How Placebo Pills Are Helping Patients With Chronic Pain

October 27, 2016 / Thomas Cohn, MD

New research suggests that knowingly taking placebo pills may help chronic pain sufferers find some pain relief.

Conventional wisdom suggests that the placebo effect should only work if the patient believes they are taking a medication with an active ingredient, but the new study suggests that may not be the case.

“These findings turn our understanding of the placebo effect on its head,” said joint senior author Ted Kaptchuk, director of the Program for Placebo Studies and the Therapeutic Encounter at Beth Israel Deaconess Medical Center and an associate professor of medicine at Harvard Medical School. “This new research demonstrates that the placebo effect is not necessarily elicited by patients’ conscious expectation that they are getting an active medicine, as long thought. Taking a pill in the context of a patient-clinician relationship — even if you know it’s a placebo — is a ritual that changes symptoms and probably activates regions of the brain that modulate symptoms.”

Placebo Study

For the study, researchers recruited 97 individuals with chronic low back pain and split them into two groups. Both groups watched a 15-minute video explaining the placebo effect, then one group continued their normal treatment, while the other group took daily placebo pills that were stored in a container marked “placebo pills” that clearly stated that they had no active ingredient. Both groups continued their specific treatment options for three weeks.

At the end of the three week period, patients in the placebo pill group reported 30 percent reductions in typical and maximum pain, while those in the treatment as usual group experienced 9 and 16 percent reductions respectively. Individuals in the placebo group also reported a 29 percent drop in pain-related disability, while those in the treatment as usual group did not report improvement in that measure.

“Our findings demonstrate the placebo effect can be elicited without deception,” said lead author, Claudia Carvalho, PhD. “Patients were interested in what would happen and enjoyed this novel approach to their pain. They felt empowered.”

However, Dr. Carvalho cautioned that the placebo effect may only provide mild relief for patients with undiagnosed chronic back pain, and that patients with specific conditions like herniated discs or pinched nerves will not experience similar results.

“You’re never going to shrink a tumor or unclog an artery with placebo intervention,” he said. “It’s not a cure-all, but it makes people feel better, for sure. Our lab is saying you can’t throw the placebo into the trash can. It has clinical meaning, it’s statically significant, and it relieves patients. It’s essential to what medicine means.”

Chronic Pain Reaches The World Series

October 26, 2016February 7, 2023 / Thomas Cohn, MD

The World Series is under way, and after a Game 1 victory the Cleveland Indians are only three wins away from capturing their first championship since 1948. Their manager, Terry Francona, already has two World Series rings from his time in Boston, and while another championship would be ideal, he’s already winning another big battle in his life – his battle with chronic pain.

Francona played eight seasons in the majors before eventually transitioning to a coaching role, but his years in the big leagues took a significant toll on his body. He eventually needed a couple knee replacement operations, and complications left him in severe pain with blood clots and staph infections. He was in a great deal of chronic pain, and he eventually turned to opioids to help manage the pain. Unfortunately, like many others, what started as a technique to manage pain transitioned into a habit and later abuse.

Opening Up About Life On Painkillers

Francona opened up about his battle with painkiller abuse in a book by Dan Shaughnessy titled, “Francona: The Red Sox Years.” He said his descent into pain pills began after some complications from knee surgery.

“I think I probably should have died with all that happened,” said Francona, referencing an extended hospitalization in 2002 when he almost needed to have his leg amputated. “There were a couple of nights in the hospital where I was thinking, I can’t take this anymore. The nurses would come running in because I’d stop breathing. I was in bad shape. There were people around who did not think I was going to make it. I know I came real close to losing the leg.”

He turned to painkillers like oxycodone and Percocet to ease his discomfort as he recovered.

“I lived on it at that time,” Francona recalled in Shaugnessy’s book. “When I left the hospital, I was on heavy-duty drugs, and it was tough.”

He eventually recovered from the problemed surgery, but he still kept taking pain pills, and eventually started hoarding them because they were easier to obtain in the clubhouse. That was until one day when his daughter found a bottle at home with more than 100 Percocet pills, and she eventually convinced her father to seek professional help and to enter a confidential drug treatment program managed by Major League Baseball. That same year, after the Red Sox collapsed in the weeks leading up to the playoffs, the Boston Globe published a piece saying that “team sources expressed concern that Francona’s performance may have been affected by his use of pain medication.”

Francona was not hired back after his contract expired that year, but he’s found a home with the Indians and appears to have put his days of painkiller abuse behind him. He mentioned that he still takes a blood thinning medication, but he’s taken to other options, like exercises and compression sleeves, to improve his blood circulation so he’s not relying solely on pills.

Francona is a shining example of how easily someone can get sucked into the world of painkiller abuse, and it’s fantastic that he’s been able to get professional help and more forward with a healthier lifestyle. Win or lose in this World Series, he’s won his battle with painkiller abuse.

Tai Chi Beneficial For Chronic Neck Pain

October 18, 2016 / Thomas Cohn, MD

Last week we shared a story on how yoga may be helpful for individuals with low back pain. Today, we’re learning of new research out of Harvard that suggests another form of low-intensity exercise may be beneficial for people with chronic neck pain.

