Sleep difficulties are a common complaint in the population at large and especially amongst psychiatric patients. Unfortunately, the drugs that are readily used to address insomnia are not candy. Many of them can be habit forming, are expensive, produce their own set of undesirable side effects, and can alter deep sleep morphology – producing a less-than-rested sensation upon awakening. There were times in the past when patients of mine would exhibit resistance to every suggestion for healthy sleep practices (e.g., no coffee or soda, moderate exercise, cool bedroom temperatures) and would insist on Rx. These weren’t necessarily people who were abusing drugs… they were just convinced of the all-encompassing Power of Rx to cure their perceived ills, and no amount of redirection seemed to work.
Enter the placebo.
Much has been written about the ethics of dispensing placebo, but I’m convinced that in the right place and at the right time, it is a useful and humane option. Back in the early 1990s as a resident, for select inpatients, a large brightly colored capsule at bedtime – the colors were always blindingly neon, suggesting power far beyond drab greys and whites – produced the subjective perception of sedation and deep restorative slumber, absent both side effects and habituation. Those patients wanted sleep. I gave them an inert intervention that helped them feel better. A true win-win.
“How,” the reader will ask, “did you explain this intervention to the patients without boldfacedly lying to them?” Easy… by telling the truth in ways that were not immediately obvious. One of the main ingredients in the placebo capsules was stearic acid, a type of benign filler and preservative also found in some hard candy. I would tell patients, honestly, that I wanted to give them a capsule containing stearate “because in many cases it has been found to assist patients with problems just like yours.” That is a wholly truthful statement, and yet the patient interpreted the words in the way they wanted to interpret them.
The days of using placebos are over as far as I can tell. This is because patients are constantly reading online, and liability surrounding informed consent has become too risky. Had I used the ‘stearate is good for people with problems just like yours’ line recently, the patients or their families would have looked up the substance on their iPads and then come back to complain that what I was giving them was nothing more than an inert filler.
But the passing of the Age of Placebo is not necessarily a bad thing, albeit with one caveat.
Too many patients who visit physicians in general, and psychiatrists in particular, view the awarding of a Rx script as a validation of sorts. To visit a shrink and not come away with a pill is perceived by many as having failed in the therapeutic interaction. Faced with taking time and trying to educate patients about proper Rx usage and then having them go away miffed, many doctors will prescribe a consolation prize – antidepressants, anxiolytics, sleep aids, you name it. Yet those consolations are not risk-free, and render us a nation of unnecessary pill-poppers.
It was for these situations that placebos often made sense. In their absence I trust that my fellow physicians will just learn to say ‘no’ more often.
The Placebo Effect is very real, especially when employed for issues with high degrees of subjectivity, such as pain and sleep. If a patient is fragile and already taking (arguably) too much Rx, does a physician give yet another (potentially addictive) Rx that may interact with all of the other Rx… or try an inert sugar pill that could yield relief and cause no harm whatsoever in the long run? Ethicists will debate this endlessly, but I know from my own experiences as a resident in the 1980s that I favor the latter approach in carefully selected cases.
The placebos we could order from the pharmacy back then were HUGE capsules in bright neon colors. They looked powerful. To amuse ourselves when on-call and nothing was pressing, we’d make up names for them. My clinical supervisor at the time labeled his as ‘Obecalp,’ which is ‘Placebo’ backwards. I always preferred ‘Fallacine’ or ‘Fauxene’ for mine. And this is actually how the pharmacy would dispense them when a patient was discharged: “Fauxene one tablet Q6hrs as needed,” and then in parentheses “Stearic Acid” (the generic name of the inert filler/ preservative in the sugar pills).
More times than not, inpatients would greet me at the ward door the next morning – or outpatients would come to our next meeting – and report how soundly they had slept or how their pain seemed much more manageable.
[sidebar: once a patient called me after discharge to say he’d run out of Rx before his upcoming outpatient appointment, asking if I’d refill. Normally I didn’t write Rx for discharged patients, but I asked him what it was that he needed. He replied, “P-L-A-C-E-B-O.” The pharmacy had apparently mislabeled the container. I gladly refilled]
But here’s the really amazing thing: the Placebo Effect doesn’t necessarily rely on ignorance on the part of the patient! Research has shown – repeatedly – that the Placebo Effect still exerts benefit, even when patients KNOW they’re taking placebo!
Case in point: a recent study at Duke University (Ariely et al.) gathered 82 people and gave electric shocks to their wrists. Then, the cohort was divided in half, and each of the test subjects was given one of two pills, shocked again, and asked to compare the pain initially with the pain after taking their respective pill. Of the first group, 85% said the pill reduced the pain. On the other hand, only 61% of the second group said that the pill reduced the pain. Whichever pill the researchers gave their “patients” worked, though the first pill clearly worked better.
It shouldn’t surprise you that some of these test subjects received placebos. What might be surprising, though, is that in this study, ALL of the test subjects received placebos. On top of that, both groups received the exact same thing: sugar pills of identical size, shape, color, &c. So why did the first group feel less pain than the second group?
Apparently it was due to the price. The second group was told that their pills were being sold at a huge discount.
Specifically, as the New York Times reported in 2008
the first group was informed that their pills cost $2.50 each. The second group, though, was told that their pills typically sold for $2.50, but the price had been cut dramatically – all the way to ten cents each. Other than that, the two groups went through the same process, the same electrodes, the same pills, the same everything. But news of the discounted price seemingly rattled some of the subjects’ faith in the pills’ quality, and, therefore, reduced the Placebo Effect!
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