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The Neurobiology of Placebo Effects
Published in Hanna Pickard, Serge H. Ahmed, The Routledge Handbook of Philosophy and Science of Addiction, 2019
Elisa Frisaldi, Diletta Barbiani, Fabrizio Benedetti
Many neuroimaging studies have been performed to understand the functional neuroanatomy of placebo analgesia (Eippert et al. 2009; Petrovic et al. 2002; Wager et al. 2004; Zubieta et al. 2005). A meta-analysis of brain imaging data using the activation likelihood estimation method (ALE) identified two distinct phases: the expectation phase of analgesia and the pain inhibition phase (Amanzio et al. 2013). During expectation, areas of activation were found in the anterior cingulate, precentral and lateral prefrontal cortex, and in the periaqueductal gray. During pain inhibition, deactivations were present in the mid- and posterior cingulate cortex, superior temporal and precentral gyri, anterior and posterior insula, claustrum and putamen, thalamus and caudate body. Overall, many of the regions that are activated during expectation are likely to belong to a descending pain inhibitory system that inhibits pain processing.
The Tao of Pain
Published in Peter Wemyss-Gorman, John D Loeser, Pain, Suffering and Healing, 2018
The placebo effect is often treated with scorn and thought of as just a response of the patient to a dummy medication, whether in treatment or in research. The main psychological processes mediating placebo analgesia are those of conditioning and expectancy and have been studied in depth focusing particularly on the patient/clinician relationship.7,8
Why it can be ethical to use placebos in clinical practice
Published in Andrew Papanikitas, John Spicer, Handbook of Primary Care Ethics, 2017
Before we delve into the debate about whether placebos are ethical, it is useful to say a few words about what placebos are. Many people have claimed that placebos are ‘inactive’, ‘inert’ or ‘nonspecific’, which is false. Assuming for the moment that placebos are effective – somewhat effective at least for some ailments – then they cannot be inactive or inert. Inert and inactive things do not have effects. Similarly, placebo analgesia seems to work by activating the brain’s reward system, releasing endogenous opioids into the bloodstream.6 This seems just as specific as, say, taking an analgesic drug. Others claim that placebos are ‘psychological’, which is partly true but inadequate; antipsychotic drugs and psychotherapy are also ‘psychological’, yet are not necessarily placebos. For the purposes of this chapter, I will assume, following recent philosophical research,8 that if a treatment is a placebo, it is relative to a disorder. So, a sugar pill might be a placebo for some things like pain, but not necessarily for a diabetic patient. The placebo should also work because the patient expects it to work (either consciously or, as we shall see below, subconsciously). On this view, an antibiotic is not a placebo for treating bacterial pneumonia, but is a placebo for treating a viral cold.
Placebo and cultural responses*
Published in Nordic Journal of Psychiatry, 2018
Antonio Ventriglio, Giuseppe Magnifico, Luisa Borraccino, Angelo Rinaldi, Antonello Bellomo
Recent studies have demonstrated that different neurotransmitter systems are involved in the placebo response. The endogenous opioid anti-nociceptive system is undoubtedly involved in placebo analgesia. In 1978, Levine et al. [5] administered placebo as an analgesic for postoperative pain, observing a significant reduction in painful symptoms and a reversal of this response by the opioid antagonist naloxone. Moreover, it was found that β-endorphin levels were higher in the cerebrospinal fluid of placebo responders than non-responders [6]. In addition, the endocannabinoid system has been recently identified as a new non-opioid component of placebo analgesia [7]. It has been observed that the administration of placebo, proposed as an anti-Parkinsonian drug, can lead to an improvement in motor performances among patients with Parkinson’s disease. This effect may be mediated by the endogenous release of dopamine in the dorsal striatum, a critical component of the motor systems [8]. In fact, the ventral striatum, and in particular the nucleus accumbens, are involved in the reward circuit, mediating reinforcement and motivational responses. Activation of the ventral striatum should be present in any response to placebo and the release of dopamine would be linked to the expectation of reward rather than the reward itself [8,9].
Placebo Analgesia as Nocebo Reduction
Published in AJOB Neuroscience, 2018
John T. Fortunato, Jason Adam Wasserman, Daniel Londyn Menkes
An important way of extending Gilgorov’s analysis is to consider the administration and function of placebo analgesia vis-à-vis nocebo effects. The way in which placebo and nocebo effects are inextricably interlinked provokes important considerations in the ethical analysis. Placebo analgesia, when used to reduce pain responses in patients, can be viewed as a counterbalance of nocebo, and not only as the straightforward administration of placebo. Since placebo analgesia reduces pain using the same biochemical pathways as pharmacologically active analgesia, it is not deceptive, or is significantly less deceptive, and therefore, it is less ethically controversial than other accepted methods used to reduce nocebo. Placebo analgesia does not engender potential infringements on patient autonomy and thus carries minimal risk. As such, the consideration of patient characteristics when choosing to use placebo analgesia may be moot, and a more liberal application of placebo analgesia can be justified.
Pain, Placebos, and the Benefits of Disclosure
Published in AJOB Neuroscience, 2018
Consider our clear case of placebo analgesia without deception. The clinician says something along the lines of “Here, taking this pill should relieve your pain,” and the patient responds with something along the lines of “Thanks Doc!,” takes the pill, and the clinical encounter ends.1 This case is problematic in at least two ways. First, it rests on an unrealistic (and condescending) view of patients as simple, sheepish, and/or uninterested in participating in decisions about their own health. Second, it likely lacks the necessary conditions for at least two of the reasons that, according to Gligorov, placebo analgesia can successfully treat pain—(1) the patient believes that what she is taking now is the same as something she has successfully taken before, and/or (2) positive prior clinical encounters have engendered trust in the patient of the clinician. In both cases, triggering the analgesic response requires that the recommendation to “take this pill” be assessed not in isolation but the context of prior experiences.