Strong Placebos

Introduction

Where placebos are concerned, I’m something of a believer. In this post I examine the placebo effect itself; non-deceptive (aka “open label”) placebos; non-ingested placebos; machine-oriented placebos; nocebos; and what I’ll call the “hypothetical reverse-placebo” effect.

What I believe about placebos

I believe that a placebo—that is, a non-drug substance like a sugar pill being used in place of real medicine—can sometimes work if the person taking it has any faith whatsoever that it will. When I say “sometimes” I don’t mean “it’ll work some of the time,” but rather that certain maladies, or at least the perception of them, can be treated with hope alone (in the guise of medicine). There is evidence that this is the case, and I’ll get to that. But first, I have a few examples of my firsthand empirical success with placebos.

The first is Airborne, the so-called immune system supplement. I would never have tried this product on my own. My wife bought it once, and I humphed and hawed and studied the packaging with extreme skepticism. Well, it has Echinacea, I reasoned, which pregnant women aren’t supposed to take, and use of Echinacea for immune system support has at least some research behind it, such as this.  On that basis I tried out the Airborne, and found it fizzy and kind of yummy, and insofar as I didn’t get sick afterward, I decided maybe its benefit is real.

On that basis, my “evidence” wasn’t much better than that joke about the guy on the bus holding an imaginary box, from which he pinches an imaginary powder that he then flings around in the air, and then a fellow passenger says, “What are you doing?” and he says, “It’s to keep away lions!” To which the fellow passenger says, “There are no lions on this bus!” and the guy says, “See? It’s working!”

But there’s possibly more to this Airborne thing. Often I think I’m getting sick, and I figure it couldn’t hurt to take some Airborne. And on several occasions when I was sure I was getting sick, I took it and then rallied. But couldn’t I have been wrong about starting to get sick in the first place? Yeah, sure. But it’s such a relief to keep a virus at bay, I’m willing to ingest a fizzy drink that purports to help, just in case it somehow does. Meanwhile, I’ve sometimes had a virus last for days and days when I didn’t take Airborne, and other times my cold seemed to go away faster after I took it. I haven’t kept great notes or anything—this is all anecdotal—and yet I feel there’s a correlation, or at least there could be.

Sure, Airborne has a silly story (“Invented by a teacher!” as if teachers knew anything about pharmacology) and sure, the Airborne company was sued for false advertising … I don’t really care. If they called themselves medicine they’d be hucksters, but what they’re really purveying is hope.

(Does the house-brand of Airborne work? Too early to tell … my wife bought some recently and I’ve just getting into my one-subject clinical trials. In general I trust generic drugs so I’m optimistic. And really, if you have optimism about a placebo, what more do you need?)

Moving along, I have good results with the Camelbak Elixir tablets.  This product claims to be an electrolyte source, which automatically aroused my suspicion when I first heard of it. Energy drinks claim to be a source of electrolytes, but generally have only a tiny amount of sodium and even less potassium. A gallon of Gatorade has only 6% of your daily requirement of potassium. (You can get that much potassium from four ounces of orange juice.) The other common electrolytes—magnesium, chloride, calcium, phosphate, and bicarbonate—aren’t even listed on the label.

All that being said, a pal recommended the Camelbak tablets for recovery after bike rides, and I was just desperate enough to try them.  Desperate?  Yep.  I have this problem of totally sucking on the second day when I ride two days in a row. It’s particularly bad on the second stage of the Everest Challenge bike race—to the point that on one occasion I actually got dizzy and thought I made have to abandon. So finally, the last time I did this race, I gave the Camelbak tablets a try, and—Eureka!—finally had a good second stage.

You might be wondering how I could believe in this product, given what I said about its mere trace amount of electrolytes. In fact, the Camelbak Elixir has just 2.3% of the US recommended daily allowance for potassium and 3% for magnesium.  That said, it does have some manganese, which could be useful. Wikipedia says, “Manganese is an important element for human health, essential for development, metabolism, and the antioxidant system.” But I learned that after the fact. My belief in the product comes simply from its having seemed to work.  (Full disclosure—Camelbak used to sponsor my bike team, and gave us free product.)

