When my daughter hurts herself, her placebo of choice is a “magic kiss”. This therapeutic intervention must be applied with care specific to the area of injury. Anecdotal evidence suggests that it is very effective. I use placebo freely at home but is it right to do this in the clinic? In a recent post I suggested that we can be more confident that acupuncture is essentially a placebo treatment. Still, patients feel benefit, so is it still OK to use it? I have often heard clinicians declare “I don’t care if it is a placebo if it works”.
Franklin Miller from the Department of Bioethics at the NIH considers these kinds of questions for a living. He has published a number of papers around this topic including this great review with his colleague Luana Colloca on the ethics of placebo in clinical practice. I was lucky enough to have a correspondence with him that had me thinking about this more deeply.
The big tension around offering a treatment that we know to be just a placebo lies with the competing interests of being committed to reducing suffering and the need to be transparent and offer informed consent. Offering a known placebo usually requires an act of deception that in its way, undermines the relationship between clinician and patient. Of course if you could offer a placebo, be honest about what you were doing and still have a powerful effect there would be no problem.
Thinking about the ethics of all this in the therapies I see something of a division. We have many passive modalities that may well work by placebo (acupuncture, maybe manipulation, electrotherapy etc: let’s call these “magic kisses”). Any placebo effect of these therapies in part rests on the effects of expectation, belief in the treatment and possibly a re-evaluation by the patient of their symptoms. Then we have therapeutic approaches like advice, pain education, CBT, lifestyle adaptation, which again seek to push patients to re-evaluate their symptoms and alter their behavioural responses (let’s call these “rational hugs”). Even with a partially shared mechanism of effect there seems to me to be a clear difference – rational hugs do not require a belief in a mystery magic ingredient, and aim to empower the patient by offering a solution that they might control. Even if we found that the effect sizes were similar between the 2 types, there are no fibs being pushed in the second.
Two other points occurred to me. The first lies around the issue of patient choice. Why do patients choose acupuncture or manipulation or ultrasound etc? I guess they do because each treatment has passionate advocates who promote them, advertise them, spread the word about them, often with a willing media tagging along like an enthusiastic labrador. So the treatments help because patients expect them to, but patients only expect them to because the culture that delivers those treatments has propagated that belief! It’s a fabulous business model (it all costs) but I smell a conflict of interest. Patient choice is difficult in a world where good information is so elusive.
The second point lies in the possible long-term harms of offering passive treatments of limited efficacy. These are much harder to measure than the short-term benefits. Treatments such as manual therapy that are based on models of pathology (that might not be identifiable or relevant) might lead to increased catastrophising and negative beliefs about what should be relatively benign conditions. Recently a number of big studies have suggested that therapies for whiplash associated disorder are a risk factor for poor outcome or delayed recovery. This isn’t the clear support for my theory of the superiority of rational hugs over magic kisses as it at first appears. Not only passive therapies like chiropractic but also therapies including advice, pain education and clinical guideline-based management (see here and here) show this trend. Maybe offering any treatment increases vigilance and attention to symptoms and thus perpetuates symptoms in somatic syndromes? I wonder whether any short-term benefits of placebo might be offset by these dangers. It seems that any therapy may have the capacity do harm, even where it is not immediately obvious.
Given the generally small clinical effects of placebo, the potential for undermining trust in the therapeutic relationship and a sinking feeling that it’s a bit demeaning for all involved, I think that if we know a treatment is essentially a placebo we might give it the elbow. We should celebrate the fact that the placebo effect is still there offering a helping hand when we deliver effective treatment with care. So let’s hear it for rational hugs.
PS: For a nice little chat about placebo from Ben Goldacre click here.
