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Dr Placebo's blog

Nothing is as good as Obecalp

Dr Placebo
Last edited 24th October 2011

It’s been tested in more clinical trials than any other drug in history. Even critics admit it is effective for mild pain, mild depression, and other ailments with subjective outcomes. It has fewer side-effects than most alternatives. And now you can buy a bottle containing 50 pills of it for £3.75 ($5.95).

It’s called Obecalp and it comes in cherry flavor.

Here’s the rub: Obecalp is ‘placebo’ spelled backwards. Their website admits: “Obecalp® is a placebo and is not intended to diagnose, treat, cure or prevent any disease, or illness”. It was designed for parents to please (‘placebo’ means ‘to please’) malingering children. But don’t placebos work because people believe they are ‘real’? If so, I’ve removed the fun – and potential benefit – of Obecalp you. Or have I?

A recent study suggests placebos work even if people know they are placebos. There are two plausible explanations for why this might be the case. The first is classical conditioning. Pavlov’s dogs salivated at the mere expectation of food after having associated the sound with imminent food, and your body might react after popping Obecalp after it has learned (over a lifetime) to associate pill popping with symptom reduction.

Another novel explanation comes from evolutionary psychology. Imagine it is the dawn of human evolution. You feel a flu coming on but a sabre-toothed tiger is attacking your clan. If your body evoked the full immune response there would be less energy for fighting the tiger. Your survival therefore depends on ignoring the flu and increasing circulation to the skeletal muscles required for fighting. (In fact, the ‘fight or flight’ response suppresses the immune system.) Thankfully, you and your fellow tribesmen scare the tiger away, and the fight or flight response subsides. Then an authority figure – an elder or shaman – tells you everything is okay. The message from the trusted figure let you know (perhaps subconsciously) that you won’t need to run or fight for a few days. You are free to lie down and let your body’s immune system get to work.

Today tigers, village elders, and shamans are rare, but people with impressive titles like ‘Doctor’ might play the same role. If an authority figure (either in person or in an advertisement) tells you that you are going to be okay, your body (again perhaps subconsciously) might get the message that it is okay to allow the full immune response to kick in.

So even now that you know what it is, Obecalp still may be better than nothing. In the worst case, nothing is as good.

The power of belief to reduce pain and alter arteries

Dr Placebo
Last edited 21st September 2011

In a recent study involving 30 patients having a procedure to evaluate chest pain, researchers found that those who were told they were being given a pain-relieving drug reported a decrease in pain. They also showed a small narrowing of their heart vessels.

Participants were randomized to receive either a verbal suggestion about the potency of an injection or not. Both groups received a saline injection. The verbal suggestion was developed on hypnotherapeutic principles. They were told:

“Mrs./Mr. XYZ, we are now injecting a drug through the catheter which will widen your coronary vessels. This procedure will improve the blood flow in your heart. This drug is very effective and starts its action immediately. It is possible that you might feel some agreeable warmness or formication after only a few seconds.”

Placebos, including verbal suggestions, are often acknowledged to have ‘psychological’ effects that can be measured using ‘subjective’ outcomes such as pain. However, their benefits for ‘objective’ outcomes, including change in the artery diameter, have often been questioned. More generally, the study explodes the myth that there is a strict mind/body division. If placebos can affect the mind, then they affect the body, and vice versa - our minds and bodies are hopelessly intertwined. If our bodies are ill and we are bedridden we are unlikely to feel good. Conversely, our ‘body language’ often reveals our moods. Emotions can affect physical activity, and vice versa. To name just a few examples, reduced serotonin activity can cause depression, dopamine affects motivation (among other things), and noradrenaline affects arousal (in a general sense).

Caregivers might use the results of this and other related studies to boost the effects of the therapies they prescribe.

To be sure, the study was too small to be conclusive. At the same time it was sufficiently well conducted (randomized and double blind) to be very suggestive …

Can placebos cure asthma? It depends on your point of view...

Dr Placebo
Last edited 18th September 2012

You feel better but your doctor tells you that according to a laboratory test, you are still sick. Who do you believe? A recent randomized trial compared outcomes in four groups of patients suffering from asthma:

  1. albuterol inhaler,
  2. placebo inhaler,
  3. sham acupuncture (a needle that either avoids known ‘acupuncture’ points or does not penetrate the skin), and
  4. no intervention (a waiting list).

Subjective patient reports indicated that the albuterol, placebo, and sham acupuncture all reduced subjective reports of wheezing and feeling suffocated equally. That means if you have asthma, you feel as much better after taking a ‘placebo’ or the ‘real’ drug. However, on the ‘objective’ outcome, how much air you can blow in 1 second (the ‘FEV’) the real albuterol inhaler outperformed the placebo inhaler and sham acupuncture.

Placebo sceptics might argue that patients in the placebo and sham acupuncture groups merely reported that they felt better, to please the investigator (this is sometimes called ‘reporting bias’). However, this is unlikely because the patients receiving no intervention also reported improvements and presumably they had no reason to please the investigators (who after all had ignored them!)

Many prefer ‘objective’ outcomes because they believe that they address the underlying cause. But as Dan Moerman points out, patients suffering from asthma visit the doctor because they wheeze and feel suffocated not because they suffer from a reduced FEV. Indeed for many conditions including migraine, schizophrenia, back pain, depression, asthma, post-traumatic stress disorder, neurologic disorders such as Parkinson's disease, inflammatory bowel disease and indeed any condition defined by symptoms, requires that patient-preferred (usually subjective) outcomes trump objective outcome measures.

More generally, what patients, doctors, and policymakers care about (or should care about) is whether a medical intervention makes a patient live better or live longer. Many ‘objective’ outcome measures such as FEVs, cholesterol levels or arrhythmias are, in fact, surrogates for patient-relevant outcomes. While these surrogates are often extremely helpful and can lead to living better or longer, the links to the patient-relevant outcome is often far more spurious than is generally assumed.

So, which outcomes should you trust? It depends on your point of view …

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