Because I’m not convinced that Airborne and the Camelbak tablets are based on real science, I refer to both as “placebo.”  Like, I’ll ask my wife, “Hey, do we have any of those placebos?” and she’ll know I’m talking about Airborne. Or on my recent Tahoe cycling weekend I told my pals, “Hey, I brought a tube of those Camelback placebo tablets.” My pals happily partook, without challenging my “placebo” label.

Look, I’m not an idiot. (Or at least, my position on placebos doesn’t by itself prove that I’m an idiot.) I rightly hold that homeopathic medicine is a total crock, and I believe that declining to immunize one’s child is tantamount to reckless endangerment. (If a person wants to try out questionable quasi-medicine on himself, that’s one thing—but putting one’s child at risk based on wacky beliefs is totally different.)

I believe in real medicine. But I also acknowledge that some things work without anybody understanding exactly why. As mentioned here, a chemist won the Nobel Prize for figuring out how aspirin works, like 90 years after it was discovered, and scientists still don’t think they understand aspirin completely. So if there’s some reason—any reason—to believe that something could work, I’ll might try it, so long as it’s not standing in for a proven medicine that I ought to be using instead.  And I limit my placebo use to scenarios involving a subjective experience of suffering.

Non-deceptive placebos

Some time ago I stumbled across an article about how patients being given a placebo found it effective even when they were told that it was only a placebo. I’ve just corroborated this with a little research, turning up multiple articles, eight of which read all the way through.  In case you are curious, here are links to them:  1   2   3   4   5   6   7   8

That first link is to the original research, published in December of 2010, concerning irritable bowel syndrome. It’s a good start, though the study had had only 80 subjects. The researchers “tested whether open-label placebo (non-deceptive and non-concealed administration) is superior to a no-treatment control with matched patient-provider interactions” and found that 60% of patients receiving an open-label placebo reported relief from symptoms, vs. 35% who received nothing. That’s right, 6 out of 10 patients got good results from knowingly taking mere placebos.

That’s the good news about non-deceptive placebos. The bad news is that articles 2 thru 7 are all based on the same original study, so they don’t support it so much as reiterate it. Moreover, articles 4 thru 6 were published in 2016, and article 7 came out this year … which suggests no other studies on this subject have been done since the first one, almost seven years ago. I’d have more faith in this study if it had been replicated by somebody else. (This begs an interesting question: if I persist in believing in a study’s findings, even if they’ve not been substantiated, does that make the study itself an intellectual placebo?)

Article number 8, by the way, is a wacky “n=1” study (that’s right, just one subject) about a guy who takes placebo pills to alleviate writer’s block. As somebody who doesn’t have time for writer’s block, I’m going to lump that one in with homeopathic medicine.

Non-ingested placebos

Placebos aren’t limited to what you can swallow. This landmark study in The New England Journal of Medicine found that patients who underwent arthroscopic knee surgery fared no better than a placebo group, whose knees had incisions made but nothing else done to them (just instruments being handed around and saline “splashed to simulate the sounds of lavage”). This and other studies are described in this New York Times article, and the results were later replicated, as described here. The conclusions are twofold: 1) arthroscopic knee surgery isn’t very effective; 2) the very idea of knee surgery does provide some relief.

Fortunately, I can’t comment personally on the sham knee surgery thing; my closest experience with knee pain is the kind you can treat with ice. But I do have a ton of experience with a putatively pressure-point-based hiccups cure (click here for details) that might be more of a placebo thing. I’ve had excellent results with this cure for almost three decades, and I’m tempted to believe that it’s grounded in something physiological. 

But I’m not convinced, because the mere idea of this remedy is enough to cure my brother Geoff’s hiccups. We rented an apartment together in the late ‘80s, and worked together too, so I was always around when he got the hiccups, which was frequently. Knowing that this cure worked for him, I’d command him to stop hiccupping whenever he started up. The command alone was enough—he never even needed to apply the pressure to his finger! In fact, he eventually got kind of pissed off, because he wanted to have a sustained case of the hiccups from time to time, just to remember what it was like—but I’d never let him. Either this hiccups cure has a placebo component, or my authoritative command to stop was scary enough to cure his hiccups. (That was a joke, BTW.)

