Coming out of the sugar pills

Christiane Fux studied journalism and psychology in Hamburg. The experienced medical editor has been writing magazine articles, news and factual texts on all conceivable health topics since 2001. In addition to her work for, Christiane Fux is also active in prose. Her first crime novel was published in 2012, and she also writes, designs and publishes her own crime plays.

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Migraine attacks can be combated with sugar pills. This even works if the patient knows for sure that only a dummy drug can help his aching head. On the trail of a phenomenon.

They relieve pain, help insomniacs, lower blood pressure - and all of this, even though they do not contain a milligram of active ingredient: placebos are still a mystery to medicine. It is undisputed, however, that there is a placebo effect.

For this reason, every drug that wants to be approved has had to compete in studies against a sham drug since the 1970s. This is the only way to determine how great the drug actually is. Because the share of the placebo effect in the overall effect can be considerable: Experts estimate it to be 20 to 80 percent.

More than just imagination

How exactly a placebo works is still uncertain. It is now clear that this is far more than pure imagination: Studies have shown that placebos trigger the release of endogenous opioids or also stimulate the production of the neurotransmitter dopamine in the brain. Trust in the doctor and in the drug has a major influence.

But the effect of the placebo goes far beyond the power of believing in the drug: Placebos work even if the patient knows that the pill he is swallowing contains only active ingredient-free sugar.

Placebo versus drug pill

This is impressively demonstrated by a study with migraine sufferers. In the event of a migraine attack, the participants received six labeled envelopes with tablets. Two of them aroused positive expectations in the patients: They were labeled with the name of a common migraine drug. Only one of them actually contained the active ingredient rizatriptan - the other contained a placebo. Two more envelopes dampened hopes of effectiveness. They said “placebo” even though there was an envelope in it that contained the real drug. Two other envelopes with placebo and medication were labeled neutrally. On them was the notice that the tablet contained is a placebo OR contains the active ingredient.

Paradoxical result

Unsurprisingly, the effect was greatest when the medication was put in an envelope that was also labeled with the medication. More precisely, it was twice as large as when the patient thought he was taking a dummy drug. The pills from the wrongly and neutrally labeled envelopes worked equally well - so the placebo was just as effective as the drug itself.

Probably the most exciting result, however, brought the scientists the envelope labeled “Placebo”, which actually contained the placebo: Here, too, the sugar pill unfolded its effect. "That doesn't work for all patients, but it does for some," explains study leader Rami Burstain in an interview with . Knowing how to swallow a placebo does not necessarily destroy the effect. This seems paradoxical at first, as it was assumed that the placebo effectiveness is based on belief in this.

"So far we can only explain this by the fact that there is classic conditioning here," explains Burstain. A migraine patient who swallows tablets for years during an attack and then feels relief is conditioned to the simple effect of “tablet equals pain relief”. And this conditioning is so deeply anchored that it still works even if the patient consciously takes an active ingredient-free tablet.

Hyped up sham drugs

This result could be groundbreaking for the targeted use of placebos. In fact, placebos are now administered in hospitals, for example when patients have an inexplicably high need for painkillers or sedatives. Here the doctors try to see whether a dummy pill might also help, in order to reduce the risk of side effects or addiction.

The catch is ethical: Patients do not know that they are being given sugar pills and are deceived. In addition, the procedure is not possible outside of the clinic. Because here no doctor monitors whether the placebo effect is sufficient for the unsuspecting patient. And prescribing active-ingredient-free tablets, packaged as branded products, would not only be logistically complex and potentially dangerous, it would also be simply fraud.

This dilemma could be overcome if the placebos could be prescribed openly, meaning that the patients knew that the pills in the box did not contain any active substance. In fact, some doctors are already practicing this unmasked use of the dummy drugs.

To make this possible on a broader basis, Burstain and colleagues are currently researching. Questions to be clarified are: For whom do placebos work even without a mask? And how does the effect really work? Another publication on this topic is already in progress.

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