Biological, clinical, and ethical advances of placebo effects
Biological, clinical, and ethical advances of placebo eﬀ ects Damien G Finniss, Ted J Kaptchuk, Franklin Miller, Fabrizio BenedettiLancet 2010; 375: 686–95 For many years, placebos have been deﬁ ned by their inert content and their use as controls in clinical trials and University of Sydney Pain treatments in clinical practice. Recent research shows that placebo eﬀ ects are genuine psychobiological events Management and Research attributable to the overall therapeutic context, and that these eﬀ ects can be robust in both laboratory and clinical Institute, Royal North Shore settings. There is also evidence that placebo eﬀ ects can exist in clinical practice, even if no placebo is given. Hospital, St Leonards, NSW, Further promotion and integration of laboratory and clinical research will allow advances in the ethical use of Australia
(D G Finniss MSc [Med]); Osher placebo mechanisms that are inherent in routine clinical care, and encourage the use of treatments that stimulate Research Center, Harvard placebo eﬀ ects. Medical School, Boston, MA, USA (T J Kaptchuk); Department Introduction of Bioethics, National Institutes of Health, Bethesda,
The notion of something called “placebo” started with laboratory and clinical settings could lead to a
MD, USA (F Miller PhD); and
St Jerome’s mistranslation of the ﬁ rst word of the ninth
reconsideration of placebo eﬀ ects with implications for
Department of Neuroscience,
line of Psalm 116, when instead of translating the clinical practice. University of Turin Medical
Hebrew “I will walk before the Lord”, he wrote “Placebo
School, and National Institute of Neuroscience, Turin, Italy
Domino in regione vivorum” (“I will please the Lord in
the land of the living”). By the 13th century, when hired
The association of placebo eﬀ ects with RCTs has caused
mourners waited for Vespers for the Dead to begin, confusion because the response in the placebo group is
they often chanted the ninth line, and so were called not necessarily a genuine psychosocial response to the
“placebos” to describe their fake behaviour.1 Later, in simulation of treatment. In fact, the reported response
TheCanterbury Tales, Chaucer named his sycophantic, to placebo in RCTs might reﬂ ect the natural course of
ﬂ attering courtier Placebo. The introduction of placebo
disease, ﬂ uctuations in symptoms, regression to the
controls, which entailed the administration of fake mean, response bias with respect to patient reporting of
procedures to separate the eﬀ ects of imagination from subjective symptoms, or other concurrent treatments. reality, began in the 16th century with progressive Furthermore, a traditional focus on the inert content of Catholic eﬀ orts to discredit right-wing exorcisms.2
Individuals “possessed” by the devil were given false understanding placebo eﬀ ects,7,8 not to mention holy objects and if they reacted with violent applying them in clinical research and practice.9contortions—as if they were genuine relics of the holy
Much of the controversy surrounding placebo eﬀ ects
cross or consecrated wafers—it was concluded that relates to how they are considered and then deﬁ ned. their possession was in their imagination. This idea of placebo controls was then used in medical experiments, beginning with the Franklin commission’s debunking
Search strategy and selection criteria
of the psychic force of mesmerism or animal magnetism
We searched the Cochrane Library (2001–09), Medline
(1902–2009), PreMedline, and Embase (1966–2009)
The use of the word placebo in a medical context to
databases for reports published in English using the search
describe innocuous treatments to make a patient
terms “placebo”, “placebo eﬀ ect”, “placebo response”,
comfortable dates from at least the end of the
“nocebo”, “context eﬀ ect”, “patient-therapist interaction”,
18th century.4 The earlier, unsavoury connections
“expectation”, and “conditioning”. We mainly selected
undoubtedly led to the tainted reputation of
reports published in the past 10 years, but did not exclude
placebos and placebo eﬀ ects that persisted until very
frequently referenced and highly regarded older
recently.1 Mainstream interest in placebo eﬀ ects only
publications, especially those that were pertinent to the
began with the widespread adoption of the randomised
history and understanding of placebo eﬀ ects. We also
controlled trial (RCT) after World War II, when it was
searched the reference lists of articles identiﬁ ed by this
times search strategy, particularly the reference lists of systematic
dramatically—in placebo control groups.5 Soon after, in
reviews and meta-analyses, and selected those we judged
his famous proto-meta-analysis, Henry Beecher claimed
relevant, including review articles and book chapters.
that about 35% of patients responded positively to
Reports were included if they studied or discussed the
placebo treatment.6 Beecher, however, encouraged an
history, ethics, and mechanisms of placebo use and placebo
inﬂ ated notion of the “powerful placebo” because he
eﬀ ects both in experimental and clinical settings. In the
failed to distinguish the placebo response from other
case of mechanistic and clinical trials, trials were only
confounding factors. Since this time, there has been
included if they were controlled; however, rare exceptions
increasing interest in investigating placebo eﬀ ects by
were made for older and relevant articles in which a control
rigorous research methods, especially in the past
10 years. In this Review, we assess whether advances in
www.thelancet.comVol 375 February 20, 2010
Generally, a placebo is seen as an inert substance or procedure and the placebo eﬀ ect (or response) is
Psychosocial context surrounding Response
something that follows administration of a placebo.
The paradox here is that if something is inert, it is by deﬁ nition unable to elicit an eﬀ ect.7,8 This deﬁ nition can be further confused with terms such as active,10 true,
Individual patient and clinician factors eg, patient’s and clinician’s beliefs,
and perceived placebos,11 which are all attempts to better
understand placebo eﬀ ects, and other terms such as
context eﬀ ects12,13 and meaning responses,7 which have
shifted the focus from the use of the word placebo.
