Arthritis, Placebo and Nocebo

This is one of a series of blogs commissioned for The Power of Placebo – a national programme of events that accompanied our performance, Placebo. The ‘placebo response’ describes an effect which occurs when a person is given a ‘fake’ or ‘inactive’ treatment but experiences an improvement in health regardless. Scientific research has also shown that factors such as the colour or size of pills can impact on their effectiveness. This programme of events brought together leading scientists, cultural thinkers, artists and medics to explore how our beliefs, relationships and environments can affect our health for better or for worse.

As part of The Power of Placebo, Paul Dieppe spoke as part of Agents of Change: The Power of Placebo at the Wellcome Collection on Saturday 3 November 2018.

‘Arthritis, Placebo and Nocebo’

by Paul Dieppe, Emeritus Professor of Health and Wellbeing at the University of Exeter Medical School, and a Scholar of the Institute for Integrative Health in Baltimore, USA.

I used to be a rheumatologist – a hospital doctor specialising in the treatment of people with arthritis. When I was first doing this, in the 1970s we had no very effective drugs, we just had ourselves. And we recognised that we could often help people simply by caring for them, and by using kind words and the confident prescription of relatively harmless medications. We did not call this placebo treatment, we held on to some form of belief in our drugs and our science, as well as the understanding that caring for each other was at the heart of our medicine.

As I got older, technology took over medicine, more effective agents became available, and some of the patients gained greatly from their use. But there were many for whom these new drugs were either inappropriate or ineffective. And I came to realise that some of these people responded well to any tablet I chose to give them, with reassurance that it was the perfect treatment for them. On the other hand, some of my patients got bad side effects whatever I suggested, and the same side effects, whatever type of drug I used. What was going on?

Let me tell you about two patients, both long dead now:

The first was my mother. As a doctor you should never treat your relatives, but it was difficult to avoid giving her some advice. My mother got arthritis in her knees (something she has passed on to me, I now go to healers for help with my knees, but that is another story). She went to her GP who did not seem to help much. Then one day, just before Christmas, she came to me ‘I know you specialise in arthritis dear, and I also know that there is nothing you doctors can do for bad knees like mine, but is there anything I could take that might ease the pain while we are away over Christmas?’ she asked me. I got some very low dose ibuprofen tablets, and suggested she take two of them twice a day over the Christmas period (the dose I recommended was the sort that should do no good at all). She improved greatly, instead of hobbling about in obvious pain, she was walking well, joining in with the dancing, and showing no signs of any discomfort. At the end of the holiday period she said to me ‘those tablets were wonderful Paul, could you contact my doctor and ask him to prescribe them for me?’ I did. A few weeks later she told me that the doctor’s tablets were no good at all, ‘They were not the same as the ones you gave me’ she said (the drug, ibuprofen, was the same, but the tablets were a different colour), ‘can you get me some more of your special ones?’ I tried, but I could not, by then the manufactures had changed, and the tablets looked different, we were never able to reproduce that placebo effect that she obtained from ‘having fancy tablets from my son who is a hospital specialist’ as she put it.

The second patient was a lady with severe rheumatoid arthritis, who got sick on every tablet anyone offered her. I could not understand this. One day I thought I would try her on anti-sickness medication, on its own, and see what happened. She came back a week or two later and told me ‘those tablets are just like all the others doctor, made me sick as a dog’ she said. I listened some more to her story (something I should have done before!). What I heard was that she first took tablets for a childhood illness (long before developing arthritis) that made her horribly sick. Ever since then any tablet she took made her sick ‘That is just how I am made’ she explained. This I realised, was a nocebo response, for her tablets were strongly associated with sickness; it was like a conditioned response. After that we agreed that we would try to treat her arthritis without using any tablets at all. She got on much better that way.

So these two people taught me about the power of placebo and nocebo in the treatment of arthritis, and led me to take a research interest in the wider subject of placebos and nocebos in health care. I have learnt that it is about the ways in which we see things, on our expectations, and also on the interactions we have with each other – the ‘therapeutic encounter’ if you like. And it is about caring; we were right in the 1970s, caring for our patients confers important therapeutic benefits. The placebo response, our recent research has shown, is responsible for about 70% of the pain relieving effects of any drug used in arthritis. But we think that the nocebo response is even more powerful: if you have reason to believe that a treatment will do harm, it most certainly will.