Can we make good use of placebos?

[Sasha]

There's an interesting programe coming up on BBC Radio 4 this week at 9pm on Tuesday:

The power of placebo. Placebos have been shown to have a huge effect on people's symptoms in a vast range of illnesses and even change the body's physiology. And their use is widespread. In recent surveys of German and American doctors half said they at some point, prescribed their patients placebos - pills with no active ingredient. But any doctor who wants to exploit their power has to take the ethically dubious step of deceiving their patients - to lie to make them think they're getting a real drug. And undermining the relationship of trust, key to success of healing and medicine. Or do they? In this week's All in the Mind Claudia Hammond talks to Ted Kaptchuk, Associate Professor of Medicine at Harvard University, who in the first experiment of its kind, has shown that even in sceptical patients who know they are getting a sugar pill, the effect of the tablets on their IBS symptoms was huge. Twice as much as those who'd had no treatment at all.

How does it work and why? Is it that the medical ritual of pill taking , even in the face of accurate information about the lack of any active drug has a powerful therapeutic effect all on its own? Ted Kaptchuk suggests this effect isn't that patients are thinking themselves better but the ritual of taking pills twice a day somehow encapsulates and unleashes the power of their initial consultation with a compassionate physician. As he says "under the white coat and despite all the hi-tech tools at modern medicines disposal, we doctors still have the feathers of the shaman". While he says this is just proof of principle, in theory it could pave the way for drugs with powerful effects on symptoms but with no side effects.

In the absence of any generally effective treatment for ME/CFS, maybe this is an interesting avenue to explore.

In this article about his study on Bloomberg's, he says he thinks an overt placebo might also work for fibromyalgia (he lists several conditions, I think on the basis of those he thinks already demonstrate large placebo effects in conventional studies where the placebos are covert).

Just to be clear, I don't see any suggestion in this that the overt placebo tackles symptoms that are just "all in the mind" and that certainly wouldn't be my view. I'd like to have seen the study going deeper in terms of measuring what is actually going on, though - are the patients with the overt placebo & active treatment changing their behaviour in some way? What goes on in the brain (i.e. which areas are activated) when patients take the overt placebo and the active drug?

Interesting that no-one has apparently tested an overt placebo against no treatment before now! I think that placebo research generally is very interesting and under-researched.

 

[wdb]

Thanks for that, it sounds worth catching, hopefully it will be on iPlayer too.
Interesting point regarding testing an overt placebo against no treatment. I'd like to see them test something like aspirin vs covert placebos vs overt placebos vs seeing a doctor but receiving no treatment vs no intervention at all, both for pain relief (measured subjectively) and platelet count (measured objectively), then I would be convinced they were really on to something.

 

[Sasha]

Thanks for that, it sounds worth catching, hopefully it will be on iPlayer too.
Interesting point regarding testing an overt placebo against no treatment. I'd like to see them test something like aspirin vs covert placebos vs overt placebos vs seeing a doctor but receiving no treatment vs no intervention at all, both for pain relief (measured subjectively) and platelet count (measured objectively), then I would be convinced they were really on to something.

Yes, I'd like to see that too - I hope there'll be some follow-up research that will start exploring this more deeply.

In the meantime, I'm wondering if we can self-administer an overt placebo. Kaptchuk's explanation is that the placebo "unleashes the power of [the] initial consultation with a compassionate physician." Not having had such an initial consultation and with one not in the offing, I'm tempted to get in a stock of my own chalk pills.

 

[wdb]

Does it even have to be in pill form ? I might just from now on consider toast to be an overt placebo, and see how things go

 

[taniaaust1]

It has been found that the placebo affect doesnt actually work well at all on ME/CFS patients. We are far less likely to get this effect than a normal person.

I cant remember now where I've read about that so I cant unfortuantly provide a reference. (Maybe it dont work well in that way for us due to us trying and having so many different meds fail to help?)

 

[Sasha]

Does it even have to be in pill form ? I might just from now on consider toast to be an overt placebo, and see how things go

That gets my vote!

 

[Sasha]

It has been found that the placebo affect doesnt actually work well at all on ME/CFS patients. We are far less likely to get this effect than a normal person.

I cant remember now where I've read about that so I cant unfortuantly provide a reference. (Maybe it dont work well in that way for us due to us trying and having so many different meds fail to help?)

That's interesting - in the past I tried all sorts of things and nothing worked, or even seemed to work - just not a glimmer, even though I would have thought I'd have got some placebo benefit because these were things I had believed might work (enough to be paying for them in the first place!).

I wonder if it's generally the case that things that actually work for PWC are long term treatments (I'm thinking of anti-virals and immune modulators) and if it follows that we'd need a long-term course of placebos? I wonder if the stuff that indicates that placebos don't work so well for PWC was relatively short-term? I'd be curious to know the source of that research, if anyone can remember.

