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Lotions, Potions and Placebos

I have been active in the pharmaceutical sector for more than 40 years now. Following a B.Sc. (Hon.) in Chemistry from Carleton University and a Ph.D. from The Ohio State University College of Pharmacy, my professional career has been spent at the interface of research, development, and commercialization. This has provided me the opportunity to observe and understand the dynamics of ‘drugs’ medically, pharmacologically, commercially, and sociologically, be they pharmaceuticals, botanicals, or street drugs, in general all things people medicate with, licit, illicit and counterfeit.

One of the more interesting classes of ‘drugs’ I have looked into are placebos. These are commonly thought of as little white sugar pills. They contain no active pharmaceutical ingredient, at least not active in the common understanding of the word. Actually, placebos come in many more dosage forms than just pills. The medical profession prescribes them in all sorts of dosage forms; pills, capsules, ointments, creams, drops, suppositories, liquids, injectables and more. In a clinical research setting they are used to measure the relative activity, and safety, of what is suspected to be an active pharmaceutical. Often, researchers are surprised to discover that what was hoped to be an active drug is no more effective than the placebo. Well, that makes sense, if the hoped-for drug is not active then why would it be more effective than the placebo? The surprising finding is that while a potential drug is no more effective than the placebo, both the placebo and the inactive drug still show surprising effectiveness in a number of patients.

There have been a large number of scientific studies looking at placebos; how they work, why they work and when they work. Placebos show no effectiveness in treating patients with serious infectious diseases little Hepatitis C, HIV or Pneumonia. Placebos do however show significant effectiveness in treating diseases like depression, pain, and anxiety. Surprisingly, placebos can also cause side effects. There are also ‘nocebos’, the evil twin of placebos. These are products that contain no active but because of expectations actually cause a reduced response to validated treatments and/or significant side effects.

In general, patients who think they are getting a newer more expensive drug, in this case a placebo, have a better clinical response than patients who are told they are getting a generic drug, also a placebo. In pill form, some colors of placebos do better than others for different indications. This shouldn’t be surprising. In any number of reported blinded taste tests of wines and liquors even experts couldn’t consistently tell the difference between expensive and cheap wines and liquors. But put a label and a price on the samples and people, including experts, consistently find the more expensive products to be better, even when labels are switched.

At the end of this post I have included links to articles you may find interesting if you want to dig a little deeper into understanding placebos.

The Local Scene

Why then this post on Parry Sounds? I have been noticing that we are starting to get more and more lotion and potion stores popping up in the area. These are generally boutique type operations offering proprietary products that can provide ‘relief’ from any number of annoying health issues using ‘natural’ ingredients. In almost all cases the ingredients and their amounts are not clearly specified, and I would speculate none of them have been subject to any type of rigorous testing in terms of quality control, stability, or safety, much less effectiveness. Personally, I am less concerned about the effectiveness of these products if used for non-life-threatening conditions than I am about their safety. If they are not effective the only thing being hurt is the purchaser’s bank account.

If these products don’t work then shouldn’t these companies go out of business? No! Since placebos can show effectiveness in 30% to 60% of patients, depending on the particular condition being treated, a successful business can be built selling placebos, as long as there is a good ‘story’ about why the products are especially effective, the business can provide relatable testimonials, and the products are a little bit pricey. If it’s expensive it must work, mustn’t it? Even better is securing the endorsement of a celebrity.

The Business of Lotions and Potions

Here is a bit of a checklist to be successful selling lotions and potions.