Nevertheless, the placebo terminology, despite its
defects, is too engrained in the scientiﬁ c literature to
Interaction between the patient,
replace it at this time, especially in the absence of a
clinician, and treatment environment
eg, factors constituting the clinician–
To resolve these confusions and better understand
placebo eﬀ ects in clinical trials and practice, it is
necessary to reconsider placebos and placebo eﬀ ects,
shifting the focus from the inert content of a placebo or
sham procedure to what the placebo intervention—
consisting of a simulated treatment and the surrounding clinical context—is actually doing to the patient. Accumulated evidence suggests that the placebo eﬀ ect Figure 1: Contribution of the psychosocial context surrounding the patient (or placebo component of a given is a genuine psychobiological event attributable to the treatment) to the overall response overall therapeutic context.9,14 This psychosocial context can consist of individual patient and clinician factors, anxiety reduction, and meaning.9,39 Although there is a and the interaction between the patient, clinician, and growing amount of research into these mechanisms, treatment environment. The treatment environment two principal mechanisms are well supported. represents the many factors associated with a treatment
The ﬁ rst mechanism involves expectancy: patients
context (such as the speciﬁ c nature of the treatment given placebo have expectations of future responses.40 and the way it is delivered) and the patient–clinician Many experiments have used simple verbal cues as relationship, which is a term that encompasses several modulators of expectations.17,33,41 For example, a factors that constitute the therapeutic interaction participant receiving experimentally induced pain is (ﬁ gure 1).12 The placebo intervention is designed to given a topical placebo cream in the context of two simulate a therapeutic context such that the eﬀ ect of diﬀ erent cues: the ﬁ rst that the cream is inert and will the intervention (placebo eﬀ ect) is attributable to the have no eﬀ ect and the second, that the cream is a way in which this context aﬀ ects the patient’s brain, powerful pain killer.41 Such verbal cues have been shown body, and behaviour.9 When an active treatment is to manipulate patients’ expectations and mediate given, the overall response is the result of the treatment
ects—eg, placebo analgesic eﬀ ects in
itself and the context in which it is given. Such a concept
experimental33 and clinical pain,42 placebo-induced
allows for progression in understanding of the many changes in motor performance in Parkinson’s factors that make up the psychosocial context disease,23,43 changes in emotions,28 and brain responses surrounding a patient and how these factors, and the in patients with drug addiction.30 Furthermore, the mechanisms by which they operate, can be enhanced in
presence of a conditioning protocol to increase
expectations results in larger analgesic responses to placebo, showing that expectation can both mediate and
Mechanisms of placebo eﬀ ects
modulate placebo eﬀ ects,17,44,45 as well as interact with
Some of the mechanisms that underlie placebo eﬀ ects other constructs such as desire and emotion.9,42are summarised in the table, showing that there is not
A second mechanism underlying placebo eﬀ ects
one placebo eﬀ ect, but many.14–16 These mechanisms can
involves classical conditioning.46 Repeated associations
be broadly discussed from psychological and neuro-
between a neutral stimulus and an active drug
(unconditioned stimulus) can result in the ability of the neutral stimulus by itself to elicit a response characteristic
of the unconditioned stimulus. Classical conditioning
From a psychological viewpoint, there are many mecha-
mechanisms have been shown in both animal34,47,48 and
nisms that contribute to placebo eﬀ ects. These human studies,35,36,44,45 although it has been diﬃ
mechanisms include expectations, conditioning, exclude any cognitive component (such as expectation) learning, memory, motivation, somatic focus, reward, in human beings.49,50 Despite this issue, conditioning
www.thelancet.comVol 375 February 20, 2010 Neurobiological mechanisms Mechanisms
Activation of endogenous opioids and dopamine (placebo); activation of
neurobiological viewpoint further emphasises that
cholecystokinin and deactivation of dopamine (nocebo)17–22
there are several placebo eﬀ ects. Placebo eﬀ ects can
Activation of dopamine in the striatum and changes in activity of neurons in
occur in diﬀ erent physiological systems in healthy
volunteers and in patients with many diﬀ erent clinical
Changes of electrical and metabolic activity in diﬀ erent brain regions (eg, ventral striatum)26,27
Changes in activity of the anterior cingulated and orbitofrontal cortices;
Most research into the neurobiology of placebo
genetic variants of serotonin transporter and tryptophan hydroxylase 228,29
responsiveness has addressed placebo analgesia;
Changes of metabolic activity in diﬀ erent brain regions30
accordingly, the neurobiology of placebo eﬀ ects is
Change of neuronal excitability in limbic regions31
usually considered in terms of opioid and non-opioid
mechanisms.54,55 Several studies have shown that
Reduction of β-adrenergic activity of heart32
placebo eﬀ ects can be completely18,19,56 or partly reversed57
Conditioning of opioid receptors in the respiratory centres33
by the opioid antagonist naloxone, supporting the
Conditioning of some immune mediators (eg, interleukin 2, interferon γ,
involvement of endogenous opioids in some placebo
analgesic eﬀ ects.58 Furthermore, placebo analgesic
Conditioning of some hormones (eg, growth hormone, cortisol)36
eﬀ ects are likely to be inhibited by the peptide
Activation of endogenous opioids and increased muscle work37,38
cholecystokinin,19 since such eﬀ ects are potentiated in
Prefrontal executive control and functional connectivity of prefrontal areas21
patients treated with cholecystokinin antagonist.59,60
Table: Mechanisms for placebo eﬀ ects in medical conditions and physiological systems
Several studies have shown that placebo eﬀ ects can occur at speciﬁ c body regions.33,41,61 This body-region speciﬁ city is reversed by naloxone,33 suggesting that
mechanisms in human beings are substantiated by the analgesic responses to placebo involve highly speciﬁ c fact that placebo eﬀ ects are higher in magnitude after a endogenous opioid release, rather than a more conditioning protocol (even if an expectation mechanism
generalised opioid release (such as increased opioid
is present).17 Additionally, conditioning mechanisms concentration in the cerebrospinal ﬂ uid).62 These results mediate placebo-induced changes in unconscious have been substantiated and extended by brain imaging physiological processes such as hormone secretion36 and
techniques such as PET63,64 and functional MRI.65–67 In
one PET study, brain changes in response to placebo
The interaction between expectation and conditioning
were reported to be similar to changes seen after
mechanisms remains an area for further research, treatment with opioid drug.68 Opioid-mediated placebo which might be particularly relevant to exploring the responses also extend beyond pain pathways. Some clinical implications of these mechanisms. Although studies have shown that placebo-induced respiratory classical conditioning, manifesting an automatic depression (a conditioned placebo side-eﬀ ect)69 and unconscious mechanism, exists in human beings, it decreased heart rate and β-adrenergic activity32 can be can also be regarded as a complex process consisting of
cognitive components and derived from previous
Many placebo eﬀ ects are mediated by non-opioid
experience of either positive or negative therapeutic mechanisms, such as the release of diﬀ erent neuro-outcomes.51 Accordingly, conditioning and expectation transmitters and neuromodulators. In one study, the are certainly entangled in the occurrence of placebo placebo response in participants who had previous eﬀ ects in clinical practice. The most reasonable conditioning with an opioid drug was reversed by interpretation of recent publications is that conditioning
naloxone; however, there was no reversal in those who had
follows expectation and is dependent on the success of conditioning with a non-opioid drug.17 Therefore, the ﬁ
rst encounter. This notion leads to the completely diﬀ erent placebo mechanisms can be produced
possibility that the ﬁ rst encounter is crucial for the depending on the drug used in the conditioning protocol. development of subsequent robust placebo responses:
Although other medical disorders have been
the higher the expectation, the greater the placebo eﬀ ect, investigated from a neurobiological perspective, the and potentially the greater the conditioning placebo mechanisms in these conditions are little eﬀ ects associated with future drug intake.
understood compared with those for pain and analgesia.
