I’d like to begin by saying this is the finest column we have ever run. We spared no expense in its creation. It is so good, in fact, I have read it myself—twice. That’s not to boast, it’s just meant to enhance the experience of reading it for you.

 

Dan Ariely began thinking about placebos during the three years he spent in a hospital in Israel, where he was recovering from third-degree burns to 70 percent of his body following the accidental explosion of a military flair.

 

While recovering from his injuries, he would overhear doctors talking about specific patients who could not receive additional painkillers because they had reached their maximum dose, and then watch nurses provide them with subsequent injections. When he asked the nurses about it, they would confess they gave the patients a simple saline solution instead of the good stuff. He watched these patients calmly drift off to sleep after the injections of placebos.

 

“One of the things I’m interested in is how the inferences we make about things changes the reality we experience—how the role of expectation changes experience,” said Ariely, a visiting professor of behavior economics at Duke University and author of the recently published book Predictably Irrational (HarperCollins).

 

Ariely said placebo effects are well known. And, in the case of placebo pain killers, there is some explanation for why they work. The body starts producing natural opiods in anticipation of receiving them. Ariely, though, wanted to see what effect expectations have on the effectiveness of drugs. What he found was that a $2.50 placebo works better than a $0.10 placebo—even when they are the same placebo.

 

Though it’s a small study with a modest finding, it raises some very big questions about the possible unintended consequences of healthcare reform. It also raises big questions about the role not only doctors and pharmacists may be able to play in enhancing drug effectiveness, but also the role of the pharmaceutical companies, insurers, and policymakers.

 

Along with collaborators at the Massachusetts Institute of Technology, Ariely conducted a test on 82 subjects. The participants were given a light electric shock to their wrists and asked them to rate their pain. The researchers shocked the subjects before giving them a placebo.

 

The researchers gave half the participants a brochure that described the placebo as a newly approved painkiller that cost $2.50 per dose. The rest of the subjects got a brochure that described the pill as having been marked down to 10 cents without explanation. A total of 85 percent of subjects in the $2.50 pill group experienced a reduction in pain after taking the placebo. In the $0.10 group, only 61 percent reported a reduction in pain.

 

In a letter to the Journal of the American Medical Association in which Ariely reported the results of the study, he said that the findings could help explain the popularity of high-cost drugs over inexpensive and widely available alternatives. It may also explain why patients who switch from branded drugs to generic equivalents may report they don’t work as well. He also points out that studies of real-world effectiveness may be more useful if they “reflect how medications are sold in addition to how they are formulated.”

 

For doctors, Ariely thinks they may have to consider that their enthusiasm for a drug could provide cues to a patient that could affect how well it works. They may also need to consider downplaying issues that could work against the drug, such as the fact that the generic version is cheap. For drugmakers, he thinks they should consider doing away with the “ugly brown bottles” and consider packaging that might help enhance the confidence a patient may have in the drug.

 

“The main issue is, how do you not create negative expectations,” he said. “It’s all about expectations.”

 

Ariely plans to expand on the work and look at what effect providing a drug for free or near free could have on its effectiveness, compare how patients respond to drugs they are told are branded or generic, and what effect price has on patient compliance to a dosing regimen.

 

But as healthcare reform under a new administration will continue to look for ways to cut prices and use less expensive alternative therapies, it will be important to remember to treat the body, you may also have to think about treating the mind.

 

I hope you enjoyed this column. If not, we’ll just have to charge you for it next time.