What do we do about placebo?

Body in Mind recently featured a piece on the ‘Moral Dilemma of Offering a Known Placebo’ in which Neil O’Connell talks about how the ‘placebo effect … in part rests on the effects of expectation, belief in the treatment and possibly a re-evaluation by the patient of their symptoms’. He was referring to treatments like acupuncture, electrotherapy and so on, and calls them ‘magic kisses’ because they work in a similar fashion to the ‘Mummy will kiss it better’ treatment I’ve given to my kids when they were younger.  The dilemma lies in the fact that placebo is simply an inert, inactive ‘intervention’ given as if it was active – inevitably requiring deception on the part of the practitioner, and what this can do to things like trust and informed choice by the patient.

So much of what we do as clinicians, particularly physical and occupational therapies, has a limited evidence base.  At the same time, some of the ‘active ingredients’ that have been identified in ‘placebo’ are the very things we are taught to develop – like active listening, instilling positive expectations, helping people re-evaluate their situation.  It’s incredibly difficult to disentangle the ‘active’ from the inactive components of the treatment.

Like Neil, I have concerns about encouraging, even inadvertently, any belief in a mystical, magical ingredient – chi anyone?  I also have concerns about any intervention that suggests the need for an ongoing relationship with a clinician – six-weekly ‘adjustments’ sir?  Or interventions that leave the power (or locus of control to be pedantic) with a gadget or device or substance that someone else needs to operate – three monthly infusions madam?

Dan Moerman’s view of health interventions suggests that every treatment inevitably contains culturally-based elements.  These are the result of an interaction between the person seeking treatment, the social environment in which they live, the treatment setting, the ritual associated with the treatment process, and the interpersonal relationship with the practitioner – everything we do in any healthcare encounter will influence the ‘healing’ or ‘meaning response’ of the patient.

Along with the placebo effect (meaning response), we sometimes forget the nocebo effect – the ill effects that people develop as a result of receiving an inactive treatment.  Take a look at any of the randomised, double-blinded, placebo controlled studies, and in a good one, you’ll see listed all the side effects that people developed when receiving the active treatment – and if you look carefully, you’ll also see the side effects that people developed when receiving the inactive treatment.  It’s entirely likely that along with our very effective, evidence-based treatments, some people will also either fail to respond, or will develop side effects that negate the positive effects of the intervention.

So what on earth do we do about this placebo thing?

Putting my ‘patient’ hat on for a moment, and remember that we are ALL patients at some point in our lives, I know that I want honesty from the practitioner I’m seeing.  I want to choose whether I have a certain treatment – or not.  And I want to know my options.  I’d like to be told about both the side effects and the hopefully positive effects of the treatment.  I want to know the evidence-base for the treatments I get (and if I don’t get told, you can bet, like many of our patients, I’ll be onto the internet and into the journals quick as a flash to find out!)

I don’t want to have a long-term relationship with a practitioner who will want to see me every six weeks or three months, and I don’t want chi (or woo).  I’m not into magic, superstition or intuition.

I’m inevitably going bring all my socially-shaped judgements and beliefs and prejudices into the treatment setting, and I know this is going to influence the outcome.

I’m likely to decide on a particular practitioner on the basis of word of mouth (reputation), what I’ve read from the literature (call that advertising if you will), and I’ll probably decide to return (or not) depending on his or her interpersonal skills – and because I too am influenced by the superficial – I’ll probably be influenced by the decor in his or her rooms and the cost of the treatment!

You see, we’re all influenced by these meaning responses.

So… what to do about placebo?  I, like Neil, hope that as the evidence accumulates, I will throw out the treatments that don’t have solid support from well-constructed RCT’s.  I will be mindful of my reputation and hope to have one that means I’m recognised by my adherence to an evidence-based approach to pain management.  I also hope I’ll always focus on helping people to help themselves, so I don’t inadvertently foster dependence on me.  I won’t be incorporating woo, chi or crystals (at least, not on the basis of current evidence!)  I won’t be using gadgets except as part of helping someone develop their own skills.  If I ask someone to come back after a bit of a break, it will be only to review how they’re going with their own goals, and to help them re-jig their plan for the future.