Machine-oriented placebos

Can a placebo work on a machine? Not exactly, but a human can enjoy a placebo effect from changes to a machine. I’m talking here about changes to our vehicles, primarily. This has come up a few times around bicycle wheels. Sure, if you put lighter wheels on a bike, it will take measurably less energy to accelerate it or propel the bike up a hill. That’s not a placebo. But not all technological changes have such a straightforward, undeniable benefit.  If we decide to believe a manufacturer’s claims, and then can “feel” the difference, but the improvement is really just hype, than we are enjoying a placebo effect, without having done anything to ourselves or ingested anything.

Case in point: my friend John bought some fancy new wheels for his racing bike recently, and explained their features and benefits thus:  

The bike shop owner described in detail the spoke lacing and why it had more “lateral stiffness blah blah when out of the saddle, but had more [unintelligible] when in the saddle.” I was all, “Really?  Cool….” The rear rim is “asymmetrical” in profile. Something about making it so spoke tensions are equal on drive side and non-drive side. Anyway, the result is new wheels on my bike, and… they feel great!  I kept trying to figure out what I was really feeling and what I was trying to convince myself of because I’d just spent a bunch of money.  I have to say they feel way smoother in multiple ways.  The most noticeable is that little bumps and cracks in the road are now less jarring, probably due mostly to the much wider rim.  I feel like they roll better too, but I could be making that up.

I myself am a believer in these wider rims, though I have to take it on faith that they really improve the ride. I went with these fat rims purely on the recommendation of ten or so bike pals who recommended them (details here.) Right away I could feel the difference … but was I perceiving anything real?  I told my dad, a former rocket scientist and engineer, about these fat rims and how the change they make to the tire profile makes the ride better (etc.), and my dad said (in a calm but authoritative voice, as if holding back exasperation), “I don’t see why they would.” More recently I put the question to a friend who’s a professor of mechanical engineering, and he also seemed puzzled at how a wider rim would improve the ride. I still do feel better on these wheels, but I don’t know enough to say where the design basis for this improvement lies along the spectrum between snake oil and aspirin.

Nocebos

In describing nocebos, Wikipedia is insistent on this point:  “We can never speak in terms of simulator-centered ‘nocebo effects,’ but only in terms of subject-centered ‘nocebo responses.’” Whatever, dudes. The point is, just as you can have a presumably unwarranted positive response to a non-drug, you can similarly unwarranted negative side effects from the same non-drug, or outsized side effects from a real drug. Prior to embarking upon this post, I’d never heard of this, but I guess it makes sense. This Times article nicely fleshes out the topic. For example, it describes how patients warned of erectile dysfunction as a side effect of a specific drug were three times as likely to suffer it.

In fact, I have firsthand experience of the nocebo effect—er, response—as well. The other night, I was suffering from some pretty bad hayfever, and I decided that my normal placebo—generic Zyrtec—wouldn’t be enough. (Even though Zyrtec has a bona fide active ingredient, it seems to make so little difference in my symptoms, I’ve decided it’s more of a placebo than anything. If this seems silly to you, consider this Times article about how hard the Claritin manufacturer had to work to get FDA approval, because the FDA medical officer declared it was “not very different than placebo clinically.”) Wanting real relief, I brought out the big guns: generic Benadryl. This drug has always worked wonders on my allergies, though its principal side effect—the near inability to wake up the next morning—is a beast.

Well, the drug did its job: my allergy symptoms were completely wiped out, though I had a really hard time getting up the next morning. My head was all muddy and I was stumbling around in the bathroom for quite a while trying to get my deodorant applied and my contact lenses put in. And then I spied something that kind of amazed me: the little pink generic Benadryl tablet, sitting there on our little bathroom shelf, uneaten.