In addition to classical conditioning, other learning For example, in patients with Parkinson’s disease,
processes such as past experiences and social administration of placebo led to dopamine release in observation mediate placebo eﬀ ects.52 For example, the striatum23,70 and resulted in changes in basal ganglia participants who observed a demonstrator simulating and thalamic neuron ﬁ ring.24,25 Studies have also shown responsiveness to a therapy had placebo analgesic changes in metabolic activity in the brain after responses that were similar in magnitude to those in administration of placebo in patients with depression26 patients who received a classical conditioning and after manipulation of expectations in patients with procedure.53
www.thelancet.comVol 375 February 20, 2010 Psychosocial context Figure 2: Receptor pathways activated by both psychosocial context and drugs Social stimuli around the treatment might activate, through expectation or conditioning mechanisms, several receptor pathways in diﬀ erent diseases and therapeutic interventions (the involvement of serotonin [5-hydroxytryptamine; 5HT] receptors in hormonal responses and depression is not deﬁ nitive). These receptors are the same to which diﬀ erent drugs bind, suggesting that psychosocial factors are capable of modulating the action of drugs. This interference has implications for our understanding of drug action: when a drug is prescribed, the very act of giving it to a patient (ie, the psychosocial context) might aﬀ ect the system and change the response to the drug. Reproduced with permission from reference 39. IFNγ=interferon γ. IL2=interleukin 2. CCK=cholecystokinin.
Less research has been concerned with the nocebo representative of normal clinical practice than a clinical
eﬀ ect, an occurrence that is opposite to the placebo trial setting. It is therefore important to bridge this gap eﬀ ect. The reason for the paucity of data is mainly by looking at placebo research from basic science, because of ethical limitations, since nocebo clinical trial, and ethical perspectives in an attempt to administration involves the induction of negative better understand how placebo eﬀ ects operate in the expectations. Cholecystokinin has a key role in nocebo clinical setting. hyperalgesia, which occurs through anticipatory anxiety
A single-blind RCT in 262 patients with irritable
mechanisms.20,21,37 De activation of dopamine release has
bowel syndrome investigated whether placebo eﬀ ects
also been found in the nucleus accumbens during can be disaggregated into two main components nocebo hyperalgesia,22 which suggests the involvement (placebo ritual alone and placebo ritual plus supportive of diﬀ
transmitters. Furthermore, a patient–clinician relationship) and then progressively
neuroimaging study has shown that nocebo aﬀ ects combined to produce clinically signiﬁ cant improvements brain activation diﬀ erently from placebo, including in compared with no treatment.77 The placebo ritual the hippocampus and regions involved with antici-
consisted of a validated placebo acupuncture device,
which was used in both treatment groups.78 Instead of penetrating the skin, the needle retracts into the needle
Implications for clinical practice
handle. The supportive patient–clinician relationship,
Understanding how placebo eﬀ ects work clinically in used only in one group, was prospectively scripted and relevant patient populations over time has not kept pace
consisted of attention, warmth, conﬁ dence, and
with the recent research into mechanisms of placebo thoughtful silence. At the 3-week outcome, adequate eﬀ
ects, which has mainly involved laboratory relief on a validated measure for irritable bowel
experiments done over short durations with healthy syndrome was reported by 62% of participants in the participants. In the case of clinical populations, the placebo ritual plus supportive care group, 44% in the study of long-term placebo responsiveness has been placebo ritual alone group, and 28% in the no-treatment limited to RCTs. However, these studies rarely included
group (p<0·001). The results were similar with three
groups of participants receiving no treatment to control
other validated measures for irritable bowel syndrome
for natural history and regression to the mean, making
used in the study. The eﬀ ect size of 62% adequate relief
cult to discern a genuine placebo eﬀ ect. Several was similar to the improvement seen in patients treated
meta-analyses have attempted to address the presence with alosetron in RCTs of irritable bowel syndrome.79 and magnitude of placebo eﬀ ects in RCTs, including Outcomes were similar after an additional 3 weeks of some studies in which no-treatment control groups follow-up. In addition to showing that genuine placebo were used. These analyses concluded that placebo eﬀ ects can be statistically and clinically signiﬁ cant over eﬀ ects are small and limited to subjective outcomes time in clinical populations, this trial showed that when placebos are used as a control condition in placebo eﬀ ects can be incrementally added in a manner RCTs.72–74 However, placebo eﬀ ects are much larger in resembling a graded dose escalation of component studies that investigate placebo mechanisms.75,76 This factors. In a separate analysis of the study, patient ﬁ nding is not at all surprising given that the mechanistic
extroversion, agreeableness, and openness to experience
experiments use controlled manipulations of verbal were found to be associated with placebo responses in instructions and context that might be more the placebo ritual plus supportive care group but not in
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(amitriptyline) and the sham acupuncture group was
Routine medical practice
Although 30% of people in both placebo groups
reported adverse eﬀ ects, the type of eﬀ ects diﬀ ered between groups and mimicked the information provided during the informed consent process.
Some commentators have suggested that alternative
therapies with elaborate procedures and distinct environmental cues might have pronounced and
clinically signiﬁ cant placebo eﬀ ects.83,84 Recent RCTs of acupuncture, although not designed to study placebo
Treatment simulation with placebo
eﬀ ects, have provided results that lend support to this
hypothesis. A series of large trials in Germany compared acupuncture done according to traditional Chinese medicine (verum acupuncture), sham acupuncture (superﬁ cial needling at non-acupuncture points), and
either no-treatment or usual clinical care. Conditions studied included migraine,85 tension headaches,86
Hidden dose of active treatment
chronic low back pain,87,88 and osteoarthritis of the
knee.89 Generally across the various trials, outcomes did not diﬀ er between verum and sham acupuncture groups; however, participants in both of these groups
had substantially greater symptom improvement than did those in the no-treatment and usual clinical care
Figure 3: Rationale of the open-hidden study design
control groups.90 Linde and colleagues91 reported that in
In routine clinical practice, any treatment has a speciﬁ c and a non-speciﬁ c eﬀ ect.
four of these RCTs (n=864), patient’s expectation of
The non-speciﬁ c eﬀ ect might come from the knowledge that a treatment is
pain relief was the most robust predictor of eﬃ
being given. The eﬀ ectiveness of the active treatment can be assessed either by eliminating its speciﬁ c eﬀ ect (placebo study) or by eliminating the non-speciﬁ c
acupuncture treatment, irrespective of the group
eﬀ ects (hidden treatment). Reproduced from reference 94.