Original Article
Miller FG, & Colloca L (2009). The legitimacy of placebo treatments in clinical practice: evidence and ethics. The American journal of bioethics : AJOB, 9 (12), 39-47 PMID: 20013499
Other References
Cassidy, J., Carroll, L., Côté, P., & Frank, J. (2007). Does Multidisciplinary Rehabilitation Benefit Whiplash Recovery? Spine, 32 (1), 126-131 DOI: 10.1097/01.brs.0000249526.76788.e8
Côté P, Hogg-Johnson S, Cassidy JD, Carroll L, Frank JW, & Bombardier C (2007). Early aggressive care and delayed recovery from whiplash: isolated finding or reproducible result? Arthritis and rheumatism, 57 (5), 861-8 PMID: 17530688
Hróbjartsson A, & Gøtzsche PC (2010). Placebo interventions for all clinical conditions. Cochrane database of systematic reviews (Online) (1) PMID: 20091554
Pape E, Hagen KB, Brox JI, Natvig B, & Schirmer H (2009). Early multidisciplinary evaluation and advice was ineffective for whiplash-associated disorders. European journal of pain (London, England), 13 (10), 1068-75 PMID: 19181548
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The morality of magic kisses: Ethics and placebo in physiotherapy http://goo.gl/fb/qovUZ
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This question often comes up when I consider whether to completely debunk homeopathy and other alternative therapies, and eliminate them from say my family, or to encourage them to the extent that they serve as effective placebos for certain ailments.
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The morality of magic kisses: Ethics and placebo in physiotherapy http://bit.ly/cj4Usr
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If neurophysiological changes occur, even with something you seem to think is placebo, is it really placebo?
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Neil O'Connell Reply:
July 27th, 2010 at 10:12 pm
Yep I would say it is.
Taken to its logical conclusion that position means that as long as the unsuspecting patient buys into it any old nonsense will do. So, in extremis, I could wave my magic cabbage (its all in the green aura) over the affected part whilst chanting to maximise the “healing energy”.
My argument only applies to treatments that have reached that point in the evidence where the most plausible explanation is that they don’t have an “active ingredient” apart from placebo/ non-specific effects. At that point it becomes ethically problematic.
What if the quality evidence strongly suggests that a treatment is just a placebo (e.g. acupuncture) but the clinician still believes strongly that it is more than that? I would strongly argue that the problem still stands. After all, willfully ignoring the evidence doesn’t make it go away.
Just because science has started to unpick some of the physiological processes underlying placebo effects it doesn’t make them viable as an approach to clinical practice. Also placebo effects are unreliable, generally small and shortlived if the Cochrane review is anything to go by. If our role is to educate and empower patients then selling a story (even a good one) seems contrary to that goal.
But of course thats all in my humble opinion! Thanks , as always, for the comments…
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SnippetPhysTher Reply:
July 28th, 2010 at 10:49 am
I’d like to continue the conversation because I am intrigued not just with hard core quantitative research, but also qualitative research.
Please do not take my questioning to assume I firmly believe it is ethical to push placebo… but the brain – the brain is quite interesting. Since you seem to agree that neurophysiological changes can occur with placebo, what if sometimes that response is actually helpful for creating some change that alters the brain enough to get it out of a rut and lead to maybe an easier path for long term change, especially if tag-teamed with evidence informed intervention choices?
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Neil O'Connell Reply:
July 29th, 2010 at 3:14 am
Don’t worry I don’t think you’re a placebo peddler!
The point you make is interesting but the thing is that if I go looking for it, any interaction I have with you might be likely to alter your neurophysiology – it would have to for you to experience it. That the brain changes in response to placebo treatments is interesting but were I to image the brains of a bunch of people whilst shouting the word “sausages!” at the top of my voice we might also measure a change in the brain. Of course changes that correlate with pain relief perhaps seem more important and desirable but they don’t take away from the fact that when we deliver a known placebo we are basically deceiving a patient. It seems paternalistic, disempowering for the patient and ultimately, given the generally tiny and rather unreliable effect sizes not worth the compromise.
Brain imaging studies do raise an ethical question – if we could pin the placebo effect down to specific mechanisms then how is it different to an active treatment? Well if we consider all the non-specific effects of care under the placebo umbrella then it is different precisely because it is the non-specific effects of interacting with somebody who is perceived as being there to help. Surely we could achieve kind of an effect that without lying or telling a fairy story. Of course the flip side is that if we argue that brain imaging findings legitimise placebo as a treatment approach if there were no such findings would the approach cease to be legitimate?
