Opinion - Placebo Effect Is Powerful - The New York Times

‘No Better Than Placebo’
Oct. 10, 2023, 5:01 a.m. ET
Dan Saelinger/Trunk Archive
By Ted J. Kaptchuk
Dr. Kaptchuk is a professor of medicine at Harvard Medical School. He

directs the Harvard-wide Program in Placebo Studies hosted at the Beth
Israel Deaconess Medical Center.
An advisory committee for the Food and Drug Administration recently

concluded that a popular oral decongestant sold over the counter was no
better than placebo. The agency now faces the question of whether to
pull medications that use the ingredient — called phenylephrine — off
store shelves.
The news spurred shock and anger over how long ineffective medicines
have been for sale. But amid the criticism, there were also some who
lamented the possibility that their favorite cold medicine would be taken
from them. In their view, it may not work — but it still does something for
them.
I’m a researcher who studies the placebo effect, and in some situations,
it’s powerful. That said, oral phenylephrine sold over the counter should
be removed from the market; despite some people’s love of phenylephrine
cold medicines, there’s no evidence that the drug even provides placebo
benefits. In clinical trials reviewed by the F.D.A. committee, phenylephrine
and a placebo each affected patients’ perceptions of nasal congestion
equally — but the existing trials do not tell us to what extent people felt
better because of placebo effects or because their cold simply resolved
on its own.
This controversy highlights the perplexing messages that imprison

placebos in general. In research settings, placebo responses are powerful
but a nuisance, as it makes detecting a drug’s superiority over a placebo
difficult. And in clinical practice they are powerful, but they often require
deception, making them unethical. But can placebos ever come out of the
dark shadows and become a legitimate component of health care? My
research suggests so.
Placebo effects are health improvements initiated from the rituals,

symbols and behaviors involved with healing. A 2020 review I co-wrote in
the medical journal The BMJ examined data from over 140,000 patients
with various chronic pain conditions. We found that placebo responses
range from moderate to large and can account for 50-75 percent of the
benefits of drug treatments for pain. Similar effects can be seen in
research around symptoms such as cancer-related fatigue and
menopausal hot flashes.
Fifteen years ago, in the middle of my career as a placebo researcher, I
had a crisis. My ultimate research goal had been to harness the power of
placebo to relieve unnecessary suffering. But my early experiments
always involved telling participants that they might receive, or were
receiving, real medications when they were not. Placebos were tainted by
trickery. I began to question the conventional dogma that placebos only
“work” if patients don’t know they’re placebos. Could I instead be honest?
My colleagues thought I was nuts.
As it turns out, placebos can work even if a patient knows they are getting
a placebo. In 2010, my colleagues and I published a provocative study
showing that patients with irritable bowel syndrome who were treated with
what we call “open-label placebos” — as in, we gave them dummy pills
and told them so — reported more symptom relief compared to patients
who didn’t receive any placebos. (These placebos were given with
transparency and informed consent.) In another blow to the concept that
concealment is required for placebo effects, my team recently published a
study comparing open-label placebos and double-blind placebos in
irritable bowel syndrome and found no significant difference between the
two. A medical myth was overthrown.
Currently, more than a dozen randomized trials demonstrate that open-

placebo treatment can reduce symptoms in many illnesses with primarily
self-reported symptoms such as chronic low back pain, migraine, knee
pain and more. These findings suggest that patients do not have to
believe, expect or have faith in placebos pills to elicit placebo effects. So
what’s happening?
To date, the best explanation for the results of open-placebo trials

suggests that, for certain illnesses where the brain amplifies symptoms,
engaging in a healing drama can nudge the brain to diminish the volume
or “false alarm” of what’s called central sensitization — when the nervous
system overemphasizes or amplifies perceptions of discomfort. This
mostly involves nonconscious brain processes that scientists call
“Bayesian brain,” which describes how the brain modulates symptoms up
or down. Both the intensification and relief of symptoms share the same
neural pathways. Considerable evidence also shows that placebos, even
when patients know they are taking them, trigger the release of
neurotransmitters like endorphins and cannabinoids and engage specific
regions of the brain to offer relief. Basically, the body has an internal
pharmacy that relieves symptoms.
What does this mean for medicine?
Physicians are unlikely to start prescribing placebo pills without much

more rigorous evidence, which I would like to see as well, though I do
think they could have a role. Especially for people who don’t receive relief
from other therapies. At least $250 billion is spent yearly to care for
symptoms like chronic pain that lack adequate or safe treatments, and the
results are dismal. People treated in our open-label placebo trials usually
express skepticism about what they are doing; it is often only their
desperation that leads them to try.
But placebos shouldn’t be a first-line treatment — patients should be

given what effective medicines are available. After all, placebos rarely, if
ever, change the underlying pathology or objectively measured signs of
disease. I like to remind people that they don’t shrink tumors or cure
infections.
Crucially, much discussion and self-reflection is needed among physicians

and our health care system as a whole to understand why the act of
treatment itself is so powerful to patients even if a pill contains no
therapeutic ingredients. Medicine is not only effective drugs and
procedures; it’s a human drama of charged engagement. Our team
published a study in The BMJ demonstrating that placebo effects can be
significantly enhanced in the context of a supportive, respectful, and
attentive patient-clinician relationship. Acts of human kindness in general
are linked to robust placebo effects.
Any health intervention, whether it’s cold medicine or placebos, should be

ethical and have measurable benefits if they are to be used. But health
care should retain the knowledge that rituals, symbols, and human-
kindness matter immensely when it comes to healing.
Ted Kaptchuk is a professor of medicine and professor of global health

and social medicine at Harvard Medical School. He directs the Harvard-
wide Program in Placebo Studies hosted at the Beth Israel Deaconess
Medical Center. He has been a leading figure in placebo studies for over
30 years.
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‘No Better Than Placebo’

Oct. 10, 2023, 5:01 a.m. ET

Dan Saelinger/Trunk Archive

Dr. Kaptchuk is a professor of medicine at Harvard Medical School. He

An advisory committee for the Food and Drug Administration recently

This controversy highlights the perplexing messages that imprison

Placebo effects are health improvements initiated from the rituals,

Currently, more than a dozen randomized trials demonstrate that open-

To date, the best explanation for the results of open-placebo trials

What does this mean for medicine?

Physicians are unlikely to start prescribing placebo pills without much

But placebos shouldn’t be a first-line treatment — patients should be

Crucially, much discussion and self-reflection is needed among physicians

Any health intervention, whether it’s cold medicine or placebos, should be

Ted Kaptchuk is a professor of medicine and professor of global health

The Times is committed to publishing a diversity of letters to the editor.

Follow The New York Times Opinion section on Facebook, Twitter

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