This essay on the placebo effect and the nocebo effects is split between successive weeks.

Let’s begin with the placebo effect. 

Once I saw a patient who was severely disabled by chronic, unrelenting pain. She was no longer able to work, took several painkillers, including an opioid, and her life was miserable.

Friends suggested that she seek out a faith healer in Quebec.

She did and, within days, the pain began to melt away to the point where she was able to return to full-time work as a custodian.

The change was striking: she was able to return to work and go off all her pain meds for more than a year — that is, until her symptoms returned.

That’s when she asked me what she should to. 

My response was to go with what worked — the results were a lot better than they were from the several drugs, including opioids, she had been on — and suggested she should seek out the same faith healer again.

She did and once more, for several months, she was nearly pain free.

Unfortunately, the faith healer retired, and her symptoms returned.

Since then, her life has been parked somewhere between her best months after her last visit to the faith healer and her worst months before she first saw her.  

She is one of several patients I saw in northwestern Ontario with similar results following visits to faith healers or the like.

Or, what about the reported effectiveness of the Zamboni treatment for multiple sclerosis and other autoimmune diseases several years ago?

Several of my patients with MS returned after following angioplastic procedures on their neck veins, convinced that their mobility and other symptoms were much improved. 

Later evidence showed that there was no evidence of obstructed venous blood flow from the brain or spinal cord.

What explained the effectiveness of this and other non-traditional treatments for chronic pain and other medical conditions?

We don’t know, but effective they sometimes are, despite scientific evidence to the contrary.

This brings us to the placebo effect.

Studies have repeatedly shown that as many as one-third of patients suffering from pain see noticeable improvement thanks to placebos, a measure of effectiveness rivalling or surpassing the effectiveness of many pain medications, including over-the-counter drugs and opioids for painful disorders such as headache and lower back pain. 

Over the years, I became convinced that there must be some physiological basis underlying the effectiveness of placebos.

I wasn’t alone in my views.

Many of my colleagues felt as I did that there had to be some plausible explanation.

Sometimes the treatments were bizarre — at least, from the perspective of Western medicine. 

Were these “cures” examples of the placebo effect, whether pills, strong beliefs or other mechanisms as yet poorly understood? 

The 2016 the highly respected scientific journal Nature highlighted the nature of the placebo effect.

For example, Jon Levine, an Italian neuroscientist, “administered intravenous infusions of saline to patients who were recovering from surgery, telling them that it was morphine. One-third reported a significant reduction in pain.”

But the interesting part was that the investigators secretly administered naloxone, a drug known to block opiate receptors in the brain — lo and behold, the pain returned.

Here was clear evidence that the placebo effect was mediated through the action of endogenous opioids released in the brain in response to the patient’s expectation.

The placebo effect was indeed real. 

Evidence mounted that other neurotransmitters such as dopamine were also involved in mediating the placebo effect.

More recently, fMRI studies — a method for revealing the activity of the brain in real time — revealed that areas of the brain related to pain, including those tasked with tamping down the response to pain, lit up in response to placebos.

So, the benefits of placebo were in the patient’s head, just not in the fashion with which some physicians dismissively speak of the placebo effect, but ways that were reasonable and consistent with the systems of the brain involved in the perception and regulation of pain. 

Other studies have shown that expectation of a benefit influences the benefit from placebos.

And until recently, many physicians believed the placebo effect depended on deceiving the patient — that is, the patient believed the placebo was actually an active drug.

That misconception was wrong, too. 

For example, in a 2010 study of a placebo given for the irritable bowel syndrome, patients were expressly told they were receiving a sugar pill, yet 59 per cent of the patients taking the sugar pill still reported “adequate relief” compared to only 35 per cent of those not receiving the sugar pill.

Results with chronic low back pain were similar and suggested that even when patients were explicitly told they were taking a placebo, the placebo was still effective — sometimes dramatically so, and without the often downside of adverse effects from many “active” drugs. 

For years, I have been impressed with the repeated observation that how physicians made the case for certain drugs or even surgical procedures often influences the patient’s perception of the outcome.

Taking time to explain the expected benefits in a sympathetic manner makes a difference.

Dr. William Brown is a professor of neurology at McMaster University and co-founder of the InfoHealth series at the Niagara-on-the-Lake Public Library.