Ultimately using placebo as a control for researching treatments is the best way we have of assessing whether our hypotheses about that treatment are correct. It seems a bizarre state of affairs that if after we test those ideas and find them false we would want to continue with the treatment anyway. Surely then we could go look for something genuinely efficacious? When a patient steps through the door they (I reckon) want a treatment that does what it says on the tin. We have to test the claims on the tin and where they are false throw the tin away!
Barbara Drummond Reply:
August 16th, 2010 at 3:36 am
But these days, evidence based medicine is turning up very little evidence for medicine. The 10 year outcome after a CABG shows survival rates do not differ from those who did not have a CABG, pain relief of people having a laminectomy versus having conservative treatement is no different after 6 months; etc. etc. etc. (Of course, emergency room treatments and public health medicine are not included in my generalization; there are some things that actually have been statistically proven to work.) Perhaps, the future of medicine may be to evolve and empower the brains of patients to the point where they can generate the placebo effect for themselves…..
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blogpost (from yesterday) the ethical placebo? Are magic kisses OK? http://bit.ly/cysgbZ
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Nice one Neil.
The one thing I would add is that any misconception by the community (and *groan* the key stakeholders – can you tell I was recently working on a funding application?) of the viability of a treatment may also lead to other – more indirect – ethical and practical problems. For instance, if we accept that a treatment works because of some intrinsic quality it holds (i.e. active component) rather than purely due to the person’s response to the treatment ritual (i.e. placebo) we may in fact not only be changing their “world-view” but also providing foundation for misguided research. If we do not separate the placebo from the active component, the treatments may become absorbed by guidelines and receive community support, funding and ultimately research time that would otherwise be spent on investigating treatments that have a greater positive effect. For instance, we may continue to spend time working out how to better use the blue pill for anxiety – playing with dosages and comparing it to other blue pills, when in fact we should be working on finding a different drug to go inside the pill.
Although the ethics of placebo are important to consider from the patient’s perspective, they are just as important for the clinician and researcher. We all work from specific paradigms after all and are all influenced by those beliefs.
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Neil O'Connell Reply:
July 29th, 2010 at 3:15 am
Couldn’t agree more Luke, we wrote about a good example of this is the (you guessed it) acupuncture literature : http://ehp.sagepub.com/content/32/4/393.abstract
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some good discussion re: ethics of placebo going on here: http://bit.ly/cysgbZ
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I think this discussion illustrates to some extent why ‘the placebo’ is so unhelpful a concept, this is also evidenced in part by the fact that attempts at definition often end in confusion and nonsense (the effect of an inert intervention… etc). In my opinion its beyond time to stop thinking it as some kind of box full of magical stuff (non-specific stuff) that we deliver on it’s own or next to another treatment. If we think treatment effects (of any treatment) are augmented by positive expectations, lets explore how and why this works, if we think conditioning has an impact on how a treatment works, then lets look at this, if there is some other theory lets go there. I do understand the role of sham interventions in searching for the mechanical/physiological effects of treatment, but even to do this we need to deconstruct placebos so we understand what it is we are and aren’t controlling for. I realise that this may sound a little utopian but once we sort out what is in the magical box we can implement what is effective and ditch the rest and the ethical issues fade.
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Luke Parkitny Reply:
July 29th, 2010 at 1:01 pm
Steve:
You are quite correct! This is becoming a little like the dualist body vs mind debate. We often try to see the placebo component as a discrete malignant entity that could, with a magic scalpel, be excised from the healthy active tissue beneath. In fact, in reality, the relationship is probably more one where the two are inextricably linked and not so discrete. Having said that, for the purposes of research and investigation, all the earlier comments hold. In interpreting research for clinical practice and indeed in engaging in clinical practice, however, it is worth remembering that the relationship is probably more complex than we sometimes think.
