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Placebo Nocebo

Everyone has heard of the placebo effect. But have you heard about the nocebo effect?

Placebo is a medication or treatment that shouldn’t actually do anything. A sugar pill for example, or a sham treatment like putting hot packs on the abdomen in someone with back pain. Patients in studies sometimes respond dramatically, and positively, to a placebo drug or treatment. The pill or treatment shouldn’t help, but it does.

Nocebo is the opposite of placebo. It is the belief that something cannot help even though it is known to be helpful to most people. The nocebo response appears to be even stronger than the placebo response and can sometimes completely prevent a powerful drug or treatment from having any effect at all.

One study used the powerful opioid drug remifentanil. This a relative of the carfentanil that is often mixed with heroin and causes overdose deaths. In this study, volunteers were exposed to pain in the form of topical heat, and then given the drug. But first, they were told one of three things: 1) The drug we are giving you may or may not do anything or; 2) The drug we are giving you will have a powerful effect in reducing the pain or; 3) The drug we are giving you will make your pain much worse. Those told statement 1 had modest relief of pain. Those told statement 2 had double the amount of pain relief compared to the first group. But those told statement 3 had no relief whatsoever from the remifentanil. A powerful opioid was neutralized by negative belief.

Another similar study used a topical anesthetic cream (combination of lidocaine and prilocaine). The result was the same: Those who were told the cream would make the pain worse actually felt more pain despite the fact that their skin was numbed by the anesthetic.

So what’s going on? Is it all in your head? Well yes and no. It is in the brain, and your brain is in your head, but it is not at all made up. The effect is very real.

We know, for example, that the placebo response for “pain” pills (i.e. sugar pills that the person thinks are pain pills) can be blocked by using an opioid blocker. This suggests that the belief in the effectiveness of the placebo causes an actual release of opioid in the brain and that these natural opioids are being prevented from causing the placebo response because of the opioid blocker. We call these natural opioids endorphins, and they are indeed just as powerful as the drugs we prescribe for pain. So why don’t more pain patients benefit from their own opioids? It’s because of belief.

Your beliefs, both your positive beliefs and your negative beliefs, have a profound effect upon your pain and upon your response to the medications and treatments we give you to try and reduce your pain. If your outlook is positive and you believe that the medications and treatments have the ability to help you, then they will. If instead your outlook is negative and you believe that the medications and treatments will fail, then they will.

This can seem silly when you first hear it - this idea that proven treatments won’t help someone because of how they think. And it can also sound like I’m trying to say that medications and treatments only work because of the placebo effect. But that is not the point at all. Medications and treatments do work, and have been proven to work, but your emotions and beliefs can have a significant impact upon the results of those medications and treatments.

You should have read previously my recommendation to change your story. To turn from the story of your pain towards a new story of what you can do despite your pain. This positive energy will have a dramatic impact upon how much you benefit from the medications and treatments given at the clinic.

There are many patients who have lived with pain that is unnecessarily severe because of their negative beliefs. Opioid pain medications can contribute to this negativity because after all, nothing else can work as quickly or as dramatically to reduce pain. The problem with this one treatment approach is that the opioids eventually stop working because of tolerance. Patient who rely solely upon their opioid medication will find their options limited when their pain increasingly breaks through the tolerance.

The treatment of chronic pain requires a multidisciplinary approach. Multiple types of treatments need to be used simultaneously. Some treatments will target the injury or disease, and some treatments will target the brain’s handling of the pain. Only by attacking the pain from all angles will the person with pain achieve their best quality of life.

In our clinic we offer a variety of treatments. Not just medication, but also therapies and modalities that can help to heal the damage. Education and classes that can help to strengthen the brain’s ability to fight pain. Opportunities to learn from your peers – from those who are walking the same walk through life and have tips and tricks to share with you that can be of benefit to you too. I hope that you will avail yourself of everything we have to offer.

1.Bingel U, Wanigasekera V, Wiech K, Ni Mhuircheartaigh R, Lee MC, Ploner M, Tracey I. The effect of treatment expectation on drug efficacy: imaging the analgesic benefit of the opioid remifentanil. Sci Transl Med. 2011 Feb 16;3(70)

2.Aslaksen PM, Zwarg ML, Eilertsen HI, Gorecka MM, Bjorkedal E. 2015. Opposite effects of the same drug: reversal of topical analgesia by nocebo information. Pain 156: 39-46

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