30 October 2008

Placebo: the most important pill

Kristina Malyantovich, "Russian Reporter" No. 34-2008

The elderly aunt of the American psychiatrist Isidore Ziferstina suffered from insomnia. One day her nephew brought her a bottle of "sleeping pills", which has always been on her bedside table since then. The woman trusted her relative and fell asleep perfectly, knowing that if she woke up in the middle of the night, the medicine would help her to fall asleep again. One day, during the cleaning, a maid moved a precious bottle somewhere. Insomnia resumed. No other means helped. The bottle was found, returned to its original place, and sleep was fully restored. Everything would be clear if it weren't for one detail: in this miraculous bottle there were pills that had absolutely no medicinal properties. Auntie's insomnia was cured by the placebo effect.

This story is described in the book "Placebo and Therapy" by Professor Izyaslav Lapin. For more than 30 years he has studied the effect of drugs on the psyche of both sick and healthy people. Lapin is considered the largest placebo effect specialist in Russia.

How to be treated with rhinoceros hornsIzyaslav Lapin — Professor, Chief Researcher of the St. Petersburg Psychoneurological Institute named after V. M. Bekhterev.

He created the first psychopharmacology laboratory in the USSR. Lapin is the author of the serotonin theory of the development of the antidepressant effect. The citation index of his works in the world scientific literature is one of the highest. Photo: Andrey Chepakin.

We met with the professor near his office. I admit, if the friendly guard had not shown me the right door, I would hardly have found it. Because there were no identification marks on it, there was only one poster: "Hush! An autogenic therapy session is underway."

— I don't like all these gold plates, — Iziaslav Petrovich explains to me. — Besides, you will screw the inscription "doctor" today, and tomorrow they will make you an academician. And my sign is correct: "Hush!" — because it's hard to work when people are talking loudly all the time and doors are constantly slamming, "autogenic therapy" is self—suggestion, the effect on my physical and emotional state, that is, self—development, which is what I actually do," the professor smiles.

The conversation about the placebo effect begins…

— While reading your book, I was reminded of "The Wizard of Oz". There Goodwin presented the Scarecrow with a bag of bran, needles and pins, saying that it was the brains of the highest grade, and he immediately felt wise. The Tin Woodman received a silk heart with sawdust and immediately felt it beating. And the Cowardly Lion drank a liquid with an unpleasant smell, allegedly being "courage", and declared that he had become brave. After all, all this can be called a positive placebo effect?

— Yes, that's right. Similar situations have been encountered since ancient times. Back in the IV century BC, rhinoceros horn began to be used as a medicine. It is considered the most expensive medicine in the history of medicine: during the heyday of its popularity, one dose cost $ 250 thousand. Nevertheless, it was bought because the high price was associated with greater benefit. And people still pay incredible money to sorcerers, magicians, psychics and folk healers. They pay for faith and hope. And rumors and advertising persistently support them in this.

— But even if these "remedies" are really useless, then here and there cured people appear every now and then…

— Many people forget that psychology plays a huge role. In pharmacotherapy, that is, in the treatment of medication, it must be taken into account. The main scientific information about the psychological components of pharmacotherapy was obtained through the use of a placebo dummy that externally imitates the drug. Most often, such tablets are made from chalk, starch, talc, and placebo solutions are made from a saline solution of table salt. Often, when taking a placebo, there really is a positive effect: well-being improves, mood rises, pain recedes. It would seem that everything is fine. Moreover, placebo has no toxic side effects, and therefore is harmless to the body.

— Then why can't placebo be treated at all?

— You can. There is even such a section of treatment — placebo therapy. With the help, roughly speaking, pacifiers treat stuttering, insomnia, alcoholism and much more. But there are pitfalls here.

— I read that in some people the body reacts noticeably to a pacifier, and in others the placebo does not work in any way…

— That's right. You can run into the fact that a person will turn out to be a placebo-nonreactor. What is one of the main problems of medicine? The fact that studies of drugs show that they are usually effective, that is, they have a positive effect on most patients. Now imagine: here is a man sitting in front of me, and my task is to help him, but he may be an exception to the rule. How to guess? There is, of course, a probabilistic forecast that the drug helps 80% of patients, therefore, most likely, it will help him. But what if he turns out to be one of those 20%?

So it is here. Many patients are placebo-reactors, but not all. In addition, even if a person reacts to a placebo, and reacts positively — he gets better for a while, you should always be careful. As you know, doubt is the best remedy against the decay of the mind. There should always be a question that, unfortunately, rarely sounds: are we starting a disease, are we missing something, getting an excellent effect from taking a placebo for a week, a month, six months? Perhaps, while we are rejoicing, some other process continues to progress. And when we realize this and replace the placebo with a drug, it turns out that it's too late.

— But besides the positive placebo effect, there is also a negative one. What can his study give?

— Here we come to another significant problem of medicine — the refusal of patients to take medications. For example, Marya Ivanovna comes and declares that she will no longer take the pills that the doctor prescribed for her, because they make her sick, and she sleeps badly now. Maybe the drug really doesn't suit her. But we must remember that "after" does not mean "because of". A woman can just be hypochondriac. To test this, you can give her a placebo, assuring the patient that this is the latest effective medicine for her illness. If after a few days she starts complaining again that the new drug is just as bad for her, you will explain to her that the last prescribed pills are not active at all. If, on the contrary, she feels an improvement, then she should carefully consider her prescriptions.

