1. Placebos from St Jerome to functional MRI or c an we double our gas mileage if we wished for it hard enough? W Wallis Middlemore Medical Society Millbrook 2011

4. Doctors like using placebos

6. Placebos Have been with us since prehistoric times

7. Placebo : Historical Aspects St Jerome (c347-420) introduced the term placebo to Christianity when translating the Hebrew Bile to vulgate but “lost in translation” Medieval placebo mourners Chaucer 1386 Squire Placebo the sycophant

8. Many other well-publicized exorcisms with exposures to sham religious objects are recorded. For example, in 1565, King Charles IX arranged to meet a notorious demoniac who testified to Protestant ungodliness. This demoniac had been tested with ordinary wine deceptively mixed with holy water. Her violent reactions to the concealed holy water confirmed to observers that her possession was genuine. Later, however, when other more sceptical investigators repeated the experiment, she could not distinguish genuine from fake exposures. Placebo Controlled Trials are not New Used by the early Church To expose fake possession by the devil (as depicted by Goya)

12. Wall Street uses placebos

13. Politicians use of Placebos The Republicans’ view of Obama’s economic stimulus package

16. People with post dental surgery pain > Randomly assigned to either morphine or placebo. Both patient and doctor > unaware (both “blind”) of which was used. Outcome judged by observers unaware of which treatment used > effects and side effects of: morphine ˄ vs. ˄ placebo Note that both the morphine and the placebo effects are reversed by a morphine antidote (naloxone) Example of double-blind controlled trial of a drug vs. a placebo

17. People with low back pain > Randomly assigned to either traditional Chinese Acupuncture (L) or “sham” > Acupuncture (R) . Patients unaware of which was used. Single-blind because only patient is unaware, not the acupuncturist. Outcome judged by observers unaware of which treatment used > effects and side effects of “real” ^ acupuncture vs. “sham” ^ acupuncture Example of single-blind controlled trial of a procedure vs. a sham procedure

18. Not all Placebo controlled Trials are with “inert” substances Sham surgery for Parkinson’s and Comparing leeches to Voltaren

20. How does placebo effect work ? The psychobiological effects and how to remove them

22. Doctors’ appearance and behaviour enhance both the placebo and nocebo effects expectation good BAD

24. Conditioning put to good use treatment of psoriasis with steroid cream full daily dose, alternate placebo-steroid, and gradually reducing steroid dose vs. relapse rate

26. Objective placebo effects on brain imaging Placebo analgesic produces identical response to opioid. Reversed by naloxone ˂ Placebo produces identical response In Parkinson's disease To levodopa ˂

27. Placebos “work” even when patients in RCTs are told that they are receiving them Welcome to the home of the original Obecalp® The first consumer placebo utilizing pharmaceutical grade ingredients available for sale at retail locations around the country.

28. How does one tell if placebos work ? ˂ 4. Covert use of placebo First remove expectation conditioning, and confounding factors . How does one remove expectation ? By 4 strategies : 2. Using cross over trial design 3. Using an untreated control to compare to the placebo 1. Use objective outcomes

30. How well would this chap respond to a placebo when he wakes up ? Thoracotomy