Updates & Features
Optimising Analgesic Treatment Outcomes with Placebo – The 2nd PainSolve Webinar
Strategies to Maximise Placebo Response in Clinical Care
PainSolve Editorial Team
We are pleased to have welcomed Prof. Ulrike Bingel (University Hospital Essen, Germany) to host her second PainSolve webinar on the 18th February 2019, titled, ‘Optimising Analgesic Treatment Outcomes: Lessons Learned from Placebo and Nocebo Research’. Following on from her first Neurobiology of the Placebo Effect webinar, Prof. Bingel presented high-impact studies that have highlighted the importance of taking the placebo and nocebo effects into consideration in all facets of the treatment process.
Prof. Bingel’s Presentation
Prof. Bingel began her presentation by reiterating the efficacy of the placebo effect at producing clinically relevant analgesic responses through the ‘placebo-mechanisms’: expectancy and learning.1
Patient–physician communication plays an important role in determining the patient expectancy level by impacting the context in which the patient receives the drug.2 Unfortunately, there are many subtle ways that a physician can deliver nocebo-enhancing communication, for example by inducing fear and anxiety: ‘one false move and you will be paralysed’. The importance of patient–physician communication was further demonstrated through a pharmacological proof-of-concept trial, where oxytocin was used to show that enhancing social bonds between physician and patient can help to augment analgesic treatment outcomes.3 Two further studies were presented to demonstrate how social4 and commercial5 aspects can manipulate the placebo effect by impacting the treatment context.
Exploiting learning mechanisms to help achieve a placebo-controlled dose reduction is another potential approach to leverage the benefits of the placebo effect. The placebo could be introduced intermittently (the exposition phase), after the patient has learnt that the drug is effective (the acquisition phase).6,7 Prof. Bingel suggests that this process could be particularly useful when prescribing drugs that cannot be used for long periods of time, e.g. sleeping pills.
Throughout both webinar sessions, participants responded with interest to the presented studies and asked some fascinating and thought-provoking questions. The first question discussed was regarding the idea of shared decision-making between the physician and patient, and how this impacts the placebo effect. During the presentation, Prof. Bingel highlighted that if the patient is able to choose their drug from options provided, this would be beneficial because the option chosen will be the one that the patient has the highest treatment expectation for. This means that the expectation placebo bonus accompanying the treatment will be enhanced. Prof. Bingel followed this up by referring to a study where the placebo effect was larger when a patient was able to decide on their treatment option, but mentioned it was also found that if a patient was given too many treatment options to decide from, the placebo effect was attenuated or even immeasurable.8
One of the following discussion points was based on the open-label placebo studies where therapeutic effects were observed after specific placebo-related communications were delivered, e.g. ‘the placebo effect is powerful’.9 Prof. Bingel mentioned that these observations were hard to explain because, in her experience, patients taking part in these studies did not have high expectations for their treatment outcomes. Further discussion around the study design of these open-label placebo studies prompted Prof. Bingel to introduce a fascinating and poorly understood concept: reattribution of natural fluctuation, which she considered to lead to an internal ‘self-fulfilling prophecy’. This concept is thought to occur due to the coincidental temporal relationship between the reduction in pain intensity due to natural fluctuations in a chronic pain condition and open-label placebo administration. Prof. Bingel suggests that this phenomenon may be explained by the patient reattributing this coincidental reduction in pain intensity to the placebo, thereby causing them to believe that the placebo is actually effective and to expect analgesic effects..
One of the final topics discussed was how these compelling findings around the placebo and nocebo effects are being implemented into clinical practice. Prof. Bingel was able to give her point of view as a physician in Germany and mentioned that there is slow progress with changes in medical education and drug approval processes. More positively, she states that the German guidelines for treatment for post-operative analgesia has explicitly implemented the augmenting effect of placebo-enhancing patient–physician communication. Furthermore, she mentions that there are currently workshops in Germany on the topic of whether placebos or placebo-enhancing strategies could somehow be covered by standard healthcare insurance, which she sees as a positive step forward.
- Vase L, et al. Pain. 2009; 145(1–2): 36–44
- Kaptchuk TJ, et al. BMJ. 2008; 336: 999–1003
- Bingel U, et al. JAMA. 2013; 310(16): 1733–1735
- Benedetti F, et al. Pain. 2014; 155(5): 921–928
- Waber RL, et al. JAMA. 2008; 299(9):1016–1017
- Ader R, et al. Science. 1982; 215(4539): 1534–1536
- Doering BK, et al. Trends Pharmacol Sci. 2012; 33(3): 165–172
- Hafner RJ, et al. Amer J Psychol. 2018; 131(2): 175–184
- Kaptchuk TJ, et al. Plos One. 2010; 5(12): e15591