Just thinking out loud...

 

[wdb]

It has been found that the placebo affect doesnt actually work well at all on ME/CFS patients. We are far less likely to get this effect than a normal person.

I cant remember now where I've read about that so I cant unfortuantly provide a reference. (Maybe it dont work well in that way for us due to us trying and having so many different meds fail to help?)

That reminds me there was this study I stumbled upon a while ago http://www.psychosomaticmedicine.org/content/67/2/301.long

 

[Sasha]

That reminds me there was this study I stumbled upon a while ago http://www.psychosomaticmedicine.org/content/67/2/301.long

That's very interesting - a systematic review saying that the placebo response is lower in CFS patients than many other conditions, particularly for psychological interventions and probably because patients don't believe in them - and the co-author is Wessely!

 

[maddietod]

I think the connections between thinking and our chemistry are astonishingly more complex than we can yet imagine. Just as nobody had the imagination 25 years ago to see my CFS/ME as a physical illness, placebo effects have been ignored because they make no sense in our current paradigms. I think the witchdoctor and the toast hypotheses have a lot going for them!

 

[heapsreal]

i have tried too many supps and meds that didnt help at all so i think placebo for me doesnt work and many others have too.

cheers!!!

 

[Snow Leopard]

The most recent Cochrane review suggests the placebo effect is not particularly useful except in very limited circumstances.

http://onlinelibrary.wiley.com/o/cochrane/clsysrev/articles/CD003974/frame.html

They conclude:

We did not find that placebo interventions have important clinical effects in general. However, in certain settings placebo interventions can influence patient-reported outcomes, especially pain and nausea, though it is difficult to distinguish patient-reported effects of placebo from biased reporting. The effect on pain varied, even among trials with low risk of bias, from negligible to clinically important. Variations in the effect of placebo were partly explained by variations in how trials were conducted and how patients were informed.

Much of the so called placebo effect can be explained via reporting biases (eg having treatment might condition patients to focus less on symptom reporting even though they are still there), rather than an actual biological effect.

 

[maddietod]

But maybe the placebo effect is a bit like the body control demonstrated by yogic adepts. Some (very rare) people can sit in the snow and melt it with their increased body temperature, or slow down body functions to a state of hibernation. We aren't supposed to be able to do these things. I wonder, if there are people who respond readily to placebos, if they just have a heightened but unrecognized ability to influence physiological processes.

 

[*GG*]

I think the connections between thinking and our chemistry are astonishingly more complex than we can yet imagine. Just as nobody had the imagination 25 years ago to see my CFS/ME as a physical illness, placebo effects have been ignored because they make no sense in our current paradigms. I think the witchdoctor and the toast hypotheses have a lot going for them!

Well in the UK at least, they knew in the 50's that ME is a physical illness! So not sure why they regressed?! Perhaps you were just referring to the US?

GG

 

[taniaaust1]

That's interesting - in the past I tried all sorts of things and nothing worked, or even seemed to work - just not a glimmer, even though I would have thought I'd have got some placebo benefit because these were things I had believed might work (enough to be paying for them in the first place!).

I wonder if it's generally the case that things that actually work for PWC are long term treatments (I'm thinking of anti-virals and immune modulators) and if it follows that we'd need a long-term course of placebos? I wonder if the stuff that indicates that placebos don't work so well for PWC was relatively short-term? I'd be curious to know the source of that research, if anyone can remember.

Just thinking out loud...

Placebo affects when they do happen are often short lived, (Im not refering to ME/CFS people here but generally with placebos) with the effect of the placebo often only lasting up to a few months, (I cant remember now exactly how long the article I once read said, but it was less then a few months), so they are basically a short term thing for most who they do work for. So I dont think taking a placebo which isnt working long term would help. (of cause it could "appear" to work after taking a placebo long term, due to the ups and downs of our illness over time).

 

[maddietod]

Yes, GG, nobody recognized MY symptom pattern as an illness, here in the US. It's news to me that ME was recognized in the '50s, anywhere! How could doctors "lose" an illness???

 

[Desdinova]

Because only a small number of the world wide population was likely infected / affected until around the end of the 70's. Since it wasn't common most Doctors probably never heard of it other then maybe an article in some journal and likely even that quickly faded from memory.

I have no doubt that the placebo affect is real but not to the extent that the loonies at the Big health agencies would have us believe. I think often what they perceive as the placebo affect is really the patients wishful thinking and hopeful optimism at work. And though it may help them mentally dull and push past the symptoms for a short time it doesn't last.

 

[Sean]

It is not strictly correct to say that something is a placebo. You can only really talk of the placebo effect in the subject. The particular 'placebo' itself is basically irrelevant, all that matters is the subjects' beliefs about it.

Personally, I think the effect is vastly over-rated, and over-invoked.