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13 Articles in Volume 18, Issue #6
Authorities’ Use of Big Data May Harm—or Help—Your Chances of Investigation
Gaps in the Pharmacist’s Pain Management Role
How can cyproheptadine manage complicated chronic pain cases?
Letters to the Editor: Trackable Pills; Buprenorphine; CRPS Diagnosis
Managing a New High-Dose Opioid Patient
Managing Opioid Use Disorder
Medication Selection for Comorbid Pain Management (Part 2)
Mobile Trackers and Digital Therapeutics
New Insights in Understanding Chronic, Central Pain
Nocebo Effects: How to Prevent them in Patients
Polarizing Topics in Chronic Pain
The Fight to End Peripheral Neuropathy
Urine Drug Monitoring

Nocebo Effects: How to Prevent them in Patients

Clinical setting, past experience with a particular treatment, and other factors may play a role in patients’ expectancies of—and reactions to—pain care.
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Similarly, in a clinical environment, a patient receiving negative disclosures related to a pending treatment (eg, explanation of pain medication’s side effects, details provided through informed consent of a procedure) may experience nocebo algesia or hyperalgesia, or a decreased effectiveness in their treatments. By avoiding overemphasizing negative information regarding a treatment or by balancing negative with positive information, a clinician may help to prevent nocebo effects in the patient.22,18 Another aspect that may help to promote placebo and prevent nocebo involves explaining upfront the mechanism of action of a therapy, as well as its potential placebo and nocebo effects.23 Some studies have shown that providing a rationale can enhance placebo responses when the placebo is given openly with an honest positive interaction.3,12

Social Interactions and Observational Learning

Researchers have increasingly demonstrated that pain modulation can be learned and modified through social processes and that it can have sex-specific effects.17,14,25,26 Individuals that interact with or observe another person experiencing a negative outcome (eg, increased pain) or receiving negative disclosures related to a treatment may experience an increase of pain or note side effects themselves. Although more research is needed to specifically identify the mechanisms behind the social modulation of pain, neurobiological studies point to factors such as the activity of neuropeptides, such as oxytocin and vasopressin, as well as empathy, mirror processes, and mentalizing.27

Clinical settings in which patients may directly interact with or observe other patients in pain, as well as other patients’ responses while receiving a treatment or interacting with medical personnel, may facilitate nocebo effects. The complexity of social behavior makes this factor especially challenging, as many social and environmental factors may be at times uncontrollable, for example when a patient is exposed to negative suggestions within their communities or through media outlets. Practitioners may be able to regain some of that control by exploring the expectations, beliefs, or preferences of patients and using that information to thwart—in advance—any negative anticipations that might influence clinical outcomes.

Negative Conditioning and Learning

Past negative individual experiences and associative learning may shape a patient’s expectations regarding a future treatment. For example, a patient who has had repeated suboptimal or negative experiences with a specific treatment regime or health professional may experience an exacerbation of side effects or a reduction in treatment efficacy, regardless of the actual pharmacological or physiological action of the treatment.17 Classical conditioning has been widely studied in the context of placebo and nocebo, where repeated stimuli are presented in association with cues that can later trigger the same effect without the stimulation being present. These effects may extinguish with time, but they also may persist—even when an individual is aware of the conditioning paradigm, especially if strong associations have been occurring for a long period of time.17,28-30

Further, nocebo algesia and hyperalgesia may occur if a patient has experienced failed treatments in the past; these effects may be more pervasive with longer durations of unsuccessful treatments. Facilitating positive associations with the treatment plan may help prevent conditioned nocebo responses. For example, patients may be encouraged to take their medications during positive moments, as this can help build an association between analgesic effects and positive experiences.18 A clinician could also try to help the patient reconsider any negative memories or expectations they have about a particular treatment to help prevent further consolidation of nocebo effects.18 This may be achieved by exploring a patient’s beliefs and expectations through targeted questioning techniques. Before considering either approach, it is important to account for the patient’s social history and environment, as well as for previous experiences within the healthcare system and related medical treatments; this information may help determine the patient’s susceptibility to experience nocebo effects.

Patient–Practitioner Interactions

The simple act of seeing a doctor has been shown to engage a context of healing that is part of the therapeutic process.31 Having an interaction that is business-like, instead of warm and empathic, and where the physician’s competence and experience may be questioned, however, can lead to nocebo effects. One study associated those characteristics with a decreased efficacy of a placebo intervention related to a provoked immune response.32 Furthermore, it has been demonstrated that the beliefs of healthcare staff can translate into subtle behaviors and cues that influence patient expectations.33 In addition, receiving treatments without a social interaction—such as through automated equipment, known as “hidden administration,” can significantly decrease the efficacy of analgesic medication.34,35,18

Positive practitioner characteristics, namely warmth and competence, induced a placebo-mediated anti-histaminic response after individuals received a histamine prick.32 In general, the literature shows that uncaring interactions that convey a message of invalidation and lack of warmth may trigger nocebo effects. Avoiding negative communication and interactions with a patient may help to shape a safe and positive environment that not only promotes placebo effects but that also reduces nocebo effects.

Last updated on: September 5, 2018
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Invoking the Placebo Effect
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