Do we get what we pay for?
The nights in the burn department were always difficult, and many of the patients would regularly ask (beg) for more painkillers to help them fall sleep. One afternoon I overheard the doctors tell the nurses not to give a certain patient any more morphine. A few hours later, when the same patient started begging for painkillers I saw the nurse go to her room with an injection and a few seconds later the patient quietly went to sleep. When the nurse stopped by my room, I asked her about it and with a smile she told me that she had given the patient IV fluid.This was the first time I experienced (secondhand) the power of placebo. I am not sure if they ever treated me with the same method, but it is certainly possible.Years later I became even more impressed with placebos when I learned that a placebo for pain has a very clear physiology. When we expect to get pain relief, our brain secretes a substance that is very much like morphine and this substance makes the pain go away. This means that even if the injection contains no painkiller we can still get pain relief courtesy of our own brain.Yesterday we published a study in The Journal of the American Medical Association about placebos. In this study we showed that when people get more expensive painkillers (placebos in our case) they expect a lot and get a lot of pain relief, but when the price of these pills is discounted, the expectations are lowered and so is their efficacy. As it turns out, with painkillers, we sometimes get what we pay for.For a story in the NYT see this link
Very similar to the recent study about the perception of wine quality, based on Price. Here is the link: http://mr.caltech.edu/media/Press_Releases/PR13091.html
I’m wondering about the effects of expectation, if any, on medical research not involving human subjects. If mice are given a placebo by lab technicians who believe they’re giving a drug, do the mice respond as if given the drug? Or, if the mice show no improvement with a placebo, might the lab technicians thinking they’d administered a real drug perceive improvement?
This brings to mind the issue of expensive cables in the audiophile world. People will spend thousands of dollars on speaker cables though the benefits are not at all obvious or universally recognized. I’d be interested in hearing Dan’s thoughts on this issue, and I’d be even more interested if he were to do some research in this area.
I have not seen the paper yet, but a brilliant study – and it must have been a pain to get it through the IRB. While some may think that this justifies overpriced drugs (“that’s why they work better!”), I hope most will realize that it actually diminishes the the role of medicines, at least for pain. It makes it even more clear why we should not believe every tale told by the pharmaceutical industry about the effectiveness of their drugs. If they only work marginally better than placebo, or another, cheaper pill, what does that tell us? That’s why studies have to be double blind – and if they are not, patient and doctor, beware!
Expectations – the larger issue of the entire Placebo effect. Hence, if you think your doctor is fantastic and (infalliable) you will believe anything and everything (s)he tells you (that you can understand).
Unfortunately, due to the difficulties in studying these effects within the brain (all those wonderful circuits to excite, inhibit, disinhibit, etc) it’s even more difficult to “prove” scientifically this effect. And, until this is reproducible, it will be difficult to ethically incorporate this into allopathic medical practice.
This is also one of the reasons we have such difficulties with “drug seekers” too – their expectations of only, say Demerol or Oxycontin (or even Vicodin)as effective for their “pain” (psychic or “physical”). Yet, if we try to “sell” another med, we are termed “unethical.” Sometimes, we can use the generic name (which is so much more polysyllabic) to have the desired effect.
But this is also the reason that some physicians are more “effective” than others – the confidence that their patients have in them, either from prior reputation (that information before the history/physical), or that “bedside manner” that convinces the patient of the “quality” issue
I’ve read that the placebo effect doesn’t work in young children since they haven’t learned it yet.