Every you every me
On placebos, medicines, and drugs
Last week brought the Caffeine as a Gateway Drug Series to a close. When I started writing it two months ago, it was on a bit of a whim. I wanted to get back into writing for fun, so building on a topic I felt comfortable with seemed like a good place to start.
It was a really pleasant surprise when a few people I knew started to read and engage with the posts. And now, at the end of the series, I find myself connected to a whole bunch of new people from various places in the world, which is so cool and I’m really grateful! Which made me think It might be a good time to share a bit about myself and where I see this Lessons on Drugs thing going from here.
The title of this post actually reveals quite a bit. First up, the fact that I’m going to use it as fuel for the next paragraph or two will expose me as an overthinker…not quite neurotic, but perhaps neurotic adjacent if that’s a thing?
The imperfect grammar of the title will also provide you some indication that perfect grammar is not something I particularly care about. I’m not here because I’ve been steeped in the fine traditions of a liberal arts education1. I’ll do my best, but if you’re into perfectly crafted sentences, correct use of punctuation and proper paragraph spacing, you’re not going to find it here. I tend to read posts like this on my phone, and I don’t like big long paragraphs that require endless scrolling. As such, there will no doubt be too many paragraph spaces for some people to handle.
The ‘every me’ part of the title is also telling. I’m a multifaceted being, as I’m sure you are too. I’m confident I can deliver consistently on writing posts that help you understand how drugs work, but the way these concepts will be packaged up is likely to be broad ranging. I’m not writing this as part of a well planned content marketing strategy walking you into a sales funnel or anything like that - I’m making this up as I go and trying to have some fun on the way.
One of the influences you’ll regularly see get a guernsey2 is the musical one. Partly because I enjoy music, but also because I struggle with titles. This week’s title is from 90s band Placebo. They’re not a particular favourite of mine or anything3, but I do have good memories of this song, and it does provide me with a perfect segue into why I called this Lessons on Drugs…the good old placebo effect.
Back when I was a baby pharmacist, I worked in the manufacturing department of a children’s hospital. We’d make up all sorts of niche products4 that pharmaceutical companies wouldn’t make enough money from, like suspensions, specially formulated creams, things like that. One of the products we made was rhubarb and soda mixture, used to treat babies with colic.
In a world where evidence based medicine rules, this was a point of contention. How could we, a science respecting pharmacy, support the use of a product that we knew had no pharmacological effect?
Because they needed a placebo.
While there might not have been any evidence to support the use of this product in colic, the evidence regarding colic as a diagnosable condition in neonates was also pretty flimsy5. What the evidence did suggest though, was if parents themselves were anxious, it negatively contributed to the overall experience of what it was like to have a ‘colicky baby’6. The idea was that giving parents an action they could take when their tiny baby was distressed would enable them to be more relaxed and better able to soothe the seemingly endless cries.
In other words, a lack of pharmacological benefit doesn’t necessarily mean a complete absence of therapeutic benefit.
I say this, because there are a whole bunch of products on the market that could loosely be considered placebos. But not all of these products are worthy of endorsement. What made the rhubarb and soda a ‘good’ placebo wasn’t just that it was pharmacologically inert, it was that it also lacked adverse effects - including the adverse financial effects. It was cheap.
Another important thing the rhubarb and soda mixture had going for it in the placebo stakes, is that it didn’t result in a delay in anyone seeking medical help. The parents weren’t unintentionally overlooking something more sinister.
This is particularly important one when it comes to some of the more inert over the counter products and alternative therapies used for life threatening or permanently disabling conditions. Homeopathy clearly fits in this category, but so do some cough and cold products. It’s a throw away line on commercials, but the old adage of ‘if symptoms persist, see your doctor’ is a good rule to live by.
The reason I’m framing it like this, is because I see a lot of healthcare practitioners who write in this space pitch it as being very black and white. They love to label things pseudoscience and make it look as though everything we use in conventional medicine has a rock solid evidence base. What can I say, I’m more pragmatic than that and I don’t think it does much to help build greater understanding. Plus, I also like to think I try my best to avoid being a hypocrite.
I’m pretty sure that if you scrutinised my daily routine you’d find a placebo product or two. Since turning 40 there’s been a sharp uptick in my expenditure on overpriced skincare products. And I can safely assure you, I’ve never once looked into the evidence about whether or not they work.
The reason why I’ve never bothered doing a literature search on this, is that I consider it a measured risk. If the product doesn’t work it’s my vanity on the line, not my health. I can afford the products in fancy packaging that smell nice and they make me feel good when I use them. That’s good enough for me.
Why am I sharing this? Because, while I’m not sure about whether or not my peptide eye cream with 75 listed ingredients will actually reduce my smile lines7, I’m very confident that it’s not going to produce any systemic side effects. Because I know enough about drugs to know the active ingredients won’t make their way into my bloodstream.
