The Placebo Effect
Drug researchers working in high-tech labs around the world use computers to design and test molecules and bring a wealth of cutting-edge knowledge to the challenge of curing disease. After spending $100m or more on a specific drug, these best-in-class people, with PhDs and decades of experience, working to assure safety and minimize side effects, perfecting a new molecule that could make the company billions, must then go up against the most formidable challenge they have ever faced:
A sugar pill.
The placebo effect has been known since the 1940s, and the interesting thing is that it’s getting stronger. We have a lot more to learn about placebos, but here is a bite-sized summary of what we know today:
The placebo effect is real. It takes advantage of the body’s ability to manufacture its own natural pain killers and neurotransmitters. We can block these transmitters and the placebo effect goes way down. People who swear by nutraceuticals, vitamins, and homeopathy are swearing by the placebo effect.
The placebo effect is cultural. Drug companies outsource their trials to clinics in China, Russia, Africa, and India, and see very different results. In many cases, being seen or treated at all, or just being in a hospital for the first time is probably more effective than either of the pills in the trial. Blue is generally a better color for tranquilizers, except in Italy, where it signifies the color of the national soccer team.
Placebo research is in its infancy. The effect can depend on the size, shape, or color of the pill, what the bottle says, what words are used, the tone of voice, the hopefulness or lack of it, dose times, etc. A few institutes now have funds to do important studies, but it will be decades before we put the full picture together. And, since people keep changing their beliefs, we may end up in a never-ending arms race against spontaneous mutations and steady evolution of of the placebo effect.
Placebos have side effects. In many studies, some patients taking placebos report having real side effects. Different groups of placebo-takers report different side effects depending on the warnings they were given.
The placebo effect can be very strong. In one study of a drug given to people with a heart-rhythm disorder called AFIB, one person in the placebo arm of the trial was converted back to a normal heart rhythm after years of abnormal rhythms! Even Parkinson’s patients have seen improvement from placebos.
The placebo effect does not require pills. Several studies have shown that old people pass away more often after a birthday than before, in contrast to what we would see in the general population. It’s likely that placebo effects take place in most of us fairly often.
Placebos can have negative effects. Tell a patient that a given experimental drug reduces the effectiveness of a pain killer, and the patient will report more pain, regardless of what is in the pill.
The effect can last a long time. It’s not just while you’re taking the sugar pills, but once you’ve “benefitted” from taking a placebo, you can go on to enjoy those benefits for weeks, months, or be cured all together.
The compliance effect shows that people who take their placebos regularly have better outcomes than people who forget to take their pills - even if they are placebos! In fact, and this has been repeated, heart patients who (unbeknown to them) take their placebos haphazardly tend to die of heart attacks earlier in the study than patients who take their sugar pills regularly. We have no idea what causes this.
Many drugs probably don’t do what they are supposed to do. The placebo effect is large in part because we’re learning more and more that many drugs are far less effective than we thought. The jury is out on most antidepressants, for example, as continual reviews show the signal to be weaker than it was when the drug was approved.
We’re not even sure what to measure. How can you tell if an antidepressant worked? There are answers to this question, but it gets complicated, and the various effects all interact. As we “discover” more and more modern ailments that affect people with high incomes, the definitions of these new ailments tend to change to keep up with market demand for quick fixes.
All drugs have the benefit of the placebo effect. When a drug goes up against the placebo effect, it also benefits from the placebo effect as well as any interaction the drug might have. So when we take pills, we are also taking a certain amount of placebo with every pill. This means that many of the drugs we take are likely more effective than they would be if the doctor could just put it into our food without our knowing it.
This is not to say there are no other problems with the gold standard of testing: randomized double-blind placebo-controlled trials. There are many. I’ll talk about them another time if people are interested.
I’ve developed a new management theory called Business Agility. Actually, I hope it’s a theory that eventually goes away, because I don’t think we need more management theories. What we need is to empower people to do experiments and see what works. And, as I’ve pointed out with drug development, it can be very difficult teasing apart cause and effect. Visit my web site to learn more, and see my bookstore for a selection of excellent books on the gap between perception and reality in business.