Placebo or nocebo: The importance of doctor-patient conversations

20170125130000, Brenda Lau
It is time to recognise the power of the doctor-patient conversations.
It is time to recognise the power of the doctor-patient conversations.
A simple conversation between doctor and patient can be as equally potent as an analgesic as many of the treatments prescribed or it can cause more harm, and this is because the mind is a powerful thing that can affect the body. However it is usually overlooked.

There are two strongly believed principles of medicine: doing no harm and providing patient with information for an informed consent. However, sometimes following one of these principles violates the other.

For instance, for patients who are told that they are likely to experience a number of side effects from a particular prescription, will more likely experience those side effects, according to Ted Kaptchuk, a professor of medicine at Harvard Medical School and the director of the Program in Placebo Studies at Beth Israel Deaconess Medical Centre.

"Almost anything can be a side effect," says Kaptchuk. This effect is commonly known as the "nocebo" effect - a negative placebo. So patients instead, expect to suffer from side effects, which are very much "real" things that have an impact on their health and lives, and can be costly.

"Nocebo effects are very, very important," Kaptchuk adds.

No "absolute" truth about side effects

In one study, 96 people testing out beta-blockers, 3.1% of the participants - unaware of the drug they were taking -experienced erectile dysfunction. In the group that were aware, 15.6% had similar problems. However, a third group of patients were told erectile dysfunction was a side effect of the drug and a stark 31.2% reported those troubles - ten times more likely.

Similarly, patients who are told that something is going to hurt, will experience more pain than patients who are told that they will just feel a cooling sensation or will be too numb to feel any pain. Studies of the brain have shown that people experiencing the nocebo effect will show increased brain activity that indicates pain and decreased dopamine and natural opioid activity, translating a psychological effect into a physical effect.

Therefore there is no "absolute" truth about side effects, but it does not mean that all side effects are changed by the nocebo effect.

A potential solution: "Contextualise informed consent"

"It's only things the brain can modulate," says Kaptchuk.

"The brain can make you feel more pain or less pain, more depressed or less, more or less nausea."

Some drugs have side effects that exist independent of neuromodulation - such as liver damage or increased ulcer risk. Those are things that cannot be changed by placebos or nocebos, therefore patients should always be told about those risks.

But what to tell patients about those slightly more vague side effects is more complicated. Kaptchuk suggests that one potential solution is "contextualised informed consent" - telling patients about definitive side effects but for those more susceptible to nocebos or placebos, may not need all details.

Positive placebos can also help in patient recovery

On the other hand, positive conversations between doctor and patient can help in recovery and pain modulation. In 2014, researchers in Canada did an interesting study about the role of communication in the treatment of chronic back pain. Half of the participants of the study received mild electrical stimulation from physical therapies, while the other half received placebo stimulation whereby the equipment was set up but no electrical current was activated.

The patients in the placebo, experienced a 25% reduction in their levels of pain, while the patients who underwent the real stimulation, did do better - a 46% reduction. It proved that the treatment worked.

Subsequently, each of these groups were further divided in half. One half experienced limited conversation from the physical therapist, whereas the other, the therapists asked open-ended questions and listened attentively to the answers. Empathy was expressed and words of encouragement were offered.

Patients who received placebo treatment, but had therapists who actively communicated, reported an astounding 55% decrease in their pain. This meant that communication alone was more effective than treatment itself. Combining the two was even better as patients who got electrical stimulation and active communication from physical therapists reported a 77% reduction in pain.

Communication as a remedy

Ethically, doctors do not want to be accused of withholding information from patients and would be deemed unethical to promote placebos to patients. However, many say it would also be unethical not to give placebos a try in situations where patients are not getting relief from traditional means.

Nevertheless, it is clear that how doctors and nurses communicate their treatment can have profound effects on how patients experience the results of that treatment - and it is time to recognise the power of doctor-patient conversations. MIMS

Read more:
Why do placebos work?
When are placebos no longer placebos?
Balancing tradition and science : how to handle patients that believe in old wives’ tales

Sources:
https://mobile.nytimes.com/2017/01/19/opinion/sunday/the-conversation-placebo.html?smid=fb-share&referer=http%3A%2F%2Fm.facebook.com%2F
http://www.businessinsider.my/how-placebo-nocebo-effects-work-2017-1/?r=US&IR=T#luDjK1xPw1mYI06M.97