I have no doubt this was the very tablet I thought I’d consumed, as it had been the last one in the package. So the antihistamine benefit, along with my Benadryl hangover, were both based on belief alone … a placebo paired with a nocebo.

Reverse-placebo effect?

This begs an interesting question: could the benefit of a drug be retroactively hampered by the suggestion that it was only a placebo? For example, if you suffered from appendicitis and had your appendix removed, and then were told later the surgery had been a sham … could your pain come back? In other words, is there any such thing as a reverse-placebo effect? Could you ruin the effect of a legitimate drug, or the results of an actual surgery, by telling the patient he hadn’t actually received it?

I don’t see any practical value in such a thing, but it would be an interesting thing to study.  Perhaps some silver-tongued professor or researcher is able to drum up some research funding. For what it’s worth, my recent experience with the generic Benadryl suggests that the placebo effect, along with the nocebo response, were unaffected by lifting the veil. I put the unconsumed tablet back in the package, shrugged, and continued to enjoy an allergy-free but decidedly hungover morning. But then, as I said, I’m a placebo believer.

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The Cure for Hiccups

NOTE:  This post is rated PG-13 for mild strong language and intimations of substance abuse.

Introduction

This post, simply enough, is about curing the hiccups.  I examine the existing literature on the topic (okay, some of it), point out the flaws inherent in traditional cures, and then unveil my simple remedy, which works 100% of the time and is demonstrably superior to all others.

In a perfect world, I’d have a research staff large enough that at any given time one or more researchers would have the hiccups and could test out these methods.  Instead, since I barely have one researcher (and he’d rather write than conduct research), I’ll have to settle for citing personal experience.

What causes the hiccups?

The answer is, who cares?  Okay, that’s not much of an answer, but then it was a rhetorical question to begin with.  Sure, there are plenty of explanations afloat, usually involving the vagus nerve, the diaphragm, and/or the esophagus,  but these explanations are about as satisfying as the Big Bang Theory—that is, not at all.  Suffice to say, everybody gets the hiccups, some people more often than others, and that’s just the way it is.

Okay, there is a valid reason for understanding what causes the hiccups, which is  to avoid getting them in the first place.  But I’m convinced that avoidance is a fool’s errand.  My older daughter used to get the hiccups a lot while she was still in the womb.  If, in utero, she’d gotten the hiccups whenever her mom did, we’d be on to something.  But there was zero correlation, and I cannot imagine that there’s much overlap between what goes on in a uterus and what goes on in the outside world.  Hiccups just happen.

The consumption cures

No, by “consumption cures” I don’t mean cures for tuberculosis.  I’m talking about the hiccup cures that require you to consume something.  There are two main websites I’ve consulted for this post:  “Reader’s Digest” and “How Stuff Works,” and they both start off with a classic remedy:  eating a tablespoon of sugar. 

I first came across this cure in “Dynamite” magazine when I was about nine; it promised that sugar would “kick the hics right out of your system!”  I found that sugar did work, but then my mom put the kibosh on it for health reasons, pointing me toward red wine vinegar instead.  (Coincidentally, vinegar is the second suggestion “Reader’s Digest” gives.)  Vinegar does work, but it’s not very pleasant.  In fact, when (at age nine) I recommended it to my brother Max, he reacted violently to the vinegar, running from the kitchen and simultaneously coughing, hiccupping, and crying.  The vinegar did end up curing his hiccups but he was really ticked.  (My older daughter will use it in a pinch, but she hates it too.)

“How Stuff Works” recommends an antacid.  This seems like overkill.  How about Benadryl, so you just sleep through the hiccups?  Or maybe heroin, would that work too? 

“Reader’s Digest” goes on to recommend peanut butter, honey, powdered cocoa, dill seeds, and hot sauce (though not all at once—these are  discrete remedies). 

Hot sauce is a laugh, because “How Stuff Works” tells you to avoid spicy foods.  (Never mind that avoiding something is a preventive measure, and this was supposed to be a list of cures.)  Many times I’ve gotten the hiccups from spicy salsa, but it’s absurd to avoid an entire cuisine on that basis.  Say you’re going out to eat with friends or family, and everybody wants Mexican:  are you really going to say, “No, we can’t do Mexican, I might get the hiccups”?  Yeah, right.

