Most of us know that a placebo is something like a sugar pill – it doesn’t do anything very much, and definitely doesn’t affect pain. But at the same time many of us also hear that if you respond to a placebo it means something odd is going on, and usually for people with chronic pain, it means someone is trying to catch you out (because if you respond, then you can’t have real pain). The implication is that you’re either faking, or your pain can’t really be all that bad because everyone knows that “real pain” wouldn’t reduce with a sugar pill.
Well, let’s set the story straight: placebo analgesia is pain relief that occurs when you’re given a treatment that doesn’t have any known effect. It’s real. Changes occur in the brain, and the effect can be reversed with a drug known to block the effects of opioids. It’s not imaginary, and you’re not faking just because you respond to a placebo – we all do, pretty much.
What are we reacting to if it’s not an active drug?
Well, the best answer at the moment is that we put together all our past experiences, all that we know “should” happen, and all the things the person administering the placebo is telling us, and our fabulous brains get into action to produce the actual response. This is cool! It means that some of the most potent pain relievers in the world actually get produced by our brain just because someone said we should expect it.
Placebo responses occur alongside every treatment – not just the ones that are fake. So, when you swallow a pain reliever, you’ve learned to expect that it should work, everything you know says it should work, and lo and behold! It works! And your brain supports this action by producing its own version of the effect.
Does this mean your pain is not real? Absolutely not! You definitely feel your own pain (and only YOU can, no-one else knows what it feels like, or whether you’ve got pain except YOU). And if your pain reduces with a placebo, it’s not a sign that your pain is imagined – it’s just a sign that you have a normal, functioning brain, and that the person giving you the placebo is very convincing, and you’ve learned to expect a good effect.
Now placebo isn’t always so nice. Placebo’s evil twin is nocebo. Nocebo is all the negative effects you can experience when you’re given a sugar pill and you’re told you can expect headache, nausea, fatigue, rash and so on. And like placebo it occurs alongside real medications as well as treatments that don’t work. So… you can end up having side effects from taking something that has no active ingredients at all! Not fair at all.
Where does this leave you?
What this means is that placebo and nocebo are real, they seem to be related to expectations, beliefs, our personal experience, and what we’re told. The effects on our body are real, and this has been shown in many different experiments. It might mean that sometimes a treatment is more effective than the active ingredients should be, because our brain is working on our side to produce a super-effective result. It might also mean that we can get negative effects when our brain is ALSO producing the negative effects.
If a treatment works every now and then, it seems that placebo effect lasts longer although it’s not as powerful as if it works every time. This might mean, once we’ve worked out how to use this for treatments, we can enhance the effect without having to have so much of the active ingredients.
A final note: if someone gives you a placebo and you find out about it – how does that make you feel? If it were me, I’d be furious. A true breach of trust. Placebo’s are NOT appropriate! But what IS appropriate is learning how what a clinician says and does, and the setting and environment of your treatments, can enhance the effect your brain produces. And that is pretty cool.
Au Yeung ST, Colagiuri B, Lovibond PF, & Colloca L (2014). Partial reinforcement, extinction, and placebo analgesia. Pain PMID: 24602997