More Expensive Placebos Bring More Relief

There is an eye catching headline in today’s New York Times:

More Expensive Placebos Bring More Relief.

“In marketing as in medicine, perception can be everything: a higher price can create the impression of higher value, just as a placebo pill can reduce pain.

Now, researchers have combined the two effects. A $2.50 placebo, they have found, works better than one that costs 10 cents.

The finding may explain the popularity of some high-cost drugs over cheaper alternatives, the authors conclude; it may also help account for patient reports that generic drugs are less effective than brand-name ones, though their active ingredients are identical. The research is being published Wednesday in The Journal of the American Medical Association…..”

In The Cockroach Catcher, Dr Am Ang Zhang mentioned one of his consultants who was nicknamed the “Chief”:

“…….There were two lady consultants and the “Chief”. The “Chief” was an Austrian émigré, six foot six and a very formidable figure that most people were scared of. He was a highly intelligent man with a French wife and two highly intelligent children. Fortunately we hit it off from the very start……”

I had my own Chief and he had his eccentric ways. He famously created three “drugs” for use with his patients: Maplac Blanc, Maplac Verde, and Maplac Rubra. These could not be found in the British National Formulary (BNF), but were only available from our hospital pharmacy, white, green and red capsules, dispensed in bottles complete with proper Hospital labels.

For those who could not swallow capsules there was only one Maplac Rubra Syrup.

“Plac” is the short for placebo. In those days there was no rule against placebos and for a long time various vitamin preparations, including Vitamin B12 injections, were used for such effect.

Some prescribed drugs may have only worked as a result of the placebo effect. In any case, some drug tablets have been found not to contain the specified dosage of the active ingredient, as with GlaxoSmithKleine’s ever popular antidepressant Paxil CR and Avandamet (used for Type II diabetes).

“FDA inspections revealed that some lots of Avandamet tablets are not always manufactured uniformly and that these tablets may not have an accurate dose of rosiglitazone (one of the two active ingredients in Avandamet). FDA also found that some lots of Paxil CR tablets are not manufactured properly and can split apart, so that patients may receive a portion of the tablets that lack any active ingredient or a portion that contains the active ingredient and does not have the intended controlled-release effect.”

Wow. A lot of drug trials would be like triple blind control trials. You would need to analyse hair samples to decipher which patients have been administered the active ingredient in the end. It could be the reason why some drugs were shown to be not more effective than placebos.

Paxil is of course one of those Antidepressants implicated in the Hull report, which is causing a lot of frenzy. As far as I can tell, the story continues.

I remember attending one of these huge American Psychiatric Association (APA) conferences shortly after Olanzapine was launched. I had some first hand experience of the voracious appetite induced by this drug. I thought I should ask a question about their supposedly double blind control trial. Written questions had to be submitted in advance. So I wrote and asked how it could be a true double blind trial if within a short time relatives reported ravenous appetite in the active drug group. “It would have been so obvious!” I wrote.

Guess what happened? They just ignored my question! I was young then.

According to the “Chief”, the white tablets were good for bed wetting and green for “naughty” children. Red was great for sleep problems.

“Taste this.” He once poured me some of the red stuff.

“It’s bitter!” How clever the “Chief” was!

Then I thought: I knew the flavour.

Angostura Bitter! It is safer than anything we can think of and we would only need to add a small amount.

“Is it legal?” No, I did not ask him.

“Now, I have this mother. Her two kids won’t sleep and I gave her two bottles of Maplac Rubra, one for each kid. She took them all herself and was unconscious for 48 hours.” The Chief told me.

As far as I know, “The Chief” never lied.

I once went to a lunch time talk by someone from a well known London hospital. It was a presentation of his findings on the effectiveness of the newer SSRIs compared to that of placebos. In his final slide he showed a cartoon of two Pharma executives during the lunch break of a big launch of one of their SSRIs, one asking the other, “How can we move into Placebo?” I could not get my hands on that slide, but did find some good Placebo cartoons on the Net. I like the one about placebo rehab!