The Story of Suffering and Health

The placebo effect is on the rise. Pharmaceutical companies are worried.

As I’m sure you know, the placebo effect is a beneficial outcome to health from the use of something that isn’t supposed to be biologically active. Since 1964, the FDA has required all new pharmaceuticals to be compared to a placebo. The regulatory hurdle is that new drugs must be statistically better.

In the late 1990s, a researcher at the pharmaceutical company Eli Lilly discovered a troubling trend. Using Lilly’s database of published and unpublished clinical trials he found that, over time, placebos were getting better compared to drugs: drugs that 10 years before were better than the placebo would now fail the FDA test and not make it to market. That list included Prozac.

The trend has continued: a significant number of drugs have not been taken to market because they failed in clinical trials. In case you’re worried, the drug companies aren’t standing still. More on that later. Right now, I want to talk about placebo research.

The word “placebo” comes from the Latin verb “to be pleasing.” A placebo is pleasing to the body because it elicits the innate capacity to heal. The effect was discovered during World War II in rationing morphine to wounded soldiers: a soldier was told he was getting morphine, injected with saline solution, and experienced pain relief as though he’d received the actual drug.

The doctor who made the discovery went on to advocate for the use of placebo controlled clinical trials in evaluating the effectiveness of drugs generally. His research along with drug disasters such as thalidomide led to the 1964 FDA rule requiring placebo controlled clinical trials.

After that, placebo research goes cold until the mid-1990s. These new researchers have asked how a placebo works. Originally, the effect was attributed to psychological peculiarities of specific test subjects. The consensus now hovers around how the placebo is administered. Through either conditioning or learning, a patient understands the placebo to be effective medicine and as a consequence a biological cascade ensues that calls forth the body’s own healing processes.

In the case of pain, for example, the brain region responsible for producing opioids increases in activity during a placebo response. One researcher says that the placebo effect results from the person’s narrative—that is, the story of which use of a placebo is part. This fact is illuminated by the plight of drug companies.

Many believe that drug companies got into trouble because 40 years ago the growth market was in psychiatric medications—that is, the murky goings on of the functional areas of the central nervous system most susceptible to the placebo effect. As the story of psychiatric meds became common knowledge, the placebo effect became more powerful because it became common knowledge that drugs benefited psychiatric conditions.

Since the increased efficacy of placebos boiled up, drug companies have embarked on systematically mining the statistics from their secret vaults. They’ve also hired virtually every mainstream placebo researcher to figure out ways to tease apart drug effects from placebo effects so that Big Pharma can combine therapies—in effect, use the placebo effect to develop and sell more drugs.

I hope you’re reassured that the drug companies will be OK so I can return to the idea that the placebo effect is a consequence of a narrative—in particular, the sufferer’s story and the biological effect that flows from this sense of self. Either consciously or unconsciously, my treatment story, placebo or not, is about whether I get better, survive, recover, return to life as I know it or I decline, return to a life of diminished capacity, die.

That story doesn’t fall from the sky. It’s certainly in my mind, but it’s my mind making sense of what’s going on around me. I’m a wounded soldier. A nurse gives me a shot of what she says is morphine. I’m in a story where nurses make me feel better and never lie and have morphine.

In other words, the placebo effect is intimately entwined with social relationships and material processes.

I invite you to consider the well-known relationship between social class and health outcomes. The harder your life, the less healthy you’re likely to be. It’s commonly agreed that the biological effect is mediated through the stress response. The story I experience is about things getting better or worse or never changing.

The placebo effect and the social determinants of health run along a continuum that is the biological effect of the story you experience of suffering and health. Surely we can put that knowledge to work toward a goal more noble than keeping the drug-besotted medical model in business.