The nocebo effect

Our brains play a powerful role in our lives. Scientists have long understood that the brain is a critical element in health and wellness. Much attention has been given to the placebo effect. In multiple studies, scientists have administered inert substances to patients as a control to medical trials. To their surprise, patients to whom the insert substances are administered sometimes experience recovery from their symptoms. The effect is more complex than simple positive thinking. It is not just believing that a treatment or procedure will work. There is a strong connection between brain and body and when they work together, physical symptoms actually disappear.

There are limits to placebo treatment. Doctors won’t be successful simply prescribing placebos for all medical conditions. There is no evidence that placebos lower cholesterol or shrink tumors. There are, however, many symptoms that are modulated by the brain, such as pain. Placebos are most effective for conditions such as pain management, stress-related insomnia, fatigue and nausea.

Less commonly understood is the opposite of placebo effect, called nocebo effect. This is when a patient anticipates a particular side effect of a medication and then goes on to experience that effect even when the medication is an inert substance. Once again the brain ha a direct effect on actual symptoms, but in the placebo effect the symptoms decrease while in nocebo the symptoms increase. Effects of nocebo can be as broad as vomiting, pain, and headaches. There are some researchers who claim that it can even result in death, although such a severe reaction is too dangerous to make its study ethical, so solid evidence of death as a result of nocebo effect is not well documented.

The nocebo effect may be a factor for law enforcement officer that affects the health and safety of the general public. A little background information is in order. Police often find themselves exposed to danger, including being exposed to dangerous substances. When people find drugs or other substances, they often call the police to come help them know what to do with these items. In recent years powerful drugs such as fentanyl and carfentanil, have posed significant dangers to law enforcement officers. Because these powerful drugs can be absorbed through the skin, any contact with them can be life-threatening. Officers have received training in the dangers of drugs and in proper handling of substances to provide for their safety and preserve evidence. They now carry gloves and other protective clothing for use at crime scenes. Many patrol officers now carry full protective clothing for extreme situations.

The fear of accidental exposure to dangerous drugs is widespread among law enforcement officers. There is a widely reported case of an Ohio officer who nearly died after brushing fentanyl off his shirt. Cases of officers experiencing dizziness, nausea, and lightheadedness have been experienced by law enforcement ages from coast to coast.

More and more law enforcement agencies are equipping officers with rescue shot cases which contain syringes and the opioid overdose reversal medication naloxone, often known by the brand names Narcan or Evizio. Properly administered, this drug can save lives, both the lives of intentional drug users who accidentally overdose and, potentially, the lives of law enforcement officers and others who are accidentally exposed.

The problem is that some symptoms of drug overdose can be the result of nocebo effect. The symptoms appear when no exposure has occurred. It may even be the case that fear of exposure contributes to the symptoms experienced. Medical professionals say that the risks from accidental exposure to opioids, even potent ones, are actually very low. You wouldn’t get that opinion from speaking with police officers, however. Most of them believe that the risk is very high and that they could be exposed to such risks on virtually every drug-related call to which they respond. Across the nation there have been dozens, and perhaps hundreds of incidents, in which officers believe they have been exposed and experience real symptoms such as dizziness, nausea and disorientation, and yet do not have actual substance in their systems when tested. The fear is rampant. Unidentified substances can kill and law enforcement officers therefore reasonably believe that most or all unidentified substances are dangerous.

Better safe than sorry is the attitude and therefore officers are likely to be treated with naloxone whenever symptoms exist whether or not actual exposure has occurred. This has lead to a variety of different approaches to the use of naloxone. Some agencies have equipped all of their squad cars with rescue shot kits and trained officers to administer naloxone. Others have noted that ambulance response is quick in most jurisdictions and that law enforcement can summon assistance of paramedics with a radio call. In those jurisdictions officers are required to summon an ambulance in order to have the drug administered. The drug begins to work within a couple of minutes, so the delay of summoning an ambulance is not a significant factor in its effectiveness.

Naloxone is a prescription medication and it is expensive. Although generic naloxone can cost between $20 and $40 a dose, most law enforcement agencies use rescue kits with two doses that cost $130 to $140 and use inhalers to administer the drug. Equipping every squad car with kits and keeping the kits up to date can be a significant expense for agencies.

Of course no one wants anyone to die when an effective treatment is available, so rapid administration of the drug is important, even if that means that it will occasionally be administered in situations where it is not necessary.

Recently another problem has been discovered. Because naloxone is a prescription substance it shows up on the pharmacy records of individuals who have purchased kits to carry in their private first aid kits in case of emergency. Some have then been denied life insurance because the substance shows up on routine insurance pre-qualification examinations.

In the midst of all of this discussion of naloxone and who should carry it, there is increasing evidence that it is most commonly used in cases where no actual exposure occurred, but where nocebo effect has produced real symptoms. Discerning when it should be used is a difficult art.

Conversations about the drug and who should be empowered to administer it continue and fears of exposure to drugs continue to rise.

We live in a dangerous world. It is not, however, as dangerous as some folks believe.

Copyright (c) 2018 by Ted E. Huffman. I wrote this. If you would like to share it, please direct your friends to my web site. If you'd like permission to copy, please send me an email. Thanks!