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occurred when analyzing only the 50% most painful shocks for Comment. These results are consistent with described phe-
each participant (80.5% [95% CI, 68.3%-92.6%] vs 56.1% [95% nomena of commercial variables affecting quality expectations1
CI, 40.9%-71.3%], respectively; P=.03). and expectations influencing therapeutic efficacy.4 Placebo re-
Considering all voltages tested, pain reduction was greater sponses to commercial features have many potential clinical im-
for the regular-price pill (P" .001). In addition, for 26 of plications. For example, they may help explain the popularity
29 intensities (from 10 to 80 V), mean pain reduction was of high-cost medical therapies (eg, cyclooxygenase 2 inhibitors)
greater for the regular-price pill (FIGURE). over inexpensive, widely available alternatives (eg, over-the-
counternonsteroidalanti-inflammatorydrugs)andwhypatients
switchingfrombrandedmedicationsmayreportthattheirgeneric
Table. Comparison of Participants Assigned to Regular-Price Placebo
vs Low-Price (Discounted) Placebo equivalents are less effective. Studies of real-world effectiveness
Regular Price Low Price P may be more generalizable if they reflect how medications are
(n = 41) (n = 41) Value sold in addition to how they are formulated. Furthermore, cli-
Women, No. (%) 27 (65.9) 24 (58.5) .50 nicians may be able to harness quality cues in beneficial ways,6
Age, mean (SD), y 30.9 (12.4) 30.0 (11.4) .74 for example, by de-emphasizing potentially deleterious com-
Calibrated maximum tolerance, 51.8 (18.7) 54.9 (23.3) .50 mercial factors (eg, low-priced, generic).
mean (SD), V
These findings need to be replicated in broader popula-
Shocks received, No. (SD) 18.2 (7.2) 18.6 (9.1) .80
tions and clinical settings to better understand how commu-
Change in pain scores a
All shocks, nicating quality cues with patient populations can maximize
No. (%) [95% CI] treatment benefits and patient satisfaction.
Pain reduction 35 (85.4) 25 (61.0)
[74.6-96.2] [46.1-75.9] Rebecca L. Waber, BS
.02b
Pain increase 6 (14.6) 16 (39.0)
Massachusetts Institute of Technology
[3.8-25.5] [24.1-54.0] Cambridge, Massachusetts
Highest-intensity shocks only, Baba Shiv, PhD
No. (%) [95% CI] c Stanford University
Pain reduction 33 (80.5) 23 (56.1) Stanford, California
[68.3-92.6] [40.9-71.3] .03b Ziv Carmon, PhD
Pain increase 8 (19.5) 18 (43.9) INSEAD
[7.4-31.6] [28.7-59.1]
Singapore
Abbreviation: CI, confidence interval.
a Comparison of participants experiencing a mean reduction in pain after vs before the Dan Ariely, PhD
placebo pill was administered (visual analog scale point reduction between 0.01 and ariely@mit.edu
48.4) and those experiencing a mean increase in pain (visual analog scale point in-
crease between 0 and 29.2). Massachusetts Institute of Technology
b Two-tailed !2 test.
Author Contributions: Dr Ariely had full access to all of the data in the study and
c Highest 50% of shocks by intensity.
takes responsibility for the integrity of the data and the accuracy of the data analysis.
Study concept and design: Waber, Shiv, Carmon, Ariely.
Acquisition of data: Waber.
Figure. Pain Ratings by Voltage Intensity Analysis and interpretation of data: Waber, Ariely.
Drafting of the manuscript: Waber, Shiv, Ariely.
Critical revision of the manuscript for important intellectual content: Waber, Shiv,
35 Carmon, Ariely.
Placebo price
Statistical analysis: Waber, Ariely.
30 Regular Obtained funding: Ariely.
Low Administrative, technical, or material support: Waber.
25 Study supervision: Ariely.
Financial Disclosures: None reported.
Funding/Support: This study was funded by the Massachusetts Institute of Technology.
Mean Difference
20
Role of the Sponsor: The sponsor had no role in the design or conduct of the study;
the collection, management, analysis, or interpretation of data; or the preparation,
15
review, or approval of the manuscript.
Additional Contributions: Taya Leary, MS, Tom Pernikoff, BS, and John Keefe, BS, all
10 with the Massachusetts Institute of Technology at the time of this study, provided as-
sistanceindatacollection.MrKeefereceivedcompensationforthisrole.AndrewLippman,
5 PhD,MassachusettsInstituteofTechnology,providedlogisticalsupportandMarkVangel,
PhD, Massachusetts General Hospital, provided statistical assistance. Neither received
0 compensation for these roles.
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–5 ers’ perceptions of product quality. J Marketing Res. 1989;26(3):351-357.
10 15 20 25 30 35 40 45 50 55 60 65 70 75 80 2. Benedetti F. How the doctor’s words affect the patient’s brain. Eval Health Prof.
Shock Intensity, V 2002;25(4):369-386.
No. 3. Koshi EB, Short CA. Placebo theory and its implications for research and clini-
Regular price 41 41 41 40 37 31 27 23 21 20 18 14 12 9 8 cal practice. Pain Pract. 2007;7(1):4-20.
Low price 41 41 41 40 38 31 29 27 24 19 17 11 7 5 4 4. Berns GS, Chappelow MC, Zink CF, Pagnoni G, Martin-Skurski ME. Neurobio-
logical substrates of dread. Science. 2006;312(5774):754-758.
Mean difference in pain ratings, after vs before placebo, by voltage intensity. Higher 5. Price DD, Fields HL. The contribution of desire and expectation to placebo an-
value indicates greater pain reduction. The table depicts the intensity of the shocks algesia: implications for new research strategies. In: Harrington A, ed. The Placebo
and the number of observations in the regular-price and low-price conditions. P Effect: An Interdisciplinary Exploration. Cambridge, Massachusetts: Harvard Uni-
value is less than .05 for the shock intensities 27.5 V through 30.0 V, 35.0 V through versity Press; 1999:118-119.
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©2008 American Medical Association. All rights reserved. (Reprinted) JAMA, March 5, 2008—Vol 299, No. 9 1017