Placebo Treatment for Pain
Painkiller addiction is becoming increasingly personal: Sixteen per cent of Canadians know someone who has died from a prescription painkiller overdose, according to a recent Kaiser Family Foundation survey; 9 per cent have seen a family member or close friend die.
Addictive opioid painkillers were once reserved for extreme situations like terminal cancer. But opioids like OxyContin, Percodan and Fentanyl are now widely prescribed for common conditions like arthritis and lower back pain. The consequences have been catastrophic: in 2015, prescription painkillers caused nearly 700 emergency room visits and almost 5 deaths every day.
How can this crisis be tackled? Right now our government is trying to regulate drug use by discouraging physicians from writing prescriptions for narcotics and monitoring their prescribing habits. If you are using the Fentanyl patch, you must now bring in all your empties before the pharmacist can give you a refill. This ensures that the patient is the only one using the drug. You must show your driver’s license and sign before picking up your narcotic prescription at the pharmacy. People in severe pain who really need these drugs are being told to use Tylenol, Ibuprofen or Aleve and these carry with them their own long term side-effects. Maybe it’s time to try placebos.
This phenomenon, in which someone feels better after receiving fake treatment, was once dismissed as an illusion. People who are ill often improve regardless of the treatment they receive. But neuroscientists are discovering that in some conditions, including pain, placebos create biological effects similar to those caused by drugs. Before a drug can be approved by Health Canada it must prove that it is more effective than a placebo and this is not always easy for the pharmaceutical companies.
When you take a placebo painkiller it dampens activity in pain related areas in the brain and spinal cord, and triggers the release of endorphins, the natural pain-relieving chemicals that opioid drugs are designed to mimic. Even when we take a real painkiller, a big chunk of its effect is delivered not by any direct chemical action, but by our expectation that the drug will work. Studies show that widely used painkillers like morphine, buprenorphine and tramadol are markedly less effective if we don’t know we are taking them.
Placebo effects in pain are so large, in fact, that drug manufacturers find it hard to beat them. Of course the drug companies hate the placebos because they ruin their drug trials and there is no money in producing placebos but this means there is a new safe and harmless way to treat pain.
Of course it is unethical to deceive patients by prescribing fake treatments. But there is evidence that some people with some conditions benefit even if they know they are taking placebos. In a 2014 study that followed 459 migraine attacks in 66 patients, honestly labelled placebos provided significantly more pain relief than no treatment, and were nearly half as effective as the headache medication known as Maxalt. (The study also found that a placebo labelled “placebo” was 60 per cent as effective a Maxalt. If the placebo was labelled “Maxalt” it was also 60 per cent as effective as the real drug.)
With placebo responses in pain so high, and the risks of drugs so severe (addiction, constipation, loss of appetite, difficulty in breathing), why not prescribe a course of honest placebos before proceeding if necessary to an active drug.
Another option is to use alternative therapies, which through placebo responses can benefit Patients even when there is no physical mode of action. A series of large trials in Germany published between 2005 and 2009 compared real and sham acupuncture (in which needles are placed at acupuncture points) with either no treatment or routine clinical care, for chronic pain conditions including migraine, tension headaches, lower back pain and osteoarthritis. Patients who received the acupuncture, real or sham, reported a similar amount of pain relief, and more than those who received no treatment or routine care that included pain medication.
Rather than relying on dummy pills and treatments, however, a broader hope is that finding out how and why placebos work, and for whom, will help to maximize the effectiveness of drugs and in some cases allow people to discontinue their medications.
Of course who is going to provide funding for placebos? But the greater our belief that a treatment will work, the better we will respond.
The placebo effect is getting stronger. Researchers reported last year that in trials published in 1996, drugs for chronic pain produced on average 27 per cent more pain relief than placebos. By 2013, new trials showed that the drugs were only 9 per cent more effective than placebos. It may be that people believe so strongly in the effectiveness of painkillers, especially because of American TV commercials, it actually makes the placebos more effective.
What this study really means that if a person has a strong belief in the ability of painkillers to be effective then they will greatly benefit from a placebo. However, we have to find out who the best candidates are because if someone is suspicious of conventional medicines then the placebo will not work at all. Trials show, for example, that strengthening patients’ positive expectations and reducing their anxiety during a variety of procedures, including minimally invasive surgery, while still being honest, can reduce the dose of painkillers required and cut complications.
Placebo studies also reveal the value of social interaction as a treatment for pain. Harvard researchers studied patients in pain from irritable bowel syndrome and found that 44 per cent of those given sham acupuncture had adequate relief from their symptoms. If the person who performed the acupuncture was extra supportive and empathetic, however, that figure jumped to 62 per cent.
Placebos tell us that pain is a mix of biological, psychological and social factors. Rather than working on stronger and stronger drugs for the pain, why not also take more seriously the idea of relieving pain without them. Too many people are dying from overdosing painkillers and too many are addicted. We need to find new ways to help these people.