The Nocebo Effect: Reading Drug Labels Can Make You Sick

November 18th, 2008 by

There is a fascinating article in today’s Wall Street Journal (subscription required) that raises interesting implications for workers compensation. Melinda Beck writes that warning labels on medications can actually stimulate symptoms, especially when stress is involved. In other words, when an injured employee reads a warning label – “this medicine may cause vomiting, headaches, drowsiness, etc” – he or she is more likely to have these symptoms. The label itself creates a self-fulfilling expectation. Doctors call this the “nocebo” effect, a phenomenon parallel to placebos.
“People’s expectations play a very important role in how they react to medications,” says Richard Kradin, a physician and psychoanalyst at MGH in Boston. He notes that 25% of patients who get completely inert placebos in clinical trials complain of the listed side effects – usually headaches, drowsiness and dizziness.
The implications for workers comp are profound: experiments have shown that telling patients they may feel pain triggers the release of neuropeptide cholecystokinin (CKK), which heightens pain sensations. Because work-related injury almost always involves pain, the expectation of pain can make the pain felt by the patient even worse.
This phenomenon may help explain the inordinate dependence upon strong narcotics in the workers comp system (a frequent Insider focus). We all dread pain. Injured workers have a heightened awareness of pain relating to their injuries. They bring this awareness to the examination table. In their efforts to alleviate (real and imagined) pain, doctors tend to reach for stronger-than-necessary medications in order to provide the relief their patients demand.
Stress is a key factor in the nocebo effect. Stress drives the anticipation of pain and the over-reaction to medication warnings. It is present in virtually all workers comp situations, so we can project that the nocebo effect is a fairly constant factor in the treatment of work-related injuries.
Calming the Waters
The article points out the importance of good communication between doctors and patients. Doctors need to focus not just on information (“this medicine might really make you sick”) but on the need to maintain contact: “If you have any problems or concerns, don’t hesitate to call me.” Reassurance from a doctor can literally reduce the amount of pain and stress experienced by the patient.
The nocebo effect may be indicative of the need to shift the focus of western medicine beyond symptom and treatment to encompass the whole being of the patient, with a particular focus on stress reduction. If injured workers received some help in eastern stress reduction techniques (e.g., meditation), their craving for stronger medications might subside. They would also recover faster. (Will insurance carriers pay for stress reduction interventions? Of course not!)
Daniel Moerman, a professor of anthropology at the University of Michigan says that “physician communication with patients is the closest thing to magic. It gets communicated in incredibly subtle ways – a flash in the eye, a smile, a spring in the step.” Doctors, in other words, are shamans. Their ability to heal is not limited to the medications and treatments they prescribe. They can heal just by conveying a strong belief in their ability to heal.
APOLITICAL FOOTNOTE: Let’s take the nocebo concept one step further. The election of Barrack Obama as president may have as much to do with his calm presence as his politics. He has a reasurring coolness in a time of transcendent stress. His body language communicates a confidence in his ability to solve problems. His Marcus Welby-esque manner conveys the notion that our imploding economy can indeed be fixed and our wounded world can eventually be healed.