The problem with all these cures is that hiccups can strike at any time, and any place.  It’s just not practical to carry around dill seeds or vinegar with you.  You need a cure that travels with you all the time, even in the bathtub.

The water cures

Remedies abound that involve drinking water, usually with some weird twist like drinking upside down, or trying to put your mouth on the far edge of the glass.  I’ve watched my kids try many variations of this, none of which seem to work and most of which make a mess, particularly if a hiccup occurs during swallowing. 

My older daughter has tried drinking through a paper towel (which turns out to be one of the “Reader’s Digest” recommendations) and says it works, though her mom put the kibosh on it for health reasons.  It does seem likely that there are chemicals (bleach, perhaps?) in paper towels and you wouldn’t want to ingest them.  Now my daughter drinks water through a coffee filter, which her violin instructor recommended.  (“If there’s one thing you can’t do when you have the hiccups, it’s play the violin.”)  This seems like a fine solution, except a) coffee filters cost money, and b) once again, you’re not always going to have them around.

The scare technique

I don’t know how this “scare away the hiccups” myth got started.  I’ve tried to scare the hiccups out of a great many people and it never, ever works.  For example, a couple decades ago I had a girlfriend who got the hiccups constantly, and it drove me crazy, so one day while we were walking along the sidewalk, she hiccupping as usual, I suddenly screamed as loud as I could.  It wasn’t a terrified type scream—more of a James Brown type scream—but it certainly packed a punch:  she screamed too (the terrified type scream), and then started crying, and kept hiccupping through it all.

Besides, even if the scare method did work, it requires the action of another person, which means it relies on somebody else deciding to help you.  It’s not like you can ask somebody to scare you—with the element of surprise gone, what’s he going to do?  Pull out a gun?

The breathing “cures”

Respiration-related techniques are classics.  As a kid I tried holding my breath countless times and it never did a damn thing.  I’ve watched lots of other people try this one and it never works.  It just makes you look like an idiot, with your cheeks puffed out and your face all red and then you hiccup anyway.  Anybody who recommends this pointless, totally ineffective remedy deserves the hiccups he’ll still have after doing it.

To my astonishment, both “Reader’s Digest” and “How Stuff Works” recommend breathing into a paper bag.  Don’t they know this is how lowlife teenagers get high?  I have no idea whether or not this remedy works, nor do I care.  I’d rather have the hiccups than overdose on carbon dioxide and pass out.  What’s next:  curing hiccups by huffing model airplane cement?

The touch-based cures

My research did turn up two rather novel approaches for curing the hiccups.  The first is on WikiHow and goes like this:  “Press hard onto the palm of a friend/family member’s palm for 30 + seconds.  This gets rid of their hiccups if they are taken by surprise.”  I have several problems with this.  First, since when do palms have palms?  Second, even if it works, this technique doesn’t get rid of your hiccups; it gets rid of somebody else’s.  It requires the element of surprise, which you’re not going to get if you ask somebody to do it for you.  What are you supposed to do, tell them about it ahead of time and say, “If I ever get the hiccups, here’s what to do”?  And what if you get the hiccups on a bus or train, with no friends around?  My final issue with this technique is that it’s one of sixty-six methods listed on this website.  If any one of these actually worked, we wouldn’t need sixty-six of them.  WikiHow has about as much credibility here as “Cosmopolitan” with its perennial lists of bedroom man-pleasing techniques.

The second touch-based approach is described in the “Huffington Post.”  The author says, “Simply take the hand of the person afflicted and squeeze hard on the surface of the fingernail of the pinky finger for ten seconds. That’s it.”  Well, this is a fun and useful parlor trick, but once again it doesn’t seem to work on yourself; he goes on, “The jury is still out on whether the method can be self-administered.  I have found varying degrees of success using myself and my pinky as test subjects.”  This seems like a mealy-mouthed way of saying it doesn’t work on yourself.  And what’s the use of curing somebody else’s hiccups?  He doesn’t say anything about this requiring the element of surprise, but it would still be awkward asking a stranger on a crowded bus to squeeze the fingernail of your pinky.  It’s a little too close to “Pull my finger!”

