Chapter Fifteen - The Power of Labeling in Nocebo Effects

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Abstract

Nocebo effects comprise two broad types: primary nocebo effects, in which overall treatment efficacy is reduced; and nocebo side effects, which result in the increased experience of unpleasant secondary side effects. An important factor in generating nocebo effects of both types is the patient's expectations of how well a treatment will work, and how likely it is to cause side effects. One source of negative expectations is the presence of generic—as opposed to brand name—labeling. A medicine's labeling is likely to be one of the first aspects of a treatment that is encountered by a patient, and perhaps the most common labeling information on pharmaceuticals is the labeling that identifies the drug as being made by the originator brand manufacturer, or as a generic copy. Although generic medicines are pharmaceutically equivalent to their brand name counterparts, generics are often viewed with distrust and perceived to be inferior to branded medicines. Negative perceptions of generic pharmaceuticals may contribute to reduced treatment efficacy via enhanced primary nocebo effects, and increased nocebo side effects. This chapter reviews evidence for the role of brand and generic labeling in treatment outcomes across a range of contexts—most often laboratory research assessing pain outcomes, as well as the influence of related factors including price, familiarity, and treatment switches. Although increasing evidence suggests that labeling of medicines can shape nocebo effects, interventions to improve perceptions of generics do not necessarily translate into more positive treatment outcomes.

Section snippets

Generic Medicines

Perhaps most associated with the concept of pharmaceutical labeling is originator brands versus generic medicine labeling. In pharmaceutical development, the originator brand name, e.g., Prozac or Viagra, is the name that is given by the manufacturer who developed, tested, and patented the medication (Chandler & Owen, 2002). Originator brand manufacturers are typically large pharmaceutical companies with wide recognition of their company name and logo. Incorporated into brand name labeling of a

Brand Name and Generic Labeling

As previously noted, at least one-third of the population holds one or more negative perceptions of generic medicines, including that generic drugs are less safe, less effective, of lower quality, more likely to cause side effects, and should not be substituted for their brand name equivalents (Colgan et al., 2015). Negative perceptions of generics appear to contribute to reduced treatment efficacy via primary nocebo effects—where negative beliefs reduce the primary or intended effect of a

Improving Perceptions of Generic Medicines

Although a substantial body of research has sought to investigate public and medical professionals’ perceptions of generic medicines, very little research has explored the utility of interventions to improve perceptions of generics. One experimental study tested the effect of a brief intervention on both perceptions of generics, and subsequent efficacy of an analgesic (ibuprofen) labeled as either a brand name or generic, in treating headache pain (Colgan et al., 2016). This study used a

Implications of Generic Labeling and Subsequent Nocebo Effects

Nocebo side effects are common in medical care; in some treatments they are likely to be responsible for the majority of reported side effects (Finegold et al., 2014; Mahr et al., 2017; Tobert & Newman, 2016). The studies reviewed in this chapter demonstrate how generic labeling and associated features of the treatment context can increase unpleasant side effects and decrease treatment efficacy. Primary nocebo effects—i.e., nocebo-induced reductions in treatment efficacy—and nocebo side effects

Conclusions

This chapter provides a comprehensive overview of research conducted to date examining the influence of generic labeling, and related attributes, on treatment outcomes. As more evidence becomes available, future work could usefully involve systematic reviews and meta-analyses of studies examining the influence of labeling on nocebo effects. However, at this relatively early stage, a narrative overview and discussion of this research is most appropriate. A range of aspects associated with

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