frauds from the doctor's black bag. They've been given topatients mainly to test whether a new medicine works. In a clinical trial, an active treatment is compared with acontrol group which receives a seemingly identical sugar pill. But often the control group does not provide areal baseline. Doctors realize that some of the patients receiving sugar pills will do as well as those who get theexperimental drug. For years, this has been dismissed as the placebo effect. In the first of two reports, AlisonRichards explores the placebo's history.

ALISON RICHARDS reporting:

Outside of clinical trials, doctors don't think much about the placebo effect. So it often takes them by surprise.

Professor DAN MOERMON (University of Michigan): Every once in a while, about every couple of years, you'llfind an article by some doctor who says, Gosh, the placebo effect, it's huge. I mean, this probably accounts forhalf of the effectiveness that I have as a physician.' And when he says that, he's probably right.

RICHARDS: Dan Moermon, who studies medical anthropology, is a professor at the University of Michigan.

Prof. MOERMON: We should look more closely at this.' And he's right. They should. That same article seems toget rewritten time and time and time again and nobody ever does anything about it.

RICHARDS: For centuries, doctors used placebos, which in Latin means I will please,' as a harmless tool tocomfort the dissatisfied, the incurable, the hypochondriac and the hopeless. These practitioners have no inklingthat their sugar pills and vials of colored water did anything more than give patients and doctors some peace. Itwas not until after the Second World War that researchers started using placebos in controlled clinical trials.And suddenly, a genie jumped out of the bottle. Ted Kaptchuk is an associate professor at Harvard MedicalSchool.

Professor TED KAPTCHUK (Harvard Medical School): In the effort to scientifically prove the efficacy of amedical intervention, what came out was the fact that a bogus treatment, a treatment that is innocuous and notsupposed to have an effect produces an effect. It's a conundrum that modern medicine has found itself in.

RICHARDS: The placebo shifted from being an insipid decoy to a powerful mischief maker that could trickdoctors and confuse clinical trials. It might appear some of the time, none of the time or all of the time, though itaverages out that about a third of patients respond. Doctors were mainly concerned with the implications of thisfor clinical trials. The whole question of how a bogus medicine could make people well,' Kaptchuk says, wasconveniently ignored.'

Prof. KAPTCHUK: Ultimately, the placebo effect threatens the self identity and the self definition of scientificmedicine in the sense that science wants to show the cause and effect relationship between a specificintervention and a specific outcome. And what happens is that the placebo effect demonstrates that thingsoccur that aren't difficult to quantify, difficult to predict and are based on hopes, emotions, dreams, memories.And those are things that are difficult for science to sort of feel comfortable with.

RICHARDS: By this time, too, the post-war concept of informed consent had made doctors uneasy with thewhole idea of innocuous treatments masquerading as medicine. With results that the research that has beendone on the placebo effect, and there's not a great deal, is the work of people like Dan Moermon, who's ananthropologist, not a doctor. What gives a placebo its power,' he says, is not what it's made of but what itmeans.' In modern Western culture, for example, being given a pill taps into some of our earliest and mostpowerful memories.

Prof. MOERMON: From the first time your mother takes you as a squalling infant who has some sort of littlecold and gives you a--when I was a kid it was baby aspirin. I guess we don't do aspirin anymore for babies. Butwhatever the equivalent is, and then gave me that little orange pill and held me to her breast and calmed medown and I calmed down. And I learned that little orange pills are calming.

RICHARDS: And take the pain away. Because the effect of a placebo depends on its association, it variesfrom culture to culture. It could just as well be a song or a feather. One of the studies that Moermon undertookwas to compare a series of clinical trials that had been conducted at different parts of the world. Everythingabout this set of trials was identical. The patients all had gastric ulcers and met the same criteria. They allreceived either the same experimental drug or took an inert pill that looked the same. But when researchersexamined the patients' ulcers a month later, they found that the response rate in those taking placebo pillsvaried dramatically between countries.

Prof. MOERMON: If you look at a place like Germany, it turns out that in the controlled trials in Germany, about65 percent of the patients who received the inert drugs are better after four weeks. And on the other end of thescale, if you look at a place like Brazil, what you discover is that it's only 6 percent or 7 percent of the patientsare better after four weeks.

RICHARDS: Moermon admits he doesn't know what the cultural differences are that account for thesevariations, only that they clearly exist. And this opens up the tantalizing possibility that learning more about themmay suggest ways that doctors can harness their power. But there is more to the workings of the placebo effectthan the fake pill by itself. There's the drama and ritual of the medical encounter and the relationship betweenpatient and physician. One of the questions researchers asked is whether a particular type of patient is morelikely to respond to placebos. But despite several hundreds studies, there's no real evidence that a patients'personality or attitude has much to do with it. When it comes to the attitude of the physician, though, thepicture's rather different. Dan Moermon.

Prof. MOERMON: One of the things that's been shown in studies in the United States, at any rate, is thatphysician enthusiasm is a significant predictor of placebo effect. That is, if you give a group of patients thesame inert drug with a kind of non-enthusiastic physician, it won't work as well as the same placebo to thesame kind of people with a physician who's very enthusiastic about this marvelous new drug that's going to bethe cure-all of whatever the problem is.