assignment to genuine or sham treatment. The eﬀ ect of positive expectation on outcome lasted for 1 year. These
the placebo ritual alone group.80 The investigators also results therefore accord with the hypothesis that reported signiﬁ cant diﬀ erences in outcomes between acupuncture works by means of a placebo eﬀ ect. A practitioners. Future integration of such study designs more recent study in 640 patients with chronic low back in RCTs with mechanistic laboratory work will allow for
pain showed that participants assigned to 8 weeks of
better understanding of these placebo mechanisms and
toothpick simulation sham acupuncture plus usual care
how they can be augmented in clinical practice.
had clinically meaningful improvements in outcomes
Several RCTs have examined whether diﬀ erent compared with those assigned to usual clinical care
methods for delivery of placebo produce diﬀ erent alone, and such eﬀ ects also lasted for 1 year.92 This study eﬀ ects.81 The largest such study, in 270 patients with however did not ﬁ nd a correlation between measured chronic arm pain caused by repetitive use, compared a
sham device (placebo acupuncture) with an inert oral
Some of the clearest evidence supporting the
pill.82 At 2 weeks of treatment, patients assigned to involvement of placebo eﬀ ects in clinical care comes placebo pills had greater improvement in ability to from trials with an open-hidden study design (ﬁ gure 3). function (mainly related to less disturbed sleep because
In this experimental approach, a treatment is given in a
of pain) than did patients assigned to sham acupuncture
routine manner (open treatment), in which the
(p<0·05); however, pain did not diﬀ er between groups.
psychosocial context surrounding treatment admin-
At the end of the study (6 weeks), patients assigned to istration is present, and in a hidden manner, in which sham acupuncture had a signiﬁ cant reduction in pain the treatment is given without the patient’s knowledge. compared with those in the placebo pill group In the case of a drug intervention, the open treatment (p<0·001). Depending on the complaint and the length
mimics normal clinical care; the clinician injects a drug
of time that placebo was received, diﬀ erent placebos in full view of the patient with verbal and contextual had diﬀ erent eﬀ ects. Not all medical rituals are the interactions. For the hidden treatment, the drug is same: placebo pills are better for sleep and sham infused by a computer pump in the absence of the needles are better for pain. Nocebo eﬀ ects also diﬀ ered clinician and the therapeutic context. Patients receiving between treatment delivery groups. Patients in the hidden treatment are aware that at some stage they will placebo pill group were told they might have the receive a drug but they do not experience the expectation adverse eﬀ ects (eg, drowsiness) of a medication component or other contextual factors surrounding the
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treatment. Because the hidden administration removes
Placebo mechanisms can interact with drug treatments,
the psychosocial context of treatment, the placebo even if no placebo is given, since every treatment is component is deﬁ ned as the diﬀ erence in outcome given in a therapeutic context that has potential to between open and hidden treatments, although no activate and modulate placebo mechanisms, many of placebo is given.94,95
which can act on similar biochemical pathways to the
The open-hidden study design has been used in actual drug (ﬁ gure 2).
several clinical settings. Hidden treatment with widely
A short-term experimental trial done in 2001 has
used painkillers (morphine, buprenorphine, tramadol, advanced our understanding of the clinical implications ketorolac, metamizol) has been shown to be markedly of modulating placebo eﬀ ects in routine clinical care. less eﬀ
ective in reducing pain than has open In this trial, which assessed postoperative pain over
treatment.94,96,97 This ﬁ nding was seen in both healthy several days, patients were given intravenous saline volunteers receiving experimentally induced pain (pain
(placebo) as a background infusion in addition to
ratings were higher in the hidden treatment group routine analgesic treatment (buprenorphine on than in the open treatment group) and in patients with
request).98 One group of patients was told that the basal
postoperative pain (the dose needed to reduce pain by infusion was a rehydrating solution (natural history 50% was much higher in the hidden treatment group control group) and another group was told that it was a than in the open treatment group).96 Similar diﬀ erences powerful painkiller (maximum placebo context). Overall between open and hidden treatment groups have been intake of buprenorphine was monitored throughout the reported after drug treatment in patients with anxiety trial. The clear diﬀ erences in the context (mainly and after deep brain stimulation in patients with expectation of beneﬁ t) of the basal infusion resulted in Parkinson’s disease.31,97 Slightly diﬀ erent methods have
substantial diﬀ erences in drug intake. The group who
been used in patients with drug addiction; the absence
believed the solution was assisting in analgesia took
of an expectation component in patients given 33% less buprenorphine for the same pain control than stimulant drug treatment resulted in reduced regional did those in the natural history control group, showing brain glucose metabolism and verbal reports of an important clinical eﬀ ect and the potential for use of eﬃ
cacy.30 Thus, the overall outcome of a treatment placebo eﬀ ects in conjunction with an active treatment
combines the speciﬁ c pharmacological or physiological
to reduce overall drug intake. A third group were told
action of the treatment and the psychosocial context in
that “the solution may or may not be a powerful
which it is delivered. The psychosocial context painkiller”, representing classic double-blind treatment represents the placebo component, which is based on used in placebo-controlled trials. In this group, patients patient expectations.
took 20% less buprenorphine than did controls.
The open-hidden study design has provided a means
Similar modulations in short-term placebo eﬀ ects
of exploring the interaction between placebo eﬀ ects and have been reported in more recent studies in patients responses to active treatments. This analysis has not with irritable bowel syndrome.42,99 In these studies, been possible in standard RCTs designed to assess patients were exposed to a painful stimulus (rectal treatment eﬃ
cacy, since they only compare the response
to placebo with the response to the index intervention anaesthetic and placebo. In one study, patients were without providing an understanding of the interaction told that they “may receive an active or a placebo between the two. For example, ﬁ ndings from a clinical agent”,99 whereas in the second, they were told that “the trial done in 1995 showed that the cholecystokinin agent you have been given is known to signiﬁ cantly antagonist proglumide was more eﬀ ective in reducing reduce pain in some patients”.42 The subtle changes in intensity of postoperative pain than was placebo, which
in turn was more eﬀ ective than no treatment.59
responses, with larger placebo responses reported in
According to methods of analysis used in classic clinical
the second trial, which had more deﬁ nite instructions.
trials, these results would suggest that proglumide is a
Clinicians’ expectations also seem to aﬀ ect placebo
good analgesic drug that acts on pain pathways, whereas
responses. In a small, double-blind trial done in 1985,
placebo reduces pain by activating placebo analgesic patients with postoperative dental pain were divided mechanisms (through expectation pathways). However,
into two groups and told that they could receive a drug
this conclusion is erroneous, since a hidden injection which would increase their pain (naloxone), decrease of proglumide had no analgesic eﬀ ect. If the drug is an
their pain (fentanyl), or have no eﬀ ect (placebo).100 By
eﬀ ective modulator of pain pathways, such a diﬀ erence contrast, the clinicians were told that in one of the between open and hidden treatment would not be seen.
