Is back pain really all in the mind?
A new study shows placebos and positive messages may be the most effective cure for the condition yet, reveals Dr Jeremy Howick
Back pain costs the NHS over a billion pounds each year. It keeps people off work, prevents them from playing with their children and quite often stops them from exercising.
The most common treatments used are imperfect at best: paracetamol has been shown to have a negligible effect, while ibuprofen produces a small benefit but has been found to produce severe adverse reactions in some. Stronger medication – morphine – is effective in the short term but less so in the long term, can lead to dependency and even opioid addiction – and sometimes even death.
But what if the answer was far simpler – and far cheaper – than prescription drugs? What if our own minds had the power to cure us? This question lies at the heart of a new BBC Horizon documentary, The Placebo Experiment: Can My Brain Cure My Body?, which grapples with the still not fully understood relationship between the mental and the physical.
The experiment itself was Britain’s largest ever trial to investigate the placebo effect in this way. As an Oxford University researcher with a background in the subject, I was the one who designed it: because Blackpool has a high prevalence of chronic back pain – one in five of the local population suffers from it, far in excess of the national average – it was decided we should recruit the participants from there. So we enlisted 117 people from all walks of life, all of whom self-identified as suffering from back pain. These people, who for years had failed to find relief in conventional medication, were allocated to one of three groups.
The first group was given a real consultation with a real doctor, although the GPS were instructed to spend only nine minutes and 20 seconds with each volunteer
– the length of an average GP consultation in the UK. At the end of the consultation they were prescribed a course of blue and white pills. (Curiously, blue and white pills have been shown to have a greater painkilling effect than pills of other colours.) They were told that the pills were completely safe and had been shown to help other people with back pain, but what we didn’t tell them was that the pills contained nothing but ground-up rice.
The second group also received our special placebo pills but could have up to half an hour with the doctor. The GPS carrying out these appointments were also instructed to be as empathetic as possible (we recruited GPS to participate in the trial, too).
It’s hard to imagine a cheaper way of making a significant difference
Finally, we had a control group, who received the GP consultation but no placebo – this way we could ensure that any positive effects were down to our pills and not just because the volunteers would have improved over time anyway.
Back pain is complex: it is often accompanied by depression and obesity, both of which can be caused by the pain. Teasing out these things often takes longer than the average GP appointment allows. GPS who show greater empathy, meanwhile, have been found to achieve better results; nothing dramatic, but we have seen reductions of pain by one or two points when patients of empathetic doctors are asked to score it out of 10. Telling a patient that “this works for 90per cent of people like you” therefore beats “this doesn’t work for 10per cent of people like you”.
The effects of our televised trial, presented by Michael Mosley, were exciting: for a large proportion of our volunteers, the effect of the placebo pill coupled with the positive messaging about it was clinically significant. Almost half the participants in the study told us they were feeling better afterwards, and 45per cent showed a medically significant improvement.
For some, the effects were dramatic. Before the trial, one patient was in a wheelchair and had been taking morphine for 10 years. After it, he was able to walk, and felt able to stop taking the medication.
The placebo alone did not make an enormous difference, and nor did the extra empathy. But the dual effect of prescribing a pill coupled with a positive message about the likelihood of its efficacy was striking.
In 380BC, Plato described the cure of a headache thus: “… it was a kind of leaf, which required to be
accompanied by a charm, and if a person would repeat the charm at the same time that he used the cure, he would be made whole; but that without the charm the leaf would be of no avail.”
Today, we might describe it less poetically: when someone takes a pill, they remember what the doctor told them. A positive message about the medication activates the brain’s reward mechanism, causing the patient’s body to produce its own painkilling endorphins, which in turn make them feel better.
Even after we’d told the participants in the study that what they’d been taking had been just a placebo, some wished to carry on taking it. This is known as an open label placebo – when the patient knows they are taking what is effectively nothing but a sugar pill – and even this can achieve good results. Indeed, 70per cent of those who carried on taking the pills actually continued to feel better.
Why? Because even if the patient lacks a conscious expectation that what they are taking will help them, their body can still have a Pavlovian response, and the pain may still start to subside. That is, if they trust the person prescribing the pill and this person tells them, “it is just a sugar pill but has been used to help some patients with your condition”, you may still at some level believe it could work; and believing it could work can be enough to make it work.
When the patients in our trial discovered they’d been taking a placebo, all but a few were pleasantly surprised. One of them, however, was in tears. For years, she told us, she had been unable to play with her children, due to the severity of her back pain. Did this mean she’d been faking it for all these years?
The answer, I told her, was absolutely not. The mind is not separate from the body, and her pain was no less real than anyone else’s.
So although the efficacy of placebos might tempt us to conclude that it’s “all in the mind”, this phrase is misleading. That placebos can work does not mean the pain is imaginary, rather that the brain can produce its own drugs.
Placebos, of course, cannot work for everything. While they can be effective for pain, depression and anxiety (all major drains on the NHS budget), a patient suffering anaphylactic shock won’t thank you for presenting them with a placebo in lieu of adrenalin; nor will someone in need of an antibiotic to treat a specific infection.
Positive messaging, too, has its limitations: there’s little point in telling someone with stage four metastatic breast cancer that they’ll be attending their granddaughter’s wedding many years from now. Yet combining the two could save the NHS huge sums, and GPS would do well to bear in mind how damaging a focus on the negatives can be. And positive messages also help people overcome fear of exercise. Many sufferers worry that it might make things worse: in fact, safe exercise helps cure back pain.
It is not about lying to patients; it’s just about framing the truth in a positive way. It’s hard to imagine a cheaper way of making a significant difference.
As told to Rosa Silverman
That placebos can work proves that the brain can produce its own drugs