Placebo Response Can be an Underappreciated Clinical Ally

LAS VEGAS—Providers may be able to help elicit placebo responses to enhance the relief patients experience from pain treatments, said R. Norman Harden, MD, Director of the Center for Pain Studies, Rehabilitation Institute of Chicago, at Northwestern University in Chicago, Illinois.

Placebo response tends to be underappreciated as a clinical tool, he said.

“Nobody ever got liver disease from a placebo response,” he said. “If you can use placebo effect in your clinical practice, why not?”

In clinical studies, placebo responses can be larger than pain relief attributable to an intervention or medication, he noted. There’s increasing evidence that in placebo-effect responders, endogenous opioids are playing a role in relief, and that patient expectations somehow “rev up” their opiate system. Naloxone can block placebo effects, he noted. “That really supports that endogenous opioids are involved.”

Patient expectations can be influenced by clinicians’ attitudes about a particular treatment, positively or negatively, he said. For example, negative provider expectations can yield so-called “nocebo” effects, diminishing treatment efficacy.

“Clinically, we want to have enthusiasm for what we’re recommending to the patient,” he explained. “It can accentuate the placebo response. In my clinics, I’m like a cheerleader. I’m jumping up and down with the pom-poms, saying, I’ve looked at the mechanisms of your disease and I really think that this compound is going to affect this physiology.”

Studies have shown that even the color of a pill or the discomfort of an intervention can affect patients’ expectations of impending relief, Dr. Harden said.

“There is a tremendous correlation between psychology and pharmacy,” Dr. Harden said. “But it is different in different diagnoses and contexts.” Knee osteoarthritis pain tends to be more resistant to placebo responses than back pain, particularly among men, for example.

Placebo responses are not limited to pain symptoms. Dr. Harden has noted placebo effects for depression symptoms and performance on functional tests like timed stair climbs and sit-to-stand tests.

Unfortunately, there is currently no way to know which patients will be placebo-responders and which will not, he noted.

“I think patient education actually can accentuate the placebo response,” Dr. Harden said. “I think therapeutic alliance helps – if they trust you and they think you’re making decisions that are going to help, that are going to be in their best interest.”When patients better understand their condition and have something they can do – something that they think is going to work – it can facilitate placebo response. Self-efficacy is a variant of placebo effect “in which the patient feels empowered,” he explained.