WhiteCoat

Placebo Power

This is a repost from a couple of years ago.

I actually had a new post planned, but had to reference something on this post. When I moved from my old blog to EP Monthly, this post apparently didn’t get transferred.

Some fond memories below.

—–

The effect of a placebo is based on someone’s belief that an inactive substance is going to help them. This belief can actually cause the brain to release chemicals that mimic the effect of antidepressant medications and/or analgesia.

Some placebos are not just “sugar pills.” For example, some people with viral upper respiratory infections must have antibiotics to make them feel better. Physicians know (or at least they should know) that using antibiotics for viral infections is a useless proposition. Like spraying Raid on dandelions. But some patients swear that the antibiotics make them feel better and will seek out physicians who inappropriately prescribe antibiotics for their head colds and bronchitis. By the way, this placebo effect wouldn’t be a big deal except that now we have made many antibiotics less effective because we prescribe them so much. MRSA is proof that single cellular organisms evolve faster than the prescribing practices of some physicians.
Vitamins. Supplements. Energy drinks. They all may help cure what ails ya, but is there a scientific basis for the improvement? Or is it the placebo effect? Who knows? Who cares? If you feel better, it doesn’t matter whether you’re popping a couple of M&Ms or chugging quart of snake oil. Go for it.

Lately a lot of patients have shown dramatic improvement in their pain symptoms with the placebo effect in our ED.

An issue some of our nurses have is that they have to get the patient to believe in the effectiveness of the placebo in order for it to work. If you give someone a shot and tell them that it is just some “saline,” you probably won’t get much of a response. If you give someone a shot of “obecalp” (which is “placebo” spelled backwards), and tell them that this is a medication for their pain that may make them sleepy, it might work. Therein lies the problem. How to you get the patient to buy into the placebo effect without lying to them? OK ….. shhhhhh. Can you keep a secret?

If a patient is looking for pain pills, hand them three regular Tylenol pills. If the patients ask what they are getting, they are told they are getting “Tylenol …. number three.” Not a lie. They really are getting three Tylenol pills. Good placebo effect. Probably half of the patients who get “Tylenol … number three” get significant relief with three plain ol’ acetaminophen pills.

One 19 year old kid with chronic back pain (how does pain become chronic at age 19?) came in the other day after running out of his pain pills. The ED doc gave him a shot of Toradol. When that didn’t help, she had the nurse give the kid a couple of Tylenol tablets. He asked what medication he was receiving. The doctor told him it was “acetaminophen.” He asked her “is that like the pain medication in Vicodin?” She replied “Of course. Acetaminophen is one of the active ingredients in Vicodin.” He was happy and pain-free 30 minutes later.

The most profound placebo effect I have ever seen actually occurred in a little old lady that I saw about 6 months ago. She was dancing around the waiting room complaining of severe pain in her hip. Howling (literally) in pain. Like if she kept it up, a rain cloud was going to form in the waiting room. We got her back to a room and she was screaming and rolling around on the bed. She had a medication “allergy” list that was extensive, but that did not contain Demerol. And she needed a pain shot … NOW. I was busy admitting someone and told the nurse just to give her a shot of saline in the butt then I would go in to see her. The nurse wouldn’t do it because she knew the patient would ask her what she was giving her and didn’t want to lie to her.

I looked at her and raised my eyebrow. Then I heard her heel spurs jingle. The theme from “The Good The Bad, and The Ugly” echoed in the distance.
“Feelin’ lucky … punk??”
“Give me that syringe of saline.”
She tossed it at me and I caught it in mid air as I walked toward the patient’s room.
“I’m Dr. WhiteCoat. I was just taking care of another patient, but the nurse told me that you’re in such bad pain that I wanted to give you some pain medication right away. I asked her to give you some strong medicine, but she felt uncomfortable giving this much to someone all at one time, so she asked me to give it to you.”
“Oh, good. My hip is killing me.”
“You aren’t driving, are you?”
“No.”
“And you don’t have anything important to do today, do you? It might cause you to be groggy for most of the day.”
“No. No. Not at all. What is it that you’re giving me?”
“The chemical name is norMAL SAHline.”
“I’ve never heard of that one.”
“It’s kind of experimental. Oh, I almost forgot. You don’t eat a lot of red beets, do you?”
“No.”
“Good. Where do you want me to give you your shot?”

I walked out of the room and squinted at the nurse in an “I’ll show YOU” kind of way, then went to see another patient.
When I returned to the desk, one of the other nurses was waiting for me with her hip cocked to the side and a smirk on her face. I was getting ready to tell her to “give it some time” when the patient’s nurse came up and squinted back at me.
“You’re a son of a beeyoch. Her pain is gone.”
I smirked along with Nurse #2, now.
“Go on, tell him the rest,” Nurse #2 said.
Nurse Nonbeliever shot her a scowl and then continued. “Not only is her pain gone, but she wants you to call her doctor to see if he can get home health to bring the medication to her home so she can have some on hand if her pain gets really bad again.”
At that point, I scowled, stopped, turned around, and walked briskly toward the lounge. I motioned for them to come along. The nurses looked at each other and then followed me.
I closed the door behind them.
They were both then treated to a WhiteCoat version of the Humpty Dance.

7 Responses to “Placebo Power”

  1. BinkRN says:

    What are the legalities on placebo? I know we have a few patients whom we are certain this approach would work on in our ED, but no one will do it for fear of legal issues. Wondering if you or another reader has insight on this.

    • Steve says:

      As far as legally…The key would be to keep it TECHNICALLY honest. Giving Tylenol…number 3…would probably fly…claiming the normal saline (no matter how its pronounced) would help your pain probably wouldn’t

      Now ethically…another story…but that was still a wildly entertaining post…

  2. When PRN orders have maxed out I’ve hung mini-bag piggybacks of norMAL saLINE with similar effect, letting the patient know it would run in more slowly and give longer relief that just an injection.

    Everyone is a little dehydrated, no?

    Isotonic hydration makes you feel better, no?

  3. DefendUSA says:

    Ha. I love this and have done it with my Grandfather. At 72, they cracked him open for a triple bypass. A year later, he was complaining where they cracked him open, it still hurt. I asked him if he was aching or burning. Burning, he said and he would not take medicine or “drugs”. I said no problem, this was a natural remedy. Calcium carbonate in “pill” form. Heh.

    About twenty minutes later, he felt better and I left him a ziploc bag labeled:
    calcium carbonate, take one or two for burning. No more than 4 per day. Like magic. He’s alive and kicking at 97 and takes no meds other than an aspirin or calcium carbonate!!

  4. Becca says:

    You can certainly tell them that this is a treatment that is very often as effective or more effective than *insert drug name here* and has a much lower profile of side effects than most medications: common ones would be a little pain at the injection site and slight increase in frequency of needing to go to the bathroom. Cos that’s what fluid does, natch.

    Wikipedia suggests some excellent alternative names: Dihydrogen monoxide
    Hydroxylic acid
    Hydrogen monoxide
    Hydrogen hydroxide
    R-718
    Oxidane
    Oxygen (di-)hydride

    I genuinely wish it were possible for me to participate in a proper controlled trial for placebo – I have major long-term pain due to a progressive condition which is mostly well managed with prolonged-release morphine but I’m hyper-aware of the potential interactions with psychy stuff around the experience of and fear of pain etc. It’s fascinating.

  5. SeaSpray says:

    i missed this one – VERY Funny!

    Clever too. :)

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