groups, there was no chance of receiving an active
In this instance, the drug achieves a response by analgesic drug, and to this extent it was the clinicians interacting with and enhancing placebo mechanisms who were manipulated and not the patients. The (expectation pathways), not by acting on pain pathways,
placebo response was substantially lower in the group
and therefore is only eﬀ ective when combined with the
that clinicians believed would receive no analgesic
placebo mechanisms inherent in the clinical encounter.
treatment. The double-blind nature of the study
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suggests that alterations in clinicians’ beliefs might concerns. To recommend or give a placebo intervention alter the therapeutic context (and placebo eﬀ ect) in deceptively as a treatment with speciﬁ c eﬃ
subtle ways, since patients were not aware of the patient’s condition violates informed consent and information given to the clinicians.
threatens the trust that is central to clinical practice.103
Loss of placebo mechanisms can have important Recent data suggest that prescriptions of sugar pills
clinical ramiﬁ cations. For example, an open-hidden and saline injections are rare,104,105 but that clinicians study in patients with Alzheimer’s disease showed that
often prescribe various active treatments with the main
the placebo component (diﬀ erence between open and intent of promoting a placebo response or complying hidden treatments) was correlated with cognitive status
with the wishes of the patient. The available evidence
and functional connectivity between brain regions.101
suggests that the practice of disclosure to patients
Reductions in both cognitive status and functional regarding such placebo treatments is deceptive or at connectivity correlated with reduced placebo least not suﬃ
mechanisms and reduced overall analgesic eﬀ ect, so
Can a recommendation for a treatment intended to
much so that an increase in dose was needed for the promote the placebo eﬀ ect be made without deception same level of analgesia. This ﬁ nding shows the and also without undermining its therapeutic potential? importance of not only attempting to increase placebo Consider, for example, the case of a clinician who components of treatments, but also of assessing recommends acupuncture treatment for a patient with situations in which loss of placebo mechanisms might chronic low back pain who has not been helped by necessitate an increased therapeutic dose.
standard medical therapy. Aware of the results of the recent acupuncture trials, this clinician thinks that
Ethical principles of enhancing placebo eﬀ ects
acupuncture might work by promoting a placebo
in clinical care
response. The clinician might provide the following
Any ethical assessment of eﬀ orts to promote placebo disclosure to the patient: “I recommend that you try eﬀ ects in clinical practice ﬁ rst requires knowledge as to
acupuncture. Several large studies have shown that
the clinical relevance and importance of placebo eﬀ ects. traditional acupuncture is not better than fake The evidence reviewed here outlines the potential for acupuncture treatment, but that both of these produce placebo interventions and the therapeutic context to substantially greater symptom improvement in patients promote clinically important symptomatic relief. with chronic low back pain compared with those Nevertheless, more studies of placebo eﬀ ects in speciﬁ c patients who receive no treatment or conventional clinical settings are needed before use of treatments medical therapy. Although the speciﬁ c type of needling with the primary aim of promoting placebo responses does not seem to make any diﬀ erence, it is possible that can be recommended as evidence-based practice.
acupuncture works by a psychological mechanism that
A second important ethical consideration relates to promotes self-healing, known as the placebo eﬀ ect”. At
whether and how placebo eﬀ ects can be promoted face value, this disclosure seems honest. A patient who without deception. Since placebo eﬀ ects are inherent in
received this disclosure and subsequently got better
routine clinical care, and the psychosocial context after undergoing acupuncture might nonetheless surrounding the patient (including the patient–clinician
develop a false belief about why it worked. This does
interaction and the therapeutic procedure) can be not mean, however, that the patient has been deceived enhanced to improve these placebo eﬀ ects, it is ethically
acceptable, not to mention clinically relevant, to provide
Can it be ethical for clinicians to prescribe inert
a supportive clinical encounter that relieves anxiety and
placebos with a disclosure that the treatment being
promotes positive expectations along with honest given “has been shown to be eﬀ ective by altering pain disclosure of the expected beneﬁ ts of a medically transmission in similar ways to other treatments”? As is indicated treatment. Therefore, routine conscious the case with most studies of the placebo eﬀ ect,102 an attempts to identify and exploit features of the clinical element of deception is involved. In this case, the encounter to augment placebo eﬀ ects represent one element of deception relates to a lack of full disclosure ethical (non-deceptive) means of applying the of the content of the placebo and the complete reason understanding of placebo mechanisms to improve for why it is being given—ie, not only to modulate pain clinical outcomes.
transmission but to do so through a placebo eﬀ ect.
Whether it is ethical to recommend a treatment Therefore, as with acupuncture, completely eliminating
primarily to produce a placebo eﬀ ect is a more deception would require additional disclosure that the complicated and controversial question. Most studies placebo had no active drug in it and would be working of the placebo eﬀ ect have used deception in the through psychological mechanisms that promote self-administration of inert placebos as a key element of healing. How such disclosure might aﬀ ect placebo experimental design. Whereas the use of deception in responses is unknown, and apart from two small trials research poses its own ethical issues,102 the problem of in patients with various mild psychiatric symptoms (and deception in clinical practice raises even stronger without a no-treatment control group),106,107 no research
www.thelancet.comVol 375 February 20, 2010
has addressed this important question. It is therefore 14 Miller FG, Kaptchuk TJ. The power of context: reconceptualizing important that clinicians who are recommending
the placebo eﬀ ect. J R Soc Med 2008; 101: 222–25.
treatments for the primary aim of enhancing placebo 15 Benedetti F. Placebo eﬀ ects: understanding the mechanisms in
health and disease. New York: Oxford University Press, 2009.
eﬀ ects are aware of the ethical implications of diﬀ erent 16 Kaptchuk TJ, Shaw J, Kerr CE, et al. “Maybe I made up the whole types of disclosure and the potential for deception.
thing”: placebos and patients’ experiences in a randomized
Clinically focused research is needed to explore non-
controlled trial. Cult Med Psychiatry 2009; 33: 382–411.
17 Amanzio M, Benedetti F. Neuropharmacological dissection of
deceptive techniques for prescribing treatments aimed
placebo analgesia: expectation-activated opioid systems versus
conditioning-activated speciﬁ c subsystems. J Neurosci 1999; 19: 484–94. Conclusions
18 Levine JD, Gordon NC, Fields HL. The mechanism of placebo
analgesia. Lancet 1978; 312: 654–57.