(On a side note, the comments below the “Huffington Post” column are—as is so often the case—totally imbecilic.  Many readers attack the premise that a pressure point could affect the diaphragm, etc., seeming to miss that the writer himself distrusts accupressure, writing, “To me [this cure] is just magic.”  Besides, the author is an economist, so the reader is expected to take his theories on blind faith.)

The cure that actually works

The cure that actually works is most similar to the pinky trick.  I learned it back in the late ‘80s from my then-stepmother (who was the non-cruel type of stepmother).  She said it was a yoga thing based on pressure points.  (I am skeptical that this cure has anything to do with yoga because it works perfectly for me, yet I’m utterly incompetent at yoga.  Except for the corpse pose.  I could do corpse pose all day, and sometimes do.)

Without further ado, here is the anti-hiccup technique:  squeeze the last knuckle of your index finger between the tip of your thumb (same hand) on one side, and the last knuckle of your flip-the-bird finger on the other side.  I know that’s not very clear so here are a couple of photos:

You do this with both hands.  How long do you need to squeeze?  Well, that’s up to you:  simply for as long as it takes for you to realize that your hiccups are completely gone.  I guess I’d give it about ten seconds.  When I do this, the hiccups go away so quickly that there’s never even a second hiccup.  It’s brilliant:  immediate, silent, simple, and requires absolutely nothing but your two hands.

Alas, this cure doesn’t work for everybody.  I cannot explain why this should be.  My best guess is that the technique requires some very subtle fine-tuning that can only be acquired through trial and error.  I’m not talking about a lot of trial and error; I got this down almost instantly, as did my brother Geoff.  I taught it to all the deejays at a radio station I worked at, and one by one they learned the trick, every last one of them.  (I was their hero; the hiccups are a deejay’s worst nightmare.)

Maybe this cure is like using the touch-screen keyboard on a modern smartphone.  When I first got my Droid, I could barely type my unlock password—it would take me three or four tries.  I was convinced my fingers were just too stubby.  But soon enough I developed the same knack that all the other touch-screen typists seem to have and I’m surprised how fast I can go.

I (reluctantly) must report that this cure doesn’t work for my daughters, but then, their manual dexterity is highly specialized.  They can play the piano like the dickens but are helpless when it comes to a knotted shoelace or even a tangled jump rope.  The older one is being phased in to dishwashing duty and it’s painful to watch her try to scrub a pot; she couldn’t do worse if she used her feet.  So I guess what I’m trying to say is, if you don’t have success with this technique, there must be something wrong with you.

(Full disclosure:  this technique doesn’t work for my wife either, but I haven’t discounted the possibility that she refuses to really try, just out of spite.  I can’t blame her ... it’s surely no picnic being married to me.)

Why does it work?

Look, I don’t know anything about pressure points or yoga and I’ve already admitted I have zero knowledge in, and zero curiosity about, the actual biomechanical cause of the hiccups.  I don’t know why this trick works and I don’t much care.

Could this cure be a placebo?  I haven’t ruled that out.  If it is, it’s a strong placebo.  (I think “Strong Placebo” would be a good name for a rock band, don’t you?)  I figure if a placebo is effective, don’t knock it!  (The medical community clearly feels the same way; check out this article about a study finding that knee surgery is no more effective than placebo-like “sham surgery.”)

I chatted about this cure with my brother Bryan the other day, because he can’t get it to work.  “Could be that I just don’t have the faith,” he said.  “But I want to believe, I really do!”  He noted that the cure works for his oldest son, so I asked, “If it requires faith, how could you have instilled that faith in your son if you lack it yourself?”  He replied, “That’s a curious question that I too have pondered.”

My advice

My advice to you is not to question this cure, and not to doubt it ... just do it.  It really does work.  What else are you going to do?  Carry around a little baggy of dill seeds wherever you go?