Puzzling Pills

Are placebos magic or real?

A bit of whimsy making the medical rounds has a pharmaceutical company petitioning the Food and Drug Administration for approval of a new pain reliever. The compound, to be packaged in red, white and blue capsules, will be sold with a label that is indisputably true: PROVED EFFECTIVE IN ONE-THIRD OF ALL CASES AND ABSOLUTELY SAFE. The nostrum's name: Placebo.

Long the butt of jokes, placebos (from the Latin for "I shall please") are one of the oldest, most useful and least understood "remedies" in the doctor's satchel. Generally they come as pills of milk sugar or talc or as injections of salt water. Such substances are considered pharmacologically inert, incapable of eliciting a response when prescribed in reasonable quantities. Yet studies have repeatedly shown that placebos help as many as 30% or 40% of patients with real enough ills, including postoperative pain, migraines, coughs, seasickness, arthritis, ulcers, hypertension, hay fever, even warts.

To account for the placebo's magic, doctors have resorted to virtually every kind of psychological and physical explanation. No luck. Drs. Jon D. Levine and Howard I. Fields and Oral Surgeon Newton C. Gordon, all of the University of California in San Francisco, may have hit upon an answer. In an experiment involving dental patients having molars extracted, they gave them either a placebo or the drug naloxone, which is known to block the effects of endorphin, a morphine-like pain reliever produced by the brain itself.

To guard against any unwitting influences on the patients or themselves, the doctors did not know which "drug" was being used in any particular case until the end of the test. In the first phase of the experiment, patients who had received placebos experienced less pain than those in the naloxone group. But when the experiment was continued, patients initially in the placebo group but now getting the blocker experienced an increase in pain. In other words, the placebo response diminished. Levine's explanation: somehow placebos apparently activate a body pain-relieving system that relies on endorphin. Says he: "Placebos are not just in people's minds but in their brains."

Perhaps so. But Psychiatrist Arthur K. Shapiro of Manhattan's Mt. Sinai Medical Center points out that the placebo effect may also be influenced by attitudes of patient and doctor toward drugs and, perhaps more important, toward each other. In fact, says Shapiro, who has collected hundreds of the "useless" nostrums over the years, patient confidence in a physician may be a kind of placebo too, increasing chances of improvement.

Dr. Herbert Benson of Boston's Beth Israel Hospital agrees with that common-sense notion. Well known for his work on the physiological effects experienced by practitioners of Transcendental Meditation, he has recently reviewed studies of patients suffering from angina, a severe chest pain related to heart disease. He found that when physicians were initially enthusiastic about a remedy, even if it later proved worthless by ordinary medical definition, it acted as a placebo in about 80% of all cases. Conversely, Benson says, flaws in the patient-doctor relationship may account for some of the equally puzzling unpleasant effects, including nausea, dizziness and pain itself, experienced by some people who have taken placebos.

Though doctors have long used placebos to appease patients eager for a drug, even when none is indicated, the practice has lately come under question, most recently in last week's Journal of the American Medical Association. At a time when patients are demanding more candor, many physicians are asking themselves whether they should prescribe deceptively. Other doubts have also been raised. In a study of 60 physicians and 39 nurses at the University of New Mexico School of Medicine, Drs. James and Jean Goodwin and Albert Vogel found that the majority gave placebos to patients they disliked, considered difficult or suspected of exaggerating pain. When patients reported relief, the doctors and nurses incorrectly took that as proof of malingering. As one doctor told the researchers: "Placebos are used with people you hate, not to make them suffer, but to prove them wrong."

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