Laboratory evidence supports the existence of several 19 Benedetti F. The opposite eﬀ ects of the opiate antagonist placebo mechanisms and placebo eﬀ ects in both healthy
naloxone and the cholecystokinin antagonist proglumide on placebo analgesia. Pain 1996; 64: 535–43.
volunteers and patients with a variety of medical 20 Benedetti F, Amanzio M, Casadio C, Oliaro A, Maggi G. Blockade
conditions. Furthermore, clinically relevant evidence
of nocebo hyperalgesia by the cholecystokinin antagonist
shows that placebo eﬀ ects can have meaningful
proglumide. Pain 1997; 71: 135–40.
therapeutic eﬀ ects, because of their long magnitude 21 Benedetti F, Amanzio M, Vighetti S, et al. The biochemical and
neuroendocrine bases of the hyperalgesic nocebo eﬀ ect. J Neurosci
and duration, in diﬀ erent patient populations. Although
2006; 26: 12014–22.
substantial progress has been made in understanding 22 Scott DJ, Stohler CS, Egnatuk CM, Wang H, Koeppe RA, placebo eﬀ ects, much laboratory and translational
Zubieta JK. Placebo and nocebo eﬀ ects are deﬁ ned by opposite opioid and dopaminergic responses. Arch Gen Psychiatry 2008;
clinical trial research remains to be done, with the
ultimate aim of harnessing placebo eﬀ ects to improve 23 de la Fuente-Fernandez R, Ruth TJ, Sossi V, Schulzer M, Calne patient care.
DB, Stoessl AJ. Expectation and dopamine release: mechanism of the placebo eﬀ ect in Parkinson’s disease. Science 2001;
Contributors 293: 1164–66.
All authors participated in the search of the published work and the
24 Benedetti F, Colloca L, Torre E, et al. Placebo-responsive
writing of the report. All authors have seen and approved the ﬁ nal
Parkinson patients show decreased activity in single neurons of
subthalamic nucleus. Nat Neurosci 2004; 7: 587–88.
25 Benedetti F, Lanotte M, Colloca L, Ducati A, Zibetti M, Lopiano L.
Conﬂ icts of interest
Electrophysiological properties of thalamic, subthalamic and
We declare that we have no conﬂ icts of interest.
nigral neurons during the anti-parkinsonian placebo response.
Acknowledgments J Physiol 2009; 587: 3869–83.
TJK is supported by a grant from National Center for Complementary
26 Mayberg HS, Silva JA, Brannan SK, et al. The functional
Medicine (number K24 AT004095), National Institutes of Health and
neuroanatomy of the placebo eﬀ ect. Am J Psychiatry 2002;
receives support from Bernard Osher Foundation, San Francisco, CA,
USA. FB is supported by grants from Istituto San Paolo and Regione
27 Leuchter AF, Cook IA, Witte EA, Morgan M, Abrams M. Changes
Piemonte (Turin, Italy) and Volkswagen Foundation (Hannover,
in brain function of depressed subjects during treatment with
placebo. Am J Psychiatry 2002; 159: 122–29.
28 Petrovic P, Dietrich T, Fransson P, et al. Placebo in emotional
processing—induced expectations of anxiety relief activate a
Aronson J. Please, please me. BMJ 1999; 318: 716.
generalized modulatory network. Neuron 2005; 46: 957–69.
Kaptchuk TJ, Kerr CE, Zanger A. Placebo controls, exorcisms, and
29 Furmark T, Appel L, Henningsson S, et al. A link between
the devil. Lancet 2009; 374: 1234–35.
serotonin-related gene polymorphisms, amygdala activity, and
Kaptchuk T. Intentional ignorance: a history of blind assessment
placebo-induced relief from social anxiety. J Neurosci 2008;
and placebo controls in medicine. Bull Hist Med 1998;
28: 13066–74. 72: 389–433.
30 Volkow ND, Wang G, Ma Y, et al. Expectation enhances the
Kerr CE, Milne I, Kaptchuk TJ. William Cullen and a missing
regional brain metabolic and the reinforcing eﬀ ects of stimulants
mind-body link in the early history of placebos. J R Soc Med 2008;
in cocaine abusers. J Neurosci 2003; 23: 11461–68. 101: 89–92.
31 Lanotte M, Lopiano L, Torre E, et al. Expectation enhances
Kaptchuk TJ. Powerful placebo: the dark side of the randomised
autonomic responses to stimulation of the human subthalamic
controlled trial. Lancet 1998; 351: 1722–25.
limbic region. Brain Behav Immun 2005; 19: 500–09.
Beecher HK. The powerful placebo. JAMA 1955; 159: 1602–06.
32 Pollo A, Vighetti S, Rainero I, Benedetti F. Placebo analgesia and
Moerman DE, Jonas WB. Deconstructing the placebo eﬀ ect and
the heart. Pain 2003; 102: 125–33.
ﬁ nding the meaning response. Ann Intern Med 2002; 136: 471–76.
33 Benedetti F, Arduino C, Amanzio M. Somatotopic activation of
Moerman DE. “Placebo” versus “meaning”: the case for a change
opioid systems by target-directed expectations of
in our use of language. Prevent Treat 2003; 6: 1–5.
analgesia. J Neurosci 1999; 19: 3639–48.
Price DD, Finniss DG, Benedetti F. A comprehensive review of
34 Ader R, Cohen N. Behaviourally conditioned
the placebo eﬀ ect: recent advances and current thought.
immunosuppression. Psychosom Med 1975; 37: 333–40. Annu Rev Psychol 2008; 59: 565–90.
35 Goebel MU, Trebst AE, Steiner J, et al. Behavioral conditioning of
10 Stewart-Williams S. The placebo puzzle: putting together the
immunosuppression is possible in humans. FASEB J 2002;
pieces. Health Psychol 2004; 23: 198–206. 16: 1869–73.
11 Ernst E, Resch KL. Concept of true and perceived placebo eﬀ ects.
36 Benedetti F, Pollo A, Lopiano L, Lanotte M, Vighetti S, Rainero I.
BMJ 1995; 311: 551–53.
Conscious expectation and unconscious conditioning in analgesic,
12 Di Blasi Z, Harkness E, Ernst E, Georgiou A, Kleijnen J. Inﬂ uence
motor, and hormonal placebo/nocebo responses. J Neurosci 2003;
of context eﬀ ects on health outcomes: a systematic review. Lancet23: 4315–23.
2001; 357: 757–62.