To better understand the benefits of the ancient martial arts technique, researchers gathered a group of 114 individuals who were at least 18 years old and who suffered from nonspecific chronic neck pain for at least three months. Half of the group was asked to participate in regular Tai Chi classes for a period of 12 weeks, while the other half acted as the control group.

It may not sound shocking that individuals in the Tai Chi group had better outcomes than individuals who did nothing to improve their condition, but that’s what researchers discovered.

“The study showed that 12 weeks of Tai Chi was more effective than no treatment to improve pain, disability, quality of life and postural control in persons with chronic neck pain,” said Peter M Wayne, assistant professor at Harvard Medical School in the US.

Something Better Than Nothing

The news about Tai Chi having benefits for neck pain isn’t revolutionary, but it speaks to the larger point we try to express to our patients – that you need to put in the work if you want to take control of your pain. Your pain isn’t going to resolve simply by sitting down and popping a pill, you’re going to need to take an active role in pain management.

The researchers went on to say that Tai Chi was no better or worse for chronic neck pain than targeted neck exercises, but it again stresses the importance of strengthening your body to fight back against pain. As we’ve said before, there is no magic pill for chronic pain, and that holds true here. Even low intensity workouts can have amazing physical and psychological benefits. Don’t just hope your neck pain resolves, attack it head on.

Pain Care – When Correlation Doesn’t Equal Causation

October 13, 2016 / Thomas Cohn, MD

It seems that there are new articles being published almost every day on the dangers of opioid pain medications. Unfortunately a lot of the studies are not very enlightening. Worse yet, some are just sensational, dumb correlations without causation.

For instance, saying obesity is correlated to eating is a great example of poor research. If you eat, of course could run the risk of being obese, but if you do not eat you could die, so obviously these findings are not very meaningful.

The latest was an article stating that a third of all adults in the United States in the last year received a prescription of opioid medication, and this is larger than the number of people who smoke cigarettes. The reason this is absolutely meaningless is this number has no real meaning. If you add up all the prescriptions for opioids written in one year and divide by the adult population, this is very likely.

Another interpretation would be that 1 in 3 people had a serious medical issue in the last year and were prescribed pain medication. Most people who have been in the hospital or emergency room for a surgery or injury may get a short-term prescription for pain medications. This is one of the very legitimate uses of these drugs, and should not be demonized. Treating acute pain aggressively at the outset has been shown to reduce the incidence of chronic pain problems. Several days of pain medications after a surgery or serious injury is appropriate but it should not be an ongoing use once the acute episode has healed.

Making Bad Connections

A third of the world population also suffers from chronic pain. A small percentage of those people are helped only by opioid medication and use these appropriately to maintain function and ability. There are many who use these medications extremely sparingly and thus continue to be highly productive in society since then they can control their symptoms. These people are dependent on these medications, they are not addicted, and oftentimes other conservative treatments have failed them. If there were better legal treatments available, many of these people would never use opioids.

Taking a prescription pain medication for a legitimate medical problem is not a significant issue or statistic. Smoking cigarettes for most is a daily addiction, affecting 25 percent of adults. It is voluntary, it causes multiple health problems, and has a huge cost to society. Comparing pain medication use to smoking is a useless correlation with no meaning.

Yoga Has Benefits Similar To PT For Low Back Pain

October 11, 2016 / Thomas Cohn, MD

New research suggests that yoga can be as beneficial as physical therapy in reducing chronic low back pain, according to a study out of Boston.

Both yoga and physical therapy have similar mechanisms in that they work to increase our range of motion and strengthen areas of our bodies that may not always get worked, but this study wanted to see if yoga could potentially be a substitute for targeted PT for chronic low back pain.

“We know that yoga is effective, we know that PT is effective, but we don’t know their comparative effectiveness,” said Robert Saper, director of integrative medicine at Boston Medical Center. “To get a complementary health practice into mainstream health care, I would say that (at minimum) it has to be as effective as the conventional therapy, and perhaps offer other benefits, like cost-effectiveness.”

How Effective Is Yoga For Back Pain?

Due to its obvious cost-effectiveness, researchers wanted to learn just how effective yoga was at treating chronic low back pain compared to physical therapy. They started by getting 320 patients in the Boston area who suffered from chronic low back pain with no obvious anatomic cause. The average pain score from their pain was a 7 out of 10, and nearly 75 percent reported taking pain medications for their discomfort.

Patients were then split into one of three groups:

Yoga
Physical Therapy
Education

The yoga group attended a 75-minute yoga session each week and were given tools to perform some yoga exercises on their own in their home throughout the week. The PT group consisted of 15, hour-long sessions of individualized physical therapy, while the education group received a comprehensive book on back pain. The yoga and PT sessions lasted for 12 weeks, then patients were tracked for a year, with random sessions assigned throughout the year.

At the end of the study, researchers noted that individuals in the yoga and PT groups reported similar levels of function, and both scores were higher than the education group. Individuals in the yoga group also reported high levels of satisfaction with their pain and their progress. Yoga also proved to be a pretty safe option, with only a few patients reporting flare ups of pain during or after a yoga session.

Saper concluded that while the findings were interesting, patients received a highly targeted form of yoga, and individuals with chronic low back pain may not see similar results if they just head to the yoga studio down the street. He hopes to conduct more studies down the road to better understand the best yoga techniques for handling spine pain.