Open Label Placebos: Why They Work Even When You Know They’re Fake

Open Label Placebos (OLP) are placebos that don’t pretend to be real drugs. They say ‘Placebo’ right there on the bottle.

Which makes it all the more surprising that… they still work.

According to the purpose of a placebo – to compare a drug against a control – they shouldn’t work. It kind of defeats the purpose, some would think, to write ‘Placebo’ on the label.

Yet they work. Really well. And incredibly, how well they work depends on whether you’ve been given some explanation about the placebo effect.

That’s exactly what a new study at the University of Basel in Switzerland found. Led by Antje Nascimento, the researchers randomised 150 women experiencing symptoms of premenstrual syndrome (PMS) into three groups: two were openly given placebos, while a third group served as a control.

Of those who took placebos, one group were given an explanation that placebos work, together with some explanation around how they seem to work.

Over the course of 3 menstrual cycles:

Women who took the placebos with an explanation saw a:

• 79.3% reduction in severity of their symptoms and 
• 82.5% reduction in how the symptoms interfered with their daily life.

The control group reported:

• 33% and 45.7% reductions respectively. 

A huge difference.

The placebo-only group (no explanation) experienced:

• around a 50% reduction in both measures.

How does it work?

OK. Let’s unpack some of what’s going on.

OLPs work via two main pathways and the study identified both of these.

First is through conditioning. We’ve all had experience of opening a bottle of pills or medicine, taking the pills with some water, and getting some relief of symptoms.

Every time we have this experience it strengthens an association between the process of taking the pills and the relief of symptoms. The more we take medicines in our life, the stronger that association becomes. It’s called ‘conditioning’.

Well, the psychological weight of that lifetime of experience – the strength of the association – is greater than the short-term awareness that it’s ‘just a placebo’. 

It’s like a tug-of-war between long-held associations and conscious awareness – and the stronger pull tends to win.

The placebo works because you’re used to the process of getting symptom-relief when you take medicine.

This accounted for the group who had around a 50% reduction in symptom severity compared with 33% in the control group. A fairly substantial difference.

Secondly, the general mechanism of the placebo effect is that the brain does what it needs to do (given the resources available to it) to meet our expectations, whatever they are – usually a reduction in symptoms.

For example, in studies into pain, a person receiving a placebo that they believe is a painkiller has an expectation that their symptoms will now go away. So their brain does what it’s able to do to meet that expectation. In this case, it produces its own painkillers: endogenous opioids. These are the brain’s own morphine – natural pain-relieving chemicals the body produces when it expects relief.

And it’s the endogenous opioids that make the pain go away. It’s a real physical process in the brain that’s activated by whatever the person’s expectation is.

When those women with PMT symptoms were given extra information about the placebo effect – that it’s a very real phenomenon and a bit about how it works –  it increased their expectation that the placebos would work even though they are just placebos, thus ensuring that they DID work.

Their brain simply did what it needed to do to reduce their symptoms.

Other OLP studies

This isn’t the first OLP study. It was the first to look into the effects on PMT and also to demonstrate both pathways that OLPs work.

Ted Kaptchuk, a professor at Harvard Medical School, has actively studied OLPs for more than a decade. A seminal study led by his team in 2010 put OLPs on the map when they were shown to be highly effective for the treatment of IBS.

Eighty volunteers either received no treatment (control group) or Open Label Placebos. Those who received the OLPs were told they were, “placebo pills made of an inert substance, like sugar pills, that have been shown in clinical studies to produce significant improvement in IBS symptoms through mind-body self-healing processes.”

The study lasted 3 weeks and those who received the OLPs had significantly less symptom severity and had made much more of an improvement than the control group.

Since then, studies have shown OLPs can benefit a surprisingly wide range of conditions, including chronic low back pain, fatigue experienced by cancer patients, ADHD, allergic rhinitis, menopausal hot flushes, depression, and for increasing the effectiveness of methadone in opioid use disorder, .

Where do we go from here?

Open Label Placebos offer a surprisingly powerful – and incredibly low cost – way of treating certain conditions by tapping directly into the mind-body connection.

They demonstrate that the mind has far more ability to impact healing than we realise. And there are simple ways that we can assist this.

Every treatment scenario has what Kaptchuk called a ‘built-in placebo effect’. The setting matters: a view of nature, gentle music, a warm and empathetic doctor or therapist – all of these can amplify the effectiveness of treatment by activating the body’s natural healing systems.

And education around the placebo effect and the mind-body connection in general can help too by increasing a person’s expectations of relief.

It raises the question: how much untapped healing potential lies in what we expect, believe, and feel?

Additional resources:
My book, ‘Why Woo-Woo Works: The surprising science behind meditation, reiki, crystals, and other alternative practices‘ includes chapters on the ‘built-in’ placebo effects of nature, the environment, sounds, empathetic doctors, and more. It also includes a more detailed explanation of how the placebo effect works, and an expansion on some more of the OLP studies.

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