37 Benedetti F, Lanotte M, Lopiano L, Colloca L. When words are
13 Di Blasi Z, Kleijnen J. Context eﬀ ects. Powerful therapies or
painful: unraveling the mechanisms of the nocebo eﬀ ect.
methodological bias? Eval Health Prof 2003; 26: 166–79. Neuroscience 2007; 147: 260–71.
www.thelancet.comVol 375 February 20, 2010
38 Pollo A, Carlino E, Benedetti F. The top-down inﬂ uence of
66 Price DD, Craggs J, Verne GN, Perlstein WM, Robinson ME.
ergogenic placebos on muscle work and fatigue. Eur J Neurosci
Placebo analgesia is accompanied by large reductions in
2008; 28: 379–88.
pain-related brain activity in irritable bowel syndrome patients.
39 Benedetti F. Mechanisms of placebo and placebo-related eﬀ ects
Pain 2007; 127: 63–72.
across diseases and treatments. Annu Rev Pharmacol Toxicol 2008;
67 Kong J, Gollub RL, Rosman IS, et al. Brain activity associated with
expectancy-enhanced placebo analgesia as measured by functional
40 Kirsch I. Response expectancy as a determinant of experience and
magnetic resonance imaging. J Neurosci 2006; 26: 381–88.
behavior. Am Psychol 1985; 40: 1189–202.
68 Petrovic P, Kalso E, Petersson KM, Ingvar M. Placebo and opioid
41 Price DD, Milling LS, Kirsch I, Duﬀ A, Montgomery GH,
analgesia—imaging a shared neuronal network. Science 2002;
Nicholls SS. An analysis of factors that contribute to the
magnitude of placebo analgesia in an experimental paradigm.
69 Benedetti F, Amanzio M, Baldi S, Casadio C, Maggi G. Inducing
Pain 1999; 83: 147–56.
placebo respiratory depressant responses in humans via opioid
42 Vase L, Robinson ME, Verne GN, Price DD. The contributions of
receptors. Euro J Neurosci 1999; 11: 625–31.
suggestion, desire, and expectation to placebo eﬀ ects in irritable
70 de la Fuente-Fernandez R, Stoessl AJ. The placebo eﬀ ect in
bowel syndrome patients. An empirical investigation. Pain 2003;
Parkinson’s disease. Trends Neurosci 2002; 25: 302–06. 105: 17–25.
71 Kong J, Gollub RL, Polich G, et al. A functional magnetic
43 Pollo A, Torre E, Lopiano L, et al. Expectation modulates the
resonance imaging study on the neural mechanisms of
response to subthalamic nucleus stimulation in Parkinsonian
hyperalgesic nocebo eﬀ ect. J Neurosci 2008; 28: 13354–62.
patients. Neuroreport 2002; 13: 1383–86.
72 Hrobjartsson A, Gotzsche PC. Is the placebo powerless? An
44 Voudouris NJ, Peck CL, Coleman G. Conditioned response models
analysis of clinical trials comparing placebo with no treatment.
of placebo phenomena: further support. Pain 1989; 38: 109–16. N Engl J Med 2001; 344: 1594–602.
45 Voudouris NJ, Peck CL, Coleman G. The role of conditioning and
73 Hrobjartsson A, Gotzsche PC. Is the placebo eﬀ ect powerless?
verbal expectancy in the placebo response. Pain 1990; 43: 121–28.
Update of a systematic review with 52 new randomized trials
46 Siegel S. Explanatory mechanisms for placebo eﬀ ects: Pavlovian
comparing placebo with no treatment. J Intern Med 2004;
conditioning. In: Guess HA, Kleinman A, Kusek JW, Engel LW,
eds. The science of the placebo: toward an interdisciplinary
74 Hrobjartsson A, Gotzsche PC. Placebo interventions for all
research agenda. London: BMJ Books, 2002: 133–57.
clinical conditions. Cochrane Database Syst Rev 2004; 3: CD003974.
47 Herrnstein R. Placebo eﬀ ect in the rat. Science 1962; 138: 677–78.
75 Vase L, Riley JL, Price DD. A comparison of placebo eﬀ ects in
48 Pacheco-Lopez G, Engler H, Niemi MB, et al. Expectations and
clinical analgesic trials versus studies of placebo analgesia. Pain
associations that heal: immunomodulatory placebo eﬀ ects and its
2002; 99: 443–52.
neurobiology. Brain Behav Immun 2006; 20: 430–46.
76 Hrobjartsson A, Gotzsche PC. Unsubstantiated claims of large
49 Stewart-Williams S, Podd J. The placebo eﬀ ect: dissolving the
eﬀ ects of placebo on pain: serious errors in meta-analysis of
expectancy versus conditioning debate. Psychol Bull 2004;
placebo analgesia mechanism studies. J Clin Epidemiol 2006;
130: 324–40. 59: 336–38.
50 Montgomery GH, Kirsch I. Classical conditioning and the placebo
77 Kaptchuk TJ, Kelley JM, Conboy LA, et al. Components of placebo
eﬀ ect. Pain 1997; 72: 107–13.
eﬀ ect: randomised controlled trial in patients with irritable bowel
51 Rescorla RA. Pavlovian conditioning. It’s not what you think it is.
syndrome. BMJ 2008; 336: 999–1003. Am Psychol 1988; 43: 151–60.
78 Steitberger K, Kleinhenz J. Introducing a placebo needle into
52 Colloca L, Benedetti F. How prior experience shapes placebo
acupuncture research. Lancet 1998; 352: 364–65.
analgesia. Pain 2006; 124: 126–33.
79 Camilleri M, Northcutt AR, Kong S, Dukes GE, McSorley D,
53 Colloca L, Benedetti F. Placebo analgesia induced by social
cacy and safety of alosetron in women with
observational learning. Pain 2009; 144: 28–34.
irritable bowel syndrome: a randomised, placebo-controlled trial. Lancet 2000; 355: 1035–40.
54 Finniss DG, Benedetti F. Mechanisms of the placebo response and
their impact on clinical trials and clinical practice. Pain 2005;
80 Kelley JM, Lembo AJ, Ablon JS, et al. Patient and practitioner
inﬂ uences on the placebo eﬀ ect in irritable bowel syndrome. Psychosom Med 2009; 71: 789–97.
55 Colloca L, Benedetti F. Placebos and painkillers: is mind as real as
matter? Nat Rev Neurosci 2005; 6: 545–52.
81 Kaptchuk TJ, Goldman P, Stone DA, Stason WB. Do
medical devices have enhanced placebo eﬀ ects? J Clin Epidemiol
56 Levine JD, Gordon NC. Inﬂ uence of the method of drug
2000; 53: 786–92.
administration on analgesic response. Nature 1984; 312: 755–56.
