Pleasing Prescriptions

Are you a serious M*A*S*H fan? If so, you’re likely to remember either the live or repeatedly re-run Season 6 Episode 25 when the 4077 medics ran out of morphine and substituted placebos, capsules filled with sugar scraped from doughnuts, instead.

The tactic worked because Hawkeye and the boys had history on their side.

The first relatively modern mention of placebos (from the Latin verb placere meaning to please) dates to the 17th century when British doctor Robert Piece described a “Dr. Placebo” who mostly treated his patients with calm and comfort rather than actual remedies. One hundred years later, the first known actual placebo prescription appears credited to William Smellie, a Scottish obstetrician.

After that, as placebos became a way to soothe frightened patients, some called the practice deceptive, but others pointed to the “placebo paradox.” While it might seem unethical to hand out meds that weren’t actually meds, if they worked in cases where there were no working meds, wasn’t that a good thing?

You bet, said anesthesiologist Henry K. Beecher. As an Army medic in WWII, Beecher often found his morphine supply running so low that he substituted a safe and simple saline (salted water) solution. Told the liquid was morphine, an amazing 40% of the wounded soldiers are said to have said it helped ease their pain.

“More Than Positive Thinking”

Two recent reports from Harvard School of Medicine confirm that – even when patients know they’re placebos.

As Ted J. Kaptchuk, director of the Program in Placebo Studies and the Therapeutic Encounter at Harvard-affiliated Beth Israel Deaconess Medical Center reports in the December issue of the Harvard Men’s Health Watch, “The placebo effect is more than positive thinking — believing a treatment or procedure will work. It’s about creating a stronger connection between the brain and body and how they work together.”

Exactly how remains a tantalizing mystery but the best guess is that when a doctor you trust tells you something will make you feel better, your brain goes to work on your body. Feel-good neurotransmitters such as serotonin trigger responses in brain regions tied to emotions make you feel good because, Kaptchuk explains, “you feel both consciously and unconsciously that you are getting the attention and care needed to heal.”

Placebo treatments work best at reducing pain and perhaps at easing side effects such as fatigue and nausea, and studies ranging from three months a year show that they work repeatedly.

“People associate the routine of taking medicine with a positive healing effect,” Kaptchuk continued. “And the more ritualized the treatment, the more serious and important it feels.” Especially for American patients, one theory goes, because the constant barrage of direct drug advertising here on TV and in print conditions us to believe that what they’re selling will work for us.

The “Nocebo Effect”

Of course, Newton’s Law that every action has an opposite and equal reaction can also crop up. The “nocebo effect” (from the Latin “I shall harm”) suggests that if a patient hears that a drugs is likely to cause an upset stomach she’s like to feel queasy even if what she was given was a placebo.

All that being true, one fascinating fact is that the future of placebos my include something even more fake that a pill. As one Harvard report noted, in 2002 Bruce Moseley, an orthopedic surgeon at Houston Methodist in Texas, performed at least 180 knee surgeries without spilling a drop of the patients’ blood. He anesthetized the candidates and then for half made a small incision in the knee, and that was it – except for telling the patient that the surgery was a success. Which, studies showed (and show) for more than 50 percent of the no-surgery guys actually was.

As always, Hawkeye had it right.