If I’m taking something orally, or in any other non invasive way that allows a substance to pass into my bloodstream, I’m more discerning. And when it comes to something that gets injected, well that’s when I let my critical thinking and evidence-based analysis fully unleash.
As I explained in this post, injecting a substance into the body is like getting John McClane8 to deliver a package by busting through the window - there is going to be collateral damage.
Infection, irritation of the local tissues like blood vessels and nerves, and scarring are risks of anything you inject. In the case of injecting something into the vein, this damage may render the vein useless for future use. Now, you might not think that’s a big deal, but I’ve worked in hospitals and palliative care enough to know that it’s very likely a day will come where you’ll be grateful for the health of your veins.
And before you get all ‘as if I’d ever inject drugs!’ on me, I just want to point out that the risk of tissue damage and infection relates to the act of injecting, not the substance itself. For example, those NAD+ therapies and vitamin infusions that are marketed as wellness strategies can still cause infection and permanent damage to your veins. Even if it’s being injected somewhere else- cosmetic procedures like dermal fillers and Botox - well, they can also cause infection, bruising and nerve damage. I’m not saying people should be banned from using these products or anything, I just don’t think it’s something to be flippant about.
Which leads me to one of the messages that underpinned the Caffeine as a Gateway Drug series and Lessons on Drugs more broadly: the line between what’s classified as a supplement, herb, medicine, or drug doesn’t really exist - it’s more like a smudgy blur.
My perspective is, if you’re using something for the purposes of eliciting an effect in your body, it’s a type of drug. The rest is a matter of semantics.
The academic in me would say a substance (including natural products) used for a therapeutic effect is a medicine, something used to supplement vitamins and minerals within the diet is a supplement, and something used for recreational purposes is a drug. But I don’t think it really matters much when it comes down to it.
The definition I’m going with is that any exogenous substance you use for its effect in your body is a drug. That includes herbs and supplements.
My approach is not to be judgemental of what you decide to put into your body or the rationale under which you make that decision. This isn’t about dogma or ideology. I just don’t want you to be hurt by the substances you take. And if that sounds good to you, then I’m hoping you’ll find some value here and stick around to see where it goes.
Thanks so much for reading! I’m really keen to understand any topics you’d be interested in learning more or, well, any level of interaction you feel comfortable with really. Comments are great, but if you’re more comfortable with private conversation just send me a message.
If you’ve got this far, chances are you liked it, so please click on that heart or share it with others - it helps the work get seen by people (and it’s nice to know people care).
I heard the best newsletter writers use footnotes.
I only know this term through watching TV and movies, I don’t even know if I’m using it right but it sounded nicer than “humanities” like we use here.
You’ll also notice I write in Australian English. Given that I’m married to a Canadian, I’m well aware that Australian English has a certain flavour to it that can, at times, be completely nonsensical. If you’ve come across the whole ‘yeah, nah’, ‘nah, yeah’ thing then you’ll understand this. This particular phrase ‘get a guernsey’ relates to Aussie Rules Football.
I was so far from emo as a teenager, although I did like this song.
One of the products we made was cocaine nasal ointment, to be used as a local anaesthetic during surgery. It involved a big pile of pure cocaine powder that had to be worked into an ointment base the old fashioned way - with a spatula on a glass slab. It made my fingers go numb. But, being the goodie goodie that I am, the story doesn’t go anywhere more interesting than that.
This is how it was in the late 2000’s - I haven’t caught up on the latest in colic evidence.
I’m not meaning to diminish the experience of having a colicky baby. It’s not a nice thing for anyone to endure, and really hard to know if it’s normal or something else going on, which makes it even more stressful and exhausting.
I’m confident there is no cream in the world that could achieve this, and that’s ok. I’ll take smile lines over frowny ones any day.
If you don’t recognise it, John McClane is a reference to the movie Die Hard, which is another flavour you can expect to see consistently employed here - pop culture is my one true love and I will shoe horn it in anyway I can.
The title track…
I confess, until today I thought the song was ‘Every me and every you’, because that’s what the lyric is. Apparently not.
Footnote to the footnotes, because the whole point of this is to give you more of a sense of who I am and what I’m doing here…
I had a thought on a topic or series you might like to cover - I wonder what kind of interesting insights you would gather from interviewing people with experience in a range of illicit drugs. It would be fascinating to see the technical/scientific side of it contrasted with the actual physical and psychological experiences of people who have gone down these various rabbit holes. Anyway just food for thought! Keep writing :)
The placebo effect is in itself fascinating to me, and also what it says about the power of ritual. I appreciate that you’ve treated this subject with care, and I love how you delineate pharmacological effects and therapeutic effects. Well done!