1. Placebo & PainPlacebo & Pain

2. PLACEBOPLACEBO
1414thth
century latin translation error (“I shallcentury latin translation error (“I shall
please” instead of “I shall walk”) that becameplease” instead of “I shall walk”) that became
a vesper sung to deada vesper sung to dead
FREAKY!!!!!FREAKY!!!!!

3. PLACEBOPLACEBO
 EFFECTEFFECT
Intervention designed toIntervention designed to
simulate medicalsimulate medical
therapytherapy
 RESPONSERESPONSE
Change in patient’sChange in patient’s
behavior or conditionbehavior or condition
after placeboafter placebo

4. Factors that influence patientsFactors that influence patients
outcomesoutcomes
 1. specific treatment effects1. specific treatment effects
 2. natural history and regression to mean2. natural history and regression to mean
 3. nonspecific treatment (placebo)3. nonspecific treatment (placebo)

5. Response ratesResponse rates
 Tens of studies – 5-55% successTens of studies – 5-55% success
 AsthmaAsthma
 Peptic ulcerPeptic ulcer
 Angina pectorisAngina pectoris
 Postoperative painPostoperative pain
 Low back painLow back pain

6. Nonspecific effects of surgeryNonspecific effects of surgery
 1950’s studies in cardiac surgery for1950’s studies in cardiac surgery for
angina pectoris (internal mammary aretryangina pectoris (internal mammary aretry
ligation vs. skin incision) – 63% vs. 58%ligation vs. skin incision) – 63% vs. 58%
curedcured
 1960’s spine surgery (diskectomies) in1960’s spine surgery (diskectomies) in
2504 pts. Surg. intervention vs. simple2504 pts. Surg. intervention vs. simple
exploration 43% vs. 37% curesexploration 43% vs. 37% cures

7. Placebo responsesPlacebo responses
 Characteristics:Characteristics:
1.1. Correlate to actual medical Rx in terms ofCorrelate to actual medical Rx in terms of
duration, peak effectduration, peak effect
2.2. Side effects: drowsiness, nausea, headaches,Side effects: drowsiness, nausea, headaches,
nervousness, insomnianervousness, insomnia
3.3. Duration of response vary from days to weeksDuration of response vary from days to weeks
to months depend. Upon characteristics of Rx,to months depend. Upon characteristics of Rx,
duration, conditions, pts characteristics (highlyduration, conditions, pts characteristics (highly
unpredictable)unpredictable)

8. Nocebo EffectNocebo Effect
 ““Causation of sickness or death byCausation of sickness or death by
expectation of sickness and death throughexpectation of sickness and death through
various emotional states”various emotional states”
 Headaches suggested by practitionerHeadaches suggested by practitioner
 Tests that are not performed e.g. notTests that are not performed e.g. not
performing MRI for back pain closelyperforming MRI for back pain closely
related to increase in painrelated to increase in pain

9. Patient FactorsPatient Factors
 1. Positive attitudes towards provider,1. Positive attitudes towards provider,
treatmenttreatment
 2. Anxiety (the higher the better)2. Anxiety (the higher the better)
 3. Expectations of effects (coffee effect,3. Expectations of effects (coffee effect,
voodoo death, seizure patches)voodoo death, seizure patches)
 4. Treatment adherence4. Treatment adherence
 and NOT gender, race, education, socialand NOT gender, race, education, social
factors!!factors!!

10. Provider factorsProvider factors
 1. warmth, friendliness, interest,1. warmth, friendliness, interest,
sympathy, empathy, positive attitudesympathy, empathy, positive attitude
 2. prestige2. prestige
 Expectations of treatment effectivenessExpectations of treatment effectiveness

11. How is it possible?How is it possible?
 1. Decreased anxiety1. Decreased anxiety
 2. Learning2. Learning
 3. Expectations3. Expectations
 4. Endorphins4. Endorphins

12. AnxietyAnxiety
 Placebo shown to work for anticipatoryPlacebo shown to work for anticipatory
anxietyanxiety
 Evidence that placebo works best forEvidence that placebo works best for
patients highly anxiouspatients highly anxious

13. LearningLearning
 Treatment can have a positive effects dueTreatment can have a positive effects due
to association with previous similarto association with previous similar
positive treatmentspositive treatments
 WE ARE PLACEBOS!!! (white coat,WE ARE PLACEBOS!!! (white coat,
syringes, sight of meds. and scripts, etc.)syringes, sight of meds. and scripts, etc.)
 Toothache gone at the dentist office!Toothache gone at the dentist office!

14. ExpectationsExpectations
 Closely linked to a conditioningClosely linked to a conditioning
mechanismmechanism
 High expectation lead to high placeboHigh expectation lead to high placebo
responseresponse
 Ex: attending vs. fellow performingEx: attending vs. fellow performing
procedureprocedure

15. EndorphinsEndorphins
 Associated with placeboAssociated with placebo
 Naloxone administration in one studyNaloxone administration in one study
decreased the pain response to placebodecreased the pain response to placebo

16. Clinical implicationsClinical implications
 Convey warmth, interest and concernConvey warmth, interest and concern
 Convey “realistic optimism” about RxConvey “realistic optimism” about Rx
 Display diplomas, board certificationsDisplay diplomas, board certifications
 Convey confidence not arroganceConvey confidence not arrogance
 Address patients worries and goalsAddress patients worries and goals
 Let them know that you reviewed theirLet them know that you reviewed their
casecase
 Provide a dg. and realistic prognosisProvide a dg. and realistic prognosis

17. CONCLUSIONSCONCLUSIONS
Is it truth or bogus?Is it truth or bogus?