And I will try to recognise that some people will come to see me and will not ‘get better’ – not because of my approach, but because they have come into treatment with their own beliefs and expectations, their own ‘meaning response’ might interfere with what I’m doing.  Above all, I hope I’ll be honest about what I’m doing and be prepared to change my approach on the basis of science.

That darned placebo – whatever do we do about it? Learn more I hope!

Moerman DE (2002). The meaning response and the ethics of avoiding placebos. Evaluation & the health professions, 25 (4), 399-409 PMID: 12449083
Moerman, D., (2003). Doctors and patients: The role of clinicians in the placebo effect. Advances in Mind-Body Medicine. Vol.19(1), pp. 14-22.
Moerman, D., (2003). “Placebo” versus “meaning”: The case for a change in our use of language. Prevention & Treatment. Vol.6(1), pp. No Pagination Specified

Links and placebo

I’m going to ‘cheat’ a little today – I want to link to someone else’s blog and an article I’ve previously posted on to discuss placebo.

It’s a vexed question for people working in pain management – the ‘meaning response’, or interpretation of the meaning the patient and clinicians place on the health care interaction and the context in which it occurs, is at the heart of so much of pain relief that we can’t ignore it. But at the same time, we know so little about the ‘meaning response’ and have incredible difficulty studying placebo especially in the field of persistant pain.

I did discuss this article a couple of days ago, but I think the questions it raises are worth considering again.

This blog post by Jake Young, who writes in ‘pure pedantry’ (a name I admire!!) discusses his response to the article by Tilburt and colleagues, and says this ‘I don’t think I would be comfortable deceiving my patient under any circumstances. I see my role as a future physician partly as a healer but also as an educator. Patients — particularly patients with intractable chronic illnesses — want to understand what is happening to them. I almost feel like in deceiving them, I would be denying them that small measure of control — that small measure of dignity — that is vital to feeling like a complete person, even in the face of a life destroying illness.’

One persons response to this comment is this: ‘ in sum, placebos are unpredictable. They cannot be effectively prescribed in any rational manner. One placebo “effect” is the relationship between doctor and patient—this should always be used anyway. Prescribing a pill, elixir, etc and giving false information as to it’s effectiveness is unethical.’

Another said ‘oh please. how many medications do we have where we do not really and truly understand how they work? Just because you have a handful of acute pharmacological effects to report doesn’t mean you really understand the critical mechanism. How the hell does Ritalin work? How about Prozac, which takes many weeks for efficacy?’

While yet another said ‘The placebo effect may very well depend on generating a false belief in the patient. If lying works, why is this necessarily unethical? It should be subject to cost/benefit analysis like any other therapy…”

Hmmmm.

Given that we don’t know how many modalities in pain management ‘work’, we could be accused of using ‘placebo’ in many situations – how does CBT work? how does exposure therapy work?

But neither of these are inert treatments, which is what placebo is. And they don’t involve deception.

And it’s the latter that really bothers me the most.

If I intentionally choose not to disclose what I’m doing and why, how can I be assured I’m providing patients with ‘informed consent’?  Don’t patients (ie, you and me when we seek health care…) have the right to know their options, and choose?

There is an attitude amongst some providers that says ‘the ends justify the means’. Do you want that for yourself as a consumer?

I don’t know how my antidepressant medication works – but I know I’m taking a specific medication, and I’ve read the evidence that says it has a good effect, and my options were explained to me very clearly by my GP and specialist.

Deliberately providing me with an inert substance in the name of an active substance without informing me is deception, and if I ever found out, my trust in my health care provider would be betrayed. And I wonder whether one of the ‘active ingredients’ in the meaning response is actually trust.

Do you really want to abuse that? It could be you next…