RICHARDS: But whether it's triggered by pills, feathers or cheerful doctors, the placebo effect seems to betapping into something at the biological level. Some of the most dramatic demonstrations of this are in studiesof pain. Fake pain medication, whether it's a pill or an injection, rarely can prevent a patient feeling the dentist'sdrill or the surgeon's knife.

Steven Hyman is a psychiatrist and head of the National Institute of Mental Health. It's been known for a longtime,' he says, that the brain has a way of protecting us from pain under certain circumstances,' on thebattlefield, for example.

Dr. STEVEN HYMAN (National Institute of Mental Health): One thought is that the placebo response to painmedications may actually tap into this real neurobiological pathway that we have in our brains to suppress painand might activate it so that the placebo response is not imagined, but actually represents a realneurobiological mechanism.

RICHARDS: If there's a real mechanism at work here,' Hyman says, there's a good chance we can learn aboutother brain processes and how they relate to the placebo response.'

Dr. HYMAN: I'd be very interested to know the precise pathways in the brain that are involved in moodregulation, just as we're interested in the precise pathways in the brain that control pain perception and we'dlike to know how these can be manipulated not only pharmacologically, but also by specific psychotherapiesand also be impacted by the doctor-patient relationship.

RICHARDS: In the end, though, the bottom line may be money. Anthropologist Dan Moermon doesn't thinkmany people will find the placebo effect an attractive research proposition.

Prof. MOERMON: The problem is that once I've done all of that research and spent millions of dollars, I can'tpatent a natural product. And as a result, it's hard to know how anybody could profit from studying this extremelypowerful human process.

RICHARDS: He's convinced, though, that such research would be extremely useful. Psychiatrist Steven Hyman

agrees. Unraveling the secrets of a treatment that costs little, can't harm you, and has a one-in-three chance ofsuccess, has to benefit patients. From where Hyman sits at the NIMH, that's the real bottom line.

Prof. MOERMON: It happens that I direct a federal agency that pays for research and what I would say is thatthis is a very important area because we have to be interested in anything that will enhance the likelihood thatpeople will get well and stay well.

RICHARDS: I think I'm feeling better already. For NPR News, this is Alison Richards in Washington.

EDWARDS: Tomorrow, how the placebo effect works in alternative medicine.

It's 11 minutes before the hour.

LANGUAGE: English

LOAD-DATE: June 29, 1999

SHOW: MORNING EDITION (10:00 AM ET)

June 30, 1999, Wednesday

LENGTH: 1261 words

HEADLINE: USING THE PLACEBO EFFECT IN ALERNATIVE MEDICINE

ANCHORS: BOB EDWARDS

REPORTERS: REBECCA PERL

BODY: BOB EDWARDS, host:

This is NPR's MORNING EDITION. I'm Bob Edwards. Imagine you have a chronic health problem, like a badknee. That despite surgery and physical therapy and drugs, it still bothers you. Now imagine if someone tellsyou he can treat you with a pill that contains nothing more than sugar and that the treatment has no side effectsand that it has a fairly good chance of working. That treatment is known as the placebo effect. In part two of aseries on placebos, Rebecca Perl reports on the role of the placebo effect in alternative medicine.

REBECCA PERL reporting:

The placebo effect occurs when someone gets relief from an illness or health problem with an inert substance.It can also happen as a result of an interaction with a health-care provider. Placebo responses show up about30 percent of the time. Some chalk it up to the power of the medical encounter, the idea that someone is goingto help you get well. But it's hard to sort out because many illnesses naturally wax and wane. When doctors aretrying to find out whether a particular treatment works, all these factors can confuse the issue. Irving Kirsch is apsychologist at the University of Connecticut who studies the placebo effect.

Dr. IRVING KIRSCH (University of Connecticut): For years and years and years it has been treated as justnoise, as trash. Now we're finding out that it's not just trash, it's really treasure. It's something to be mined,something to be understood, something to be made use of.

PERL: One of the few physicians who has no qualms about using the placebo effect is David Reilly. Reillydirects a small, publicly funded hospital in Glasgow, Scotland, that combines orthodox medicine withalternative treatments. He says throughout history, when it comes to healing people, there are always twoelements at play.

Dr. DAVID REILLY: There's what you might call the tools in the toolbox, the particular therapy which is beingimplied. Perhaps it's a drug or a surgical technique or an acupuncture needle or homeopathic medicine,Harrappan, so on. And there's then what's often called, in the jargon, the non-specific aspects ofcare--everything else. And I think the research is emerging that often it's the everything else that's sometimesthe greater factor. The aspect of one human being sitting down with another, of them sharing intention to bringabout positive change and of listening and compassion. And sometimes if that variable's right, if that element'sright, it's sufficient unto itself.

