November 7, 2018

ALL IN YOUR HEAD:

What if the Placebo Effect Isn't a Trick? (Gary Greenberg, Nov. 7, 2018, NY Times Magazine)

When Ted Kaptchuk was asked to give the opening keynote address at the conference in Leiden, he contemplated committing the gravest heresy imaginable: kicking off the inaugural gathering of the Society for Interdisciplinary Placebo Studies by declaring that there was no such thing as the placebo effect. When he broached this provocation in conversation with me not long before the conference, it became clear that his point harked directly back to Franklin: that the topic he and his colleagues studied was created by the scientific establishment, and only in order to exclude it -- which means that they are always playing on hostile terrain. Science is "designed to get rid of the husks and find the kernels," he told me. Much can be lost in the threshing -- in particular, Kaptchuk sometimes worries, the rituals embedded in the doctor-patient encounter that he thinks are fundamental to the placebo effect, and that he believes embody an aspect of medicine that has disappeared as scientists and doctors pursue the course laid by Franklin's commission. "Medical care is a moral act," he says, in which a suffering person puts his or her fate in the hands of a trusted healer.

"I don't love science," Kaptchuk told me. "I want to know what heals people." Science may not be the only way to understand illness and healing, but it is the established way. "That's where the power is," Kaptchuk says. That instinct is why he left his position as director of a pain clinic in 1990 to join Harvard -- and it's why he was delighted when, in 2010, he was contacted by Kathryn Hall, a molecular biologist. Here was someone with an interest in his topic who was also an expert in molecules, and who might serve as an emissary to help usher the placebo into the medical establishment.

Hall's own journey into placebo studies began 15 years before her meeting with Kaptchuk, when she developed a bad case of carpal tunnel syndrome. Wearing a wrist brace didn't help, and neither did over-the-counter drugs or the codeine her doctor prescribed. When a friend suggested she visit an acupuncturist, Hall balked at the idea of such an unscientific approach. But faced with the alternative, surgery, she decided to make an appointment. "I was there for maybe 10 minutes," she recalls, "when she stuck a needle here" -- Hall points to a spot on her forearm -- "and this awful pain just shot through my arm." But then the pain receded and her symptoms disappeared, as if they had been carried away on the tide. She received a few more treatments, during which the acupuncturist taught her how to manipulate a spot near her elbow if the pain recurred. Hall needed the fix from time to time, but the problem mostly just went away.

"I couldn't believe it," she told me. "Two years of gross drugs, and then just one treatment." All these years later, she's still wonder-struck. "What was that?" she asks. "Rub the spot, and the pain just goes away?"

Hall was working for a drug company at the time, but she soon left to get a master's degree in visual arts, after which she started a documentary-production company. She was telling her carpal-tunnel story to a friend one day and recounted how the acupuncturist had climbed up on the table with her. ("I was like, 'Oh, my God, what is this woman doing?' " she told me. "It was very dramatic.") She'd never been able to understand how the treatment worked, and this memory led her to wonder out loud if maybe the drama itself had something to do with the outcome.

Her friend suggested she might find some answers in Ted Kaptchuk's work. She picked up his book about Chinese medicine, "The Web that Has No Weaver," in which he mentioned the possibility that placebo effects figure strongly in acupuncture, and then she read a study he had conducted that put that question to the test.

Kaptchuk had divided people with irritable bowel syndrome into three groups. In one, acupuncturists went through all the motions of treatment, but used a device that only appeared to insert a needle. Subjects in a second group also got sham acupuncture, but delivered with more elaborate doctor-patient interaction than the first group received. A third group was given no treatment at all. At the end of the trial, both treatment groups improved more than the no-treatment group, and the "high interaction" group did best of all.

Kaptchuk, who before joining Harvard had been an acupuncturist in private practice, wasn't particularly disturbed by the finding that his own profession worked even when needles were not actually inserted; he'd never thought that placebo treatments were fake medicine. He was more interested in how the strength of the treatment varied with the quality and quantity of interaction between the healer and the patient -- the drama, in other words. Hall reached out to him shortly after she read the paper.

The findings of the I.B.S. study were in keeping with a hypothesis Kaptchuk had formed over the years: that the placebo effect is a biological response to an act of caring; that somehow the encounter itself calls forth healing and that the more intense and focused it is, the more healing it evokes. He elaborated on this idea in a comparative study of conventional medicine, acupuncture and Navajo "chantway rituals," in which healers lead storytelling ceremonies for the sick. He argued that all three approaches unfold in a space set aside for the purpose and proceed as if according to a script, with prescribed roles for every participant. Each modality, in other words, is its own kind of ritual, and Kaptchuk suggested that the ritual itself is part of what makes the procedure effective, as if the combined experiences of the healer and the patient, reinforced by the special-but-familiar surroundings, evoke a healing response that operates independently of the treatment's specifics. "Rituals trigger specific neurobiological pathways that specifically modulate bodily sensations, symptoms and emotions," he wrote. "It seems that if the mind can be persuaded, the body can sometimes act accordingly." He ended that paper with a call for further scientific study of the nexus between ritual and healing.

When Hall contacted him, she seemed like a perfect addition to the team he was assembling to do just that. He even had an idea of exactly how she could help. In the course of conducting the study, Kaptchuk had taken DNA samples from subjects in hopes of finding some molecular pattern among the responses. This was an investigation tailor-made to Hall's expertise, and she agreed to take it on. Of course, the genome is vast, and it was hard to know where to begin -- until, she says, she and Kaptchuk attended a talk in which a colleague presented evidence that an enzyme called COMT affected people's response to pain and painkillers. Levels of that enzyme, Hall already knew, were also correlated with Parkinson's disease, depression and schizophrenia, and in clinical trials people with those conditions had shown a strong placebo response. When they heard that COMT was also correlated with pain response -- another area with significant placebo effects -- Hall recalls, "Ted and I looked at each other and were like: 'That's it! That's it!' "

It is not possible to assay levels of COMT directly in a living brain, but there is a snippet of the genome called rs4680 that governs the production of the enzyme, and that varies from one person to another: One variant predicts low levels of COMT, while another predicts high levels. When Hall analyzed the I.B.S. patients' DNA, she found a distinct trend. Those with the high-COMT variant had the weakest placebo responses, and those with the opposite variant had the strongest. These effects were compounded by the amount of interaction each patient got: For instance, low-COMT, high-interaction patients fared best of all, but the low-COMT subjects who were placed in the no-treatment group did worse than the other genotypes in that group. They were, in other words, more sensitive to the impact of the relationship with the healer.

The discovery of this genetic correlation to placebo response set Hall off on a continuing effort to identify the biochemical ensemble she calls the placebome -- the term reflecting her belief that it will one day take its place among the other important "-omes" of medical science, from the genome to the microbiome. The rs4680 gene snippet is one of a group that governs the production of COMT, and COMT is one of a number of enzymes that determine levels of catecholamines, a group of brain chemicals that includes dopamine and epinephrine. (Low COMT tends to mean higher levels of dopamine, and vice versa.) Hall points out that the catecholamines are associated with stress, as well as with reward and good feeling, which bolsters the possibility that the placebome plays an important role in illness and health, especially in the chronic, stress-related conditions that are most susceptible to placebo effects.

Her findings take their place among other results from neuroscientists that strengthen the placebo's claim to a place at the medical table, in particular studies using f.M.R.I. machines that have found consistent patterns of brain activation in placebo responders. "For years, we thought of the placebo effect as the work of imagination," Hall says. "Now through imaging you can literally see the brain lighting up when you give someone a sugar pill."

Posted by at November 7, 2018 5:13 PM

  

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