Double-blind treatment— So, some doctors conduct placebo therapy, but this does not happen very often, and they prescribe a placebo solely by their own choice.

And are there any situations where there is no way to do without a placebo at all?

- of course. Now there are a huge number of different drugs, and every month there are more and more of them. And, of course, before entering the market, all of them are tested for effectiveness. A prerequisite for the introduction of the drug, without which a license is not granted, is a check using the so-called double-blind method. It implies that neither the patient nor his doctor knows what exactly is used for treatment: medicine or placebo.

— Then who knows?

— Brigadier. He receives several bottles with the same pills, which have the same characteristics: smell, color, taste. But on the labels of some of them there is a small red line. No one will notice it, but the foreman will be able to distinguish the placebo vials with it. He gives the vials to the doctor, who distributes them to patients. It turns out that one group of patients takes a real medicine, and the other takes a dummy. After a while, questionnaires are collected, which are filled out by patients all the time, the results are processed statistically, and only after that the foreman reveals the cards. If it turns out that not only the drug, but also a placebo gives an improvement in health in 40% of patients, such a drug does not receive a license. For such testing, placebo is used everywhere — from Australia to Alaska.

— Can a placebo help in everyday life?

— Yes, here I can share my own experience. In the 80s, I worked as a consultant psychotherapist for the athletics and swimming teams. The job was to receive athletes who had various psychological difficulties several times a week during training. One runner, for example, could not control herself when she saw a hated rival on the starting line of the marathon. One of the best high jumpers was unsure of himself, doubted the correctness of his innovations in the technique of jumping, was insanely worried before the start. It started after one formidable briefing by the national team management, which obliged him to set a European record so that the team would get more points at the championship. Etc. Each athlete had some weaknesses of his own.

— And you chose a placebo for their treatment. Why?

— Firstly, we have developed warm, trusting relations with almost all athletes in the course of conversations. Secondly, all athletes who were subsequently prescribed a placebo expressed a positive attitude to pharmacotherapy: they believed in the effectiveness of drugs in general, not necessarily in their particular case. Moreover, many had an ambivalent attitude to the successes achieved with the help of drugs by their foreign colleagues, envy — white or black, it's hard to say — and fear of following their example, fraught with career collapse. Work was started with such a "contingent".

— And how did it go?

— I prescribed placebos to several athletes — they were such white pills. In the instructions, the drug was called "KOS-3" and stood for "a complex vitamin preparation with a harmonizing effect on the central nervous system." It was also noted that it has no side effects and contraindications. The same information was received by the coaches. The training and rest regime remained the same.

— And what was the result?

— Out of 19 athletes, 16 were positive placebo-reactors and only three were placebo—nonreactors. The positive effect was to improve well-being, in a calmer and more rational attitude to difficulties in training, in greater concentration of attention and self-control. But the most important thing is that seven people — almost half — have significantly improved their results at competitions in the next three months.

Taste and color— As far as I know, you have investigated a person's perception of the color of medicine…

— Certain colors evoke different associations. No wonder we divide the tones into cold, warm, gloomy. Our research has shown that a tonic, invigorating, mood-enhancing drug should be orange or red. Conversely, soothing medications should be blue or pale lilac in color. After studying the placebo effect of different colored pills, we turned to the plant that produces medicines: "You produce sedatives—don't make them brown, it's better to make them lilac or blue."

— And they listened to you?

- no. They stated that the amount of dyes they can use in their work is strictly limited.

— Yes, it's a sad story… And if the pill is just white, what do people expect from it?

— In this case, expectations depend on the name. In our studies, three groups of students received the same white placebo with different names: "Stimulin", "KOS", "Sedatan". The students were doctors and immediately realized what was meant by the names "Stimulin" and "Sedatan". Those who took the first "medicine" experienced a surge of cheerfulness, those who drank the second felt calmed down. And the students who took KOS decided that the drug was intended for astronauts, so it should also enhance energy. Then we conducted another study: we were given stimulant and sedative drugs under different names. Only the instructions for the pills, which in theory should calm a person, said that it was an aphrodisiac, and vice versa. And it turned out that a standard inhibitory drug called "Energan" gives a stimulating effect. That is, the instruction interrupts the chemical action of the drug itself.

— Are any placebo effect studies underway now?

— No, except for the mandatory use of placebo control, there are no studies.

- why?

— Because now the main problem of medical scientific institutions is survival. There is simply nowhere to finance research.

— And if the funds had appeared, would you have resumed research?

Professor Lapin did not immediately answer this question.

— The question is, what is there to think about? — he said after a long pause. — It would seem, it is necessary to shout: "Yes, of course! Send money!" Only it's not that simple. Our laboratory stopped doing these studies at the end of the 90s. Of course, it is impossible to lag behind here. And even if you lag behind, you can always catch up. I continue to follow the work that is being done in this area in the world. But now I don't see such nodal problems that I would rush to study, even if I were given a million dollars, and the study of which would really help science to move far ahead. Now we should do more to educate people, write, tell them about placebo, because even many doctors have a bad idea of what a placebo effect is.

At parting, the professor gave me another of his books — "Personality and Medicine" — with an autograph: "Personality is probably very good; medicine is when and how. In any case, let's not forget about the placebo effect. Thank you."

Portal "Eternal youth" www.vechnayamolodost.ru30.10.2008

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