PERL: The importance of non-specific aspects of care like time and attention is something alternativemedicine practitioners seem much more willing to acknowledge than traditional doctors. For instance, saysReilly, take the treatment of asthma. He says doctors are deluding themselves thinking that the disease cansimply be treated by following a medical protocol out of a book, that it doesn't matter who administers it.

Dr. REILLY: The consequence of that, we are thinking, is that patients may see a different doctor at each visit,they may be rushed, they may be stressed and they may be lacking understanding. But we've got ourself into afantasy in the scientific sense that that doesn't matter too much, just so long as we've made the right diagnosisand prescribed the right treatment. And yet we now understand that states of fear or tension unresolved in aconflict, for example, can actually help bring on asthma or worsen asthma.

PERL: On the other hand, an experiment that is soothing and supportive may help, and this type of environmentis often part of the stock and trade of alternative practitioners. Peter Martin practices homeopathy inWashington, DC. Homeopaths treat with herbs and minerals that are so highly diluted that nothing remains inthe remedy they offer except what they contend is the memory of the substance. On a recent evening, Martin isexplaining to one of his patients how he chooses the right remedy for her. He looks for subtle changes as hebrings vials of homeopathic medicines within close range of her body.

Dr. PETER MARTIN: All right. So what I'm doing, I'm looking at your pulse like I always do. And I'm looking atthe different homeopathic medicines to see what is the most appropriate, because no matter what therepertory says, it could be wrong, I could be wrong. But you're never wrong, because it's your pulse and yoursymptoms.

PERL: The walls of Martin's small office are a rich cream color; roses arranged here and a single orchid there.With new patients, Martin routinely spends an hour and a half asking questions and listening; much more timethan the average doctor offers patients. Even with a young woman he's been seeing for a year, they speak fornearly an hour. And though she comes to him because she has digestive problems, allergies and asthma, theyspeak about a range of issues.

Dr. MARTIN: Where you live is very important for any person, and that can add up to your whole health picture.How are you doing with finding a site to live?

Unidentified Woman: Terribly.

Dr. MARTIN: You're not happy.

Woman: It's a disaster, seriously.

PERL: Though this woman says all of her symptoms have, to some degree, improved under Martin's care,skeptics of alternative medical treatments insist there's no real science or medicine at work here, that ifhomeopathy helps patients at all, it does so by a placebo effect. Physician David Reilly, trained in homeopathy,doesn't object.

Dr. REILLY: I think critics of complementary medicine who say, for example, that it's due to time andtherapeutic relationship--my answer to them is you're absolutely right. And is it not wonderful if the research andexperience is telling us that better time and better therapeutic relationship can lead to less drugs prescribed,less side effects, better customer satisfaction and better relief of stress?

PERL: Connecticut psychologist Irving Kirsch also believes in harnessing the power of the mind. But, he says,rather than waste time trying alternative methods that might work but are largely unproven, he favors treatmentsthat have been put to the test scientifically.

Dr. KIRSCH: I would like to see people making use of the research findings. When we know that we have aparticular psychological treatment that's targeted to a particular problem, such as short-term psychotherapy fordepression or hypnotic interventions for pain, then we should make use of those.

PERL: Experts who study the placebo effect say even if health-care practitioners don't like to admit it, all ofthem make use of the placebo effect. For orthodox medicine, it's the power of the white coat and theprescription pad; for alternative practitioners, it's the acupuncture needles and the smell of burning herbs.

Walter Brown is a clinical professor of psychiatry who studies the placebo effect at Brown University. He sayspatients are pretty smart about the kind of problems they bring to alternative practitioners.

Professor WALTER BROWN (Brown University): Most people don't go to alternative medicine practitionerswith bacterial infections or traumatic injuries or diabetes. They go with chronic, moderate or mildly severeproblems, including chronic pain, headaches, anxiety, depression, arthritis and so forth. And these areconditions which tend to fluctuate in the normal course of the illness, which--in which distress plays a large roleand which are highly placebo responsive.

PERL: But most alternative practitioners, homeopaths, acupuncturists and the like, will tell you that the resultsthey're getting aren't due to a placebo effect but to the actual treatments they use. This is hard to sort out, asmost of these therapies still haven't been well-studied. Psychiatrist Walter Brown has a theory.

Prof. BROWN: When all is said and done, the overwhelming majority of alternative medicine treatments aregoing to be shown to derive the benefit from the placebo effect, just has been the case with the overwhelmingmajority of conventional medical treatments used throughout history.

PERL: In fact, up until World War II, the vast majority of what doctors had to offer worked by a placebo effect.Dummy pills and kind assurances had to be a large part of their arsenal. Today, some complain that busydoctors rely on drugs and modern technology to the exclusion of the healing arts. So even if a time-presseddoctor can diagnose a case of bronchitis in a matter of minutes, patients report greater satisfaction if they geta little more time. Perhaps the lesson alternative medicine brings is a reminder that there's no replacement forbedside manner. Rebecca Perl, NPR News, Washington.

EDWARDS: It's 11 minutes before the hour.

LANGUAGE: English

LOAD-DATE: June 30, 1999