April 21, 2017

IT'S ALL IN YOUR HEAD:

Why I Take Fake Pills : Surprising new research shows that placebos still work even when you know they're not real (Robert Anthony Siegel, May 2017, SMITHSONIAN MAGAZINE)

Ted Kaptchuk, Kelley's boss and the founder and director of PiPS, has traveled an eccentric path. The child of a Holocaust survivor, he became embroiled in radical politics in the 1960s and later studied Chinese medicine in Macao. ("I needed to find something to do that was more creative than milking goats and not so destructive as parts of the antiwar movement.") After returning to the U.S., he practiced acupuncture in Cambridge and ran a pain clinic before being hired at Harvard Medical School. But he's not a doctor and his degree from Macao isn't even recognized as a PhD in the state of Massachusetts.

Kaptchuk's outsider status has given him an unusual amount of intellectual freedom. In the intensely specialized world of academic medicine, he routinely crosses the lines between clinical research, medical history, anthropology and bioethics. "They originally hired me at Harvard to do research in Chinese medicine, not placebo," he told me, as we drank tea in his home office. His interests shifted when he tried to reconcile his own successes as an acupuncturist with his colleagues' complaints about the lack of hard scientific evidence. "At some point in my research I asked myself, 'If the medical community assumes that Chinese medicine is "just" a placebo, why don't we examine this phenomenon more deeply?'"

Some studies have found that when acupuncture is performed with retractable needles or lasers, or when the pricks are made in the wrong spots, the treatment still works. By conventional standards, this would make acupuncture a sham. If a drug doesn't outperform a placebo, it's considered ineffective. But in the acupuncture studies, Kaptchuk was struck by the fact that patients in both groups were actually getting better. He points out that the same is true of many pharmaceuticals. In experiments with postoperative patients, for example, prescription pain medications lost half their effectiveness when the patient did not know that he or she had just been given a painkiller. A study of the migraine drug rizatriptan found no statistical difference between a placebo labeled rizatriptan and actual rizatriptan labeled placebo.

What Kaptchuk found was something akin to a blank spot on the map. "In medical research, everyone is always asking, 'Does it work better than a placebo?' So I asked the obvious question that nobody was asking: 'What is a placebo?' And I realized that nobody ever talked about that."

To answer that question, he looked back through history. Benjamin Franklin's encounter with the charismatic healer Franz Friedrich Anton Mesmer became a sort of paradigm. Mesmer treated patients in 18th-century Paris with an invisible force he called "animal magnetism." Franklin used an early version of the placebo trial to prove that animal magnetism wasn't a real biological force. Franklin's one mistake, Kaptchuk believed, was to stop at discrediting Mesmer, rather than going on to understand his methods. His next question should have been: "How does an imaginary force make sick people well?"

Kaptchuk sees himself as picking up where Franklin left off. Working with Kelley and other colleagues, he's found that the placebo effect is not a single phenomenon but rather a group of inter-related mechanisms. It's triggered not just by fake pharmaceuticals but by the symbols and rituals of health care itself--everything from the prick of an injection to the sight of a person in a lab coat.

And the effects are not just imaginary, as was once assumed. Functional MRI and other new technologies are showing that placebos, like real pharmaceuticals, actually trigger neurochemicals such as endorphins and dopamine, and activate areas of the brain associated with analgesia and other forms of symptomatic relief. As a result of these discoveries, placebo is beginning to lose its louche reputation.

"Nobody would believe my research without the neuroscience," Kaptchuk told me. "People ask, 'How does placebo work?' I want to say by rituals and symbols, but they say, 'No, how does it really work?' and I say, 'Oh, you know, dopamine'--and then they feel better." 

Posted by at April 21, 2017 1:12 PM

  

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