Fake Pills Can Work, Even If Patients Know It

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Study says it might be the ritual of taking placebos that makes them work like pills.

Published: December 23, 2010

by Richard Knox

Placebos don't shrink tumors or stop multiple sclerosis in its tracks, but there's tons of evidence that they can relieve pain and an array of other symptoms.

However, conventional wisdom is that placebos require deception. In order to work, a patient has to think it’s an active drug. So the American Medical Association and other authorities frown on the use of placebos in everyday medical care for ethical reasons.

But along came the "honest placebo" study.

An intriguing Harvard study in the online journal PLoS ONE seems to up-end conventional wisdom about placebos. It strongly suggests placebos can work even if patients know they're taking a fake pill.

"Fifty-nine percent of our patients who were taking the placebo reported adequate relief, compared to people on the no-treatment control – 35 percent," says study author Ted Kaptchuk of Beth Israel Deaconess Medical Center. "That's almost twice the…improvement!"

The study subjects were 80 volunteers with long-standing irritable bowel syndrome or IBS, a nasty stress-related ailment involving abdominal bloating, cramps, and diarrhea alternating sometimes with constipation.

Patients who knowingly took placebos improved on a range of IBS measures. In fact, their symptom relief was actually better than earlier studies showed for a potent IBS drug called alosetron.

Linda Buonanno was one of the placebo study volunteers. She's had IBS for 16 years, and when the researchers told her she was getting fake pills, she didn't think they would do anything. "I said, 'How in the world is that going to work?'" Buonanno says. "But they said, 'Well, it's mind over matter.' I said, 'Well, alright, let's see how good my mind is.'"

Buonanno apparently has a pretty good mind, placebo-wise.

Her cramps, bloating and diarrhea disappeared after just three days of taking two placebos twice a day. Three weeks later, when she ran out of placebo, she asked for more – as many in the study did. But the study was over, and she couldn't get any more official placebos.

"The symptoms came right back," Buonanno says. So she went to a health food store and bought some of her own placebos -- herbal supplement pills.

"I stuck it in my head that this is really helping out the IBS, and I've gotten rid of, like, 70 percent of my (IBS) problems," she says.

But how does it work? Researcher Kaptchuk thinks it's the ritual.

Dr. Anthony Lembo, a Beth Israel Deaconess gastroenterologist who participated in the study, says he told study subjects that the placebo "is something that will help you with your symptoms, there's a good chance of making you feel better."

He also said it didn't matter if they believed in the placebo or not. He told patients: "You just need to take it regularly, and the drug will work over time if you give it a chance."

Kaptchuk says the reason for asking people to take the placebo twice a day is part of the "self-healing ritual."

"They're immersed in it," he says. "It's not something they're thinking about, it's something they're doing... This is the context in which the pill is administered."

The study may open a door toward ethical use of placebos in daily medical practice. But first, researchers need to do bigger, longer trials.

TRANSCRIPT:

STEVE INSKEEP, Host:

We're learning more about the so-called placebo effect. You know, a placebo is a fake pill. It has no active ingredient. Doctors have known for a long time that people taking placebos often get better. Most people believe that's because patients think they might be getting real medicine.

NPR's Richard Knox reports that's not necessarily so.

RICHARD KNOX: For 16 years, irritable bowel syndrome has made Linda Buonanno's life miserable. So when she saw a TV ad about a study of IBS, she called right up to volunteer. But when they told her what the study was about, she thought they were kidding.

LINDA BUONANNO: I didn't really think it would work.

KNOX: The researchers told her if she signed up, Buonanno would be assigned to no treatment at all, or she'd be given placebo pills. And she'd be told up- front they were fake pills, with no real medicine in them. Call it an honest placebo.

BUONANNO: I said, how in the world is that going to work? But they said, well, it's mind over matter. I said, well, all right. Let me see how great my mind is.

(SOUNDBITE OF LAUGHTER)

KNOX: Ted Kaptchuk of Harvard was the mastermind of the experiment.

TED KAPTCHUK: Everyone believes - the conventional wisdom in medicine is placebo only works if the patient thinks it's a drug.

KNOX: If that's right, a placebo involves deception. So it's not ethical for a doctor to prescribe one. But Kaptchuk did a survey that showed many doctors often prescribe placebos. So he decided to see if placebos can work even if patients know that's what they're taking. He talked his colleague Anthony Lembo into helping.

ANTHONY LEMBO: I actually didn't think we'd find very much or see that there was a significant effect. So I was a bit skeptical myself.

KNOX: Lembo's a gastrointestinal specialist at Beth Israel Deaconess Hospital in Boston. I asked him what he told Buonanno and other study participants.

LEMBO: This drug is something that will help you with your symptoms. There's a good chance of making you feel better.

KNOX: But what if I don't really - I know it's a placebo. It doesn't have any medicine in it. Doesn't that affect whether it's going to work or not?

LEMBO: It won't. This is a mind-body effect. And so you don't actually have to believe in it. You just need to take it regularly. And the drug will work over time if you give it a chance.

KNOX: And, lo and behold, most of the time, it did.

KAPTCHUK: Fifty-nine percent of our patients who were taking the placebo reported adequate relief - 59 percent compared to the people on the no- treatment: 35 percent. That's almost twice the size of improvement.

KNOX: Kaptchuk thinks it's more than the placebo pill itself. It's the whole ritual that makes the difference, what the doctor says and the ritual of pill- taking. Buonanno was one of the volunteers whose cramps, bloating and diarrhea magically went away while she was taking two placebos, twice a day.

BUONANNO: I was shocked that at the end of the three weeks when I went back to his office. I said can I have more of these? I know they're sugar tablets, but something's working. All right. He started laughing. And within three days after I wasn't taking it anymore, the symptoms came right back.

KNOX: Since the study was over, she couldn't get any more official placebos. So she went to a health food store and bought some of her own.

BUONANNO: I stuck it in my head that this is really helping out the IBS, and I've gotten rid of, I'd say, at least 70 percent of my problems.

KNOX: The study appears in the online journal P-L-o-S-ONE. Kaptchuk and Lembo admit the research raises a lot of questions. For instance, will the honest placebo effect work longer than three weeks?

LEMBO: You know, the follow-up studies will need to be a lot longer.

KNOX: And why did you choose just three weeks?

KAPTCHUK: Because we had no money to do a real big study.

KNOX: There's no big placebo manufacturer out there who wants to fund it?

(SOUNDBITE OF LAUGHTER)

KAPTCHUK: No, no.

KNOX: But with these intriguing data in hand, they hope to convince the National Institutes of Health to pay for a bigger, longer trial of honest placebos.

Richard Knox, NPR News.

(SOUNDBITE OF MUSIC)

INSKEEP: This is NPR News. Transcript provided by NPR, Copyright NPR.

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