  1. Target conditions that are largely subject to subjective opinion. A thermometer may be able to tell if you have a fever, or a blood test can determine if you do or don’t have a venereal disease or anemia, but only you can tell if your pain or anxiety is severe, moderate, or mild and whether it is getting better or worse. Although these lotion and potion folks should stay away from serious conditions like diabetes and HIV, they often can’t help targeting desperate people, through an impersonal media like the internet. If you never meet your customers in person, it’s a bit easier to ignore the real world consequences of what you are selling.
  2. Put together an interesting story of why your lotion, potion or pill is ‘special’. Perhaps it has an ingredient from a unique plant, or perhaps it has a special blend of hard to find ingredients. A story associated with ancient or foreign cultures can also be a winning strategy.
  3. Understand that not all your customers will have a favourable response. You just need 30% of the folks to be ‘satisfied’ with the results of using your product. Once they have some success they will be sure to come back again and again.
  4. Be sure that the lotion, potion or pill doesn’t unintentionally cause serious side effects. That’s a no-no, because not only will customers be unlikely to buy from you again, they are likely to tell others about their bad experience. (In some cases, very mild side effects are a desirable feature of lotions and potions, it gives folks a sense that your product is ‘working’.)
  5. Budget for a 30% placebo response rate but hope for something more like 50%. Because the people trying your product already have some belief or hope that your product will be effective based on your story and/or a personal recommendation it is likely that they will be ‘primed’ to have a positive experience.
  6. Price for profit. Typically, pharmaceuticals have a profit margins (selling price less cost of production) in the range of 90-95%. In the ethical pharmaceutical industry this profit is used to provide executives with outsized salaries, support sales and marketing efforts and, of course, research and development activities. Since you have no R&D to support beyond your imagination, you need to invest in advertising, preferably social media advertising that offers significant reach to very specific audiences with very little governmental scrutiny. If social media is a go-to platform for politicians, you can feel comfortable that it will work for lotions and potions.

If half the people who buy your product return, and you have priced it for profit, you have a winner. There are more than enough folks looking for that little bit of ‘extra help’ with a troubling condition that their physician is unable, or unwilling, to help manage.

CBD Placebos

One of everybody’s favourite placebo lately is CBD, cannabidiol, extracted from the hemp plant. The problem with CBD is not that it isn’t a powerful placebo for almost all of the promoted uses, it is, but rather that everyone is selling it in any number of presentations; capsules, solutions, lotions, tinctures, suppositories, nasal sprays and more. It’s hard to build a story of why your product should be better than the competition if you are all selling the same ‘story’ and dosage forms. The CBD placebo market is suffering from issues of price erosion, it has become a matter of who can sell it for less. (Note: CBD is approved by the regulatory authorities for the treatment of rare forms of epilepsy. The doses used for these indications exceed by a factor of 10-100x what is recommended for the lotions and potions crowd. At those doses even CBD lotions and potions would costs thousands of dollars per year.)

I have noticed one local lotion and potion shop is prominently promoting their product as not containing CBD and offering their product as a clear alternative. Smart marketing in my opinion, don’t sell into a buyer’s market like CBD where it is difficult, if not impossible, to create a unique story.

Mind Safety

I just hope these lotion and potion companies are paying attention to the quality and safety of the products they are offering. Many of these herbal ingredients are being sourced from Asian suppliers who have a very poor record of quality control and have been associated with significant safety issues. Even pharmaceutical companies who source many of their raw materials from Asia, and have significant quality control operations, have run into unexpected safety issues.

If these lotions and potions are in fact ‘active’, they will have certainly desirable and undesirable effects. Even if they are not active for the intended applications they may still an have undesirable impact when used in combination with prescription products or other lotions and potions. Prescription products generally have a long list of possible drug-drug interactions in their prescribing information. The pharmaceutical industry cannot be expected to test their products for interactions with the lotions and potions ‘eye of newt’ or ‘toe of frog’ offerings and none of the lotions and potions folks are going to invest in testing how their products interact with prescription medications. The lotion and potion folks can only hope their products have no actual pharmacological activity and then pray for a significant placebo effect.

Final Thoughts

As a business consultant, I will be interested in seeing how these local Parry Sound area companies do. I wish them no ill so long as they are careful enough to not hurt their customers by compounding potentially dangerous ingredients or not paying enough attention to their raw material suppliers.

I can empathize with folks who are experiencing pain, depression, anxiety, IBS, arthritis and any other number of conditions who are not getting relief working within the formal medical system. If it works, go for it. Just be sure to let your medical care provider (physician and pharmacist) know what you are taking. Even if the lotion and potion is safe it may still have a dangerous interaction with prescription pharmaceuticals you are taking.

Selected Readings (the links below will open in a new tab):

  1. Placebo (Wikipedia).
  2. Nocebo (Wikipedia).
  3. Is the placebo effect real?
  4. The Power of Drug Color.
  5. The weird power of the placebo effect, explained.
  6. Notes from the Field: Methylmercury Toxicity from a Skin Lightening Cream Obtained from Mexico — California, 2019.