January 28,2015
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At long last, there may be a thin silver lining to high drug costs. A new study shows that a handful of patients who received fake treatments for Parkinson’s disease experienced improved symptoms. This placebo effect was stronger for one of two “drugs” that patients were told was more expensive--though only when the expensive drug was administered first.
Dr. Alberto Espay, the head researcher and a neuroscientist at the University of Cincinnati, says physicians may be able to leverage the power of a placebo to help patients, without writing more prescriptions.
Researchers have long known that a fake drug can cause changes based purely on a patient’s expectations about its intended purpose – to relieve pain, for instance -- even if the “drug” is a sugar pill with no proven pharmacological value. Now, it appears that the perceived price of a fake drug may strengthen this placebo effect.
“That's a new wrinkle on the placebo story,” Espay says. He reported his findings from a small study of 12 patients with Parkinson’s disease on Wednesday in Neurology, the journal of the American Academy of Neurology. Parkinson’s disease is a nervous system disorder characterized by low levels of dopamine, a neurotransmitter that transfers signals between cells. The lack of dopamine causes victims to gradually lose control over muscles.
Espay told patients that he was studying two drugs that were priced differently but thought to have similar effects. He told patients that the first “drug” cost $1,500 and that the second one cost $100. Then, Espay injected each of them with the two placebos. After each dose, patients underwent brain scans and performed a series of tests to measure motor skills. Espay compared the results of each placebo with the effects of a drug called levodopa, a leading treatment for Parkinson’s.
He found that the expensive placebo injection improved motor skills in patients by 10 percent as compared with the cheap injection, so long as the expensive injection was administered first. However, the results did not hold when the cheap injection was given to patients first. Espay says the results for the expensive injection even rivaled those from levodopa but John Kelley, director of the program in placebo studies at Harvard Medical School, disagrees based on the fact that the statistical analysis is based on only 12 patients.
Espay likens the placebo effect of drug prices to shopping for expensive wine. In fact, he said his latest work was partly inspired by a study he once read about how wine drinkers rate expensive wine as tastier even if there is no difference in the wine itself. “In medicine, there really isn't any reason for us to think a brand name drug should be any different in quality,” Espay says. “But there is a very important thought among patients that their response should be better if they're on the brand name.”
Kelley says cheap drugs have at times been shown to have lower efficacy based on patient perception, but he doesn't think Espay's analysis is clear evidence of that since the effect was only detected when the expensive placebo was administered first.
"Overall, it doesn't seem like there's much difference between the cheap and expensive," Kelley says. "Given that's [Espay's] principle outcome, that seems problematic."
Researchers have only begun to understand the full effects of placebos and still have a ways to go in figuring out how the effect occurs. Achieving a better understanding may help companies and researchers create better controls to take the full impact of placebos into account when testing new drugs. As Dr. Peter LeWitt of Wayne State University writes in an editorial accompanying Espay's study, “The effects of placebo can confound clinical trial outcomes or lead to endorsement of worthless treatments.”
Espay has worked with or served in an advisory role for a number of drug companies including Eli Lilly and Company and Novartis.
Espay and Kelley both say there may also be ways for physicians to incorporate the lessons of the placebo effect into everyday consultations. Espay suggests that doctors talk with patients about the expense of developing drugs, for example, to heighten a patient’s sense of their value or emphasize the effectiveness of a treatment to raise expectations of success. “It's rather poignant when you think about it,” says Espay. “Placebo in Parkinson’s disease is really about the patient themselves, without any pharmacological interventions, coming up with results only from their expectations of the experience.”
It’s important to note that people with Parkinson’s disease tend to experience stronger placebo effects than average. Espay says this could be because placebos somehow boost dopamine levels, which therefore brings an exaggerated effect to the dopamine-starved brains of patients. Furthermore, Espay’s study was limited in size because of ethical concerns about lying to patients about their treatment.
Even so, LeWitt called it a well-designed study in his editorial. “The outcome of this study, despite its limitations, opens our eyes to another nuance of placebo effect with implications for clinical practice, the research enterprise, and health policy,” he writes.
At least one other team has found similar results from using placebos to investigate the effect of drug prices on patient outcomes. In 2006, a duo from Massachusetts Institute of Technology compared the reactions of 82 participants to electrical shocks after taking a fake pain reliever. One group received a pill said to be regularly-priced at $2.50 and another group took a discounted pill that supposedly sold for $0.10. The team found that subjects reported less pain overall after taking the regularly-priced pill.
“I hope this will be the beginning of a concerted effort to making patients do better with resources that don't necessarily require another drug or therapy for their care,” says Espay. “They have something very powerful within themselves.”
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