The term “placebo” entered the English medical lexicon from the Latin word “placeo,” which means “I please” or “I shall please.” Its current usage, which primarily refers to treatments, frequently pharmaceutical, that provide symptom relief through the mind-body connection rather than through the treatment’s direct effect on the disease, has been in use since the early 1800s. In research, a placebo is a substance or treatment with no therapeutic effect on the condition being studied. It’s often used in clinical trials as a control to compare the effects of a new treatment or intervention with the effects of a substance that lacks inherent therapeutic properties. Placebos are administered to a control group, while the experimental group receives the actual treatment.

Traditionally, placebos were believed to work only when the person taking them didn’t know they were taking a placebo. However, recent placebo research in irritable bowel syndrome (IBS) suggest this is no longer so. Both open-label placebos (where patients know they’re taking a placebo) and double-blind placebos had nearly the same effect. This indicates that keeping patients in the dark about whether they’re receiving a real or fake pill might not be essential for placebos to work. It also suggests that open-label placebos could be beneficial for helping people with IBS. These results suggest that patients can experience placebo effects even without believing in or having faith in the placebos. The question arises: Can these findings be extended to the management of pain and other symptoms? If so, how does it work?

What has nursing got to do with this?

Symptom management is a complex process in which pills and a great deal of nursing care play a vital role. This care may be provided by nurses, other healthcare professionals, nursing assistants, or family members. Dr. Ted Kaptchuk, a professor of medicine who directs the Harvard-wide program in placebo studies, offers insight into why placebos can still have therapeutic effects, even when the patient knows that’s what they’re taking. He recently stated in a New York Times article:

“… the act of treatment itself is so powerful to patients even if a pill contains no therapeutic ingredients. Medicine is not only effective drugs and procedures; it’s a human drama of charged engagement… placebo effects can be significantly enhanced in the context of a supportive, respectful and attentive patient-clinician relationship. Acts of human kindness in general are linked to robust placebo effects.”

During medication administration, nurses go beyond the routine checklist of the 11 Rs for safe medication administration (right patient, medication, dose, route, time, assessment, evaluation, documentation, right to refuse, right education, and right reason). They also cultivate a therapeutic patient relationship, which can enhance the patient’s response to the medication, whether it’s a placebo or a genuine treatment. Nurses who fluff a patient’s pillow as they assist the patient in taking their meds, hold the patient’s hand, or provide comforting words while administering pain medication all influence certain neural and, some might say, spiritual pathways that contribute to the synergistic effect of empathy on the body’s internal pharmacy. Empathy in patient care also could be seen as a way of willing the good of another. In essence, a spoonful of kindness not only helps the medicine go down but also augments its efficacious qualities as we accompany our patients in their healing journey.

Nocebo: Placebo’s nemesis

Nocebo, Latin for “I will harm,” is a substance or suggestion that has no therapeutic effect but can trigger negative or adverse effects in a patient because they expect them. The nocebo effect occurs when patients experience negative effects during fake treatments, such as in a research study’s control group. Subjects experience adverse effects because they expect to or because someone told them something negative, even if they didn’t receive any actual treatment. It’s essentially a self-fulfilling prophecy for the worst outcomes. The power of the mind is indeed significant.

The nocebo effect underscores the importance of what and how we communicate with patients. There is evidence that merely informing patients about potential side effects can increase the likelihood that they’ll experience them. Striking the right balance of honesty, gentleness, and positivity can mitigate the impact of the nocebo effect and improve patient outcomes. For instance, telling a patient about to receive nitroglycerin that “this medication will help you feel more comfortable” is preferable to saying “nitroglycerin is known to cause headaches.” The reciprocal trust between patients and nurses can be enhanced with the right communication because, like the mind, words are powerful.

Do pricier placebos work better?

In a 2006 double blind study, researchers enlisted 82 participants to assess the discomfort induced by electric shocks administered to their wrists. This evaluation took place both before and after ingesting a pain reliever. Notably, half of the participants were informed that the pill, described as a newly approved prescription pain reliever, typically retailed for $2.50 per dose, while the remaining half was informed that the pill they were taking was discounted to 10 cents. Both groups received placebo pills. The placebo effect was distinctly evident in both sets of participants, with 85% of those consuming the higher-priced pills reporting significant pain relief in contrast to 61% in the group receiving the cheaper pills.

The findings of this study suggest that pain and pain relief are a complex biochemical and psychosocial phenomenon where expectations play a significant role. I wonder if patients would rate the quality of their nursing care better or worse if they were told its price. But then again, this would be a tough one to study, given that exceptional nursing care frequently is considered priceless.

Fidelindo Lim, DNP, CCRN, FAAN, is a Clinical Associate Professor at New York University Meyers College of Nursing.