82 Kaptchuk TJ, Stason WB, Davis RB, et al. Sham device v inert pill:
57 Grevert P, Albert LH, Goldstein A. Partial antagonism of placebo
randomised controlled trial of two placebo treatments. BMJ 2006;
analgesia by naloxone. Pain 1983; 16: 129–43. 332: 391–97.
58 Fields HL, Levine JD. Placebo analgesia—a role for endorphins.
83 Kaptchuk TJ. The placebo eﬀ ect in alternative medicine: can the
Trends Neurosci 1984; 7: 271–73.
performance of a healing ritual have clinical signiﬁ cance?
59 Benedetti F, Amanzio M, Maggi G. Potentiation of placebo
Ann Intern Med 2002; 136: 817–25.
analgesia by proglumide. Lancet 1995; 346: 1231.
84 Kaptchuk T, Eisenberg DM. The persuasive appeal of alternative
60 Benedetti F, Amanzio M. The neurobiology of placebo analgesia:
medicine. Ann Intern Med 1998; 129: 1061–65.
from endogenous opioids to cholecystokinin. Prog Neurobiol 1997;
85 Linde K, Streng A, Jurgens S, et al. Acupuncture for patients with
migraine: a randomized controlled trial. JAMA 2005;
61 Montgomery GH, Kirsch I. Mechanisms of placebo pain
reduction. An imperical investigation. Psychol Sci 1996; 7: 174–75.
86 Melchart D, Streng A, Hoppe A, et al. Acupuncture in patients
62 Lipman JJ, Miller BE, Mays KS, Miller MN, North WC, Byrne WL.
with tension-type headache: randomised controlled trial. BMJ
Peak B endorphin concentration in cerebrospinal ﬂ uid: reduced
2005; 331: 376–82.
in chronic pain patients and increased during the placebo
87 Brinkhaus B, Witt CM, Jena S, et al. Acupuncture in patients with
response. Psychopharmacology 1990; 102: 112–16.
chronic low back pain: a randomized controlled trial.
63 Zubieta JK, Bueller JA, Jackson LR, et al. Placebo eﬀ ects mediated
Arch Intern Med 2006; 166: 450–57.
by endogenous opioid neurotransmission and μ-opioid receptors.
88 Haake M, Muller HH, Schade-Brittinger C, et al. German
J Neurosci 2005; 25: 7754–62.
Acupuncture Trials (GERAC) for chronic low back pain:
64 Wager TD, Scott DJ, Zubieta JK, Wager TD, Scott DJ, Zubieta J-K.
randomized, multicenter, blinded, parallel-group trial with
Placebo eﬀ ects on human mu-opioid activity during pain.
3 groups. Arch Intern Med 2007; 167: 1892–98. Proc Natl Acad Sci USA 2007; 104: 11056–61.
89 Witt C, Brinkhaus B, Jena S, et al. Acupuncture in patients with
65 Wager TD, Rilling JK, Smith EE, et al. Placebo-induced changes
osteoarthritis of the knee: a randomised trial. Lancet 2005;
in fMRI in the anticipation and experience of pain. Science 2004;
366: 136–43. 303: 1162–66.
www.thelancet.comVol 375 February 20, 2010
90 Cummings M. Modellvorhaben Akupunktur—a summary of the
99 Verne GN, Robinson ME, Vase L, et al. Reversal of visceral and
ART, ARC and GERAC trials. Acupunct Med 2009; 27: 26–30.
cutaneous hyperalgesia by local rectal anesthesia in irritable
91 Linde K, Witt CM, Streng A, et al. The impact of patient
bowel syndrome (IBS) patients. Pain 2003; 105: 223–30.
expectations on outcomes in four randomized controlled trials of
100 Gracely RH, Dubner R, Deeter WD, Wolskee PJ. Clinicians’
acupuncture in patients with chronic pain. Pain 2007; 128: 264–71.
expectations inﬂ uence placebo analgesia. Lancet 1985; 325: 43.
92 Cherkin DC, Sherman KJ, Avins AL, et al. A randomized trial
101 Benedetti F, Arduino C, Costa S, et al. Loss of expectation-related
comparing acupuncture, simulated acupuncture, and usual care
mechanisms in Alzheimer’s disease makes analgesic therapies
for chronic low back pain. Arch Intern Med 2009; 169: 858–66.
less eﬀ ective. Pain 2006; 121: 133–44.
93 Sherman KJ, Cherkin DC, Ichikawa L, et al. Treatment
102 Miller FG, Wendler D, Swartzman LC. Deception in research on
expectations and preferences as predictors of outcome in
the placebo eﬀ ect. PLoS Med 2005; 2: e262.
acupuncture for chronic back pain. Spine (in press).
103 Brody H. The lie that heals: the ethics of giving placebos.
94 Colloca L, Lopiano L, Lanotte M, Benedetti F. Overt versus covert
Ann Intern Med 1982; 97: 112–18.
treatment for pain, anxiety, and Parkinson’s disease. Lancet Neurol
104 Hrobjartsson A, Norup M, Hrobjartsson A, Norup M. The use of
2004; 3: 679–84.
placebo interventions in medical practice—a national
95 Price DD. Assessing placebo eﬀ ects without placebo groups: an
questionnaire survey of Danish clinicians. Eval Health Prof 2003;
untapped possibility? Pain 2001; 90: 201–03. 26: 153–65.
96 Amanzio M, Pollo A, Maggi G, Benedetti F. Response variability
105 Tilburt JC, Emanuel EJ, Kaptchuk TJ, et al. Prescribing “placebo
to analgesics: a role for non-speciﬁ c activation of endogenous
treatments”: results of national survey of US internists and
opioids. Pain 2001; 90: 205–15.
rheumatologists. BMJ 2008; 337: a1938.
97 Benedetti F, Maggi G, Lopiano L, et al. Open versus hidden
106 Park LC, Covi L. Nonblind placebo trial: an exploration of neurotic
medical treatments: the patient’s knowledge about a therapy
patients’ responses to placebo when its inert content is disclosed.
aﬀ ects the therapy outcome. Prevent Treat 2003; 6: ArtID 1a. Arch Gen Psychiatry 1965; 12: 336–45.
98 Pollo A, Amanzio M, Arslanian A, Casadio C, Maggi G,
cacy of a non blind placebo prescription.
Benedetti F. Response expectancies in placebo analgesia and their
Encephale 2003; 29: 68–71.
clinical relevance. Pain 2001; 93: 77–84.
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Did you know… • Many types of medication Taking these medicines while drinking can make you even more drowsy, dizzy, and light-headed. Interactions: You may have trouble con centrating or performing mechanical skills. Mixing Mixing Alcohol alcohol with certain medi cines makes it dangerous for you to drive. Combining alcohol with some with Medicines medicine