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Neil O'Connell Reply:
July 29th, 2010 at 5:37 pm
Fair points Steve,
Like Luke I value the placebo control in research as it tests reasonable predictions about any proposed treatment modality. I would maintain that when those precitions are found false we should dump the treatment. I think this goal is somewhat distinct from investigating the effects of care. Understanding how conditioning and expectation work is key tom undersatanding the cloinical interaction but while the overall concept of “placebo” is perhaps unhelpful and covers a variety of aspects and mechanisms, the idea of placebo controls still gets my vote.
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SnippetPhysTher Reply:
July 29th, 2010 at 9:37 pm
I think my hang up is I don’t understand how a patient’s perceptions can be yanked out of the equation. My experience is more clinical versus research oriented, so I have a better handle on what happens in the clinic. Okay, reality, maybe I don’t know what the heck goes on during the provision of physical therapy.
I know in my experience that sometimes, I think, administratively we sometimes shoot ourselves in the foot. In big hospital systems, a physical therapist is just a physical therapist and there doesn’t necessarily seem to be an attitude that each therapist has strengths and weaknesses. The attitude is *all* the therapists are great. But now that I’ve been out on my own, and I have a name and an identity so to speak, for lack of a better word, something “magical” does happen when a patient requests me as a therapist by name and/or knows something about me. If it’s a physician who tells a little something about me – that’s like double “magic.” If the patient searched the net and found me and chose me, “magic” again. Honestly, no, I haven’t measured anything – so maybe I’m wrong in my thinking, but in those situations, it’s easier for me – almost like there is already a burst of trust in me.
From a purely clinical perspective, if I can understand the non-specific stuff that would be helpful – along with learning of possibilities of changing the non-specific stuff to be more suitable and receptive to physical therapy intervention. It’s almost like during my initial evaluations, I snag a lot of “physical” data, but probably a bigger more relevant chunk of information is missing – a person’s receptiveness to physical therapy… readiness for self-efficacy… belief in being able to successfully manage the situation.
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Hmm, I’m not sure that you’ve read any of my other blog posts, because I totally agree that it’s vital to give patients information and let them decide – what I’ve said in this post is that what I offer will aim to be honest and based on empirical findings rather than woo or mysticism, or treatments with limited support in evidence. If, however, people want to know what else is available to them, then I think the provenders of woo have that market well-covered via advertising. I guess I have a question as to how you would select the ‘placebo-like treatments’ that you suggest could be incorporated, and how you would judge them to be ‘appropriate’? If you’re not using a scientific basis for deciding this, how do you decide, or is this simply about the preference of either the clinician or the patient? I’d hope that some underlying principles would be present – mine are to minimise ongoing dependence on clinicians or procedures that mean the person needs to come into a health care facility, to be able to maintain and increase activity, self reliance, participation in valued activities/roles and to reduce distress.
The majority of the strategies I provide are quite simple – living well with chronic pain is pretty much the same as living well generally, with just a bit more rigour in terms of managing energy.
I agree that it’s unnecessary to take advantage of patients by over-servicing them, but beware of simplistic thinking: even simple ‘reassurance’ is not always reassuring!
Linton, S. J., McCracken, L. M., & Vlaeyen, J. W. (2008). Reassurance: Help or hinder in the treatment of pain. Pain, 134(1-2), 5-8.
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Great post Bronnie (thanks for the mention) and I couldn’t agree more. I think patient choice is a difficult concept here because it is very difficult for patients to access or distinguish good health information. There is so much misdirection, anecdote and outright fraud out there and when you are in desperate need you become vulnerable to the peddlers of false hope. I guess it boils down to “keep what works, keep the care and dump the magic”.
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Hi Neil and thank you for the trigger to this post! Patient choice is an incredibly difficult thing to manage – I see people who have spent thousands of dollars on treatments, both ‘conventional’ and not, that have failed to address their concerns about their pain. Many of these people have never been informed about self management, despite the strong support for a cognitive behavioural approach for self managing chronic pain. By being very upfront about my adherence to evidence-based practice – that also tries to help people live lives full of things they value – and posting as I do, I hope to inform and enthuse practitioners and patients of things that do seem to help, given the current status of the science!
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Depends on your definition of ethics. Deontology? Utilitarianism? Other?
I’m guessing too that there’s some confusion over codes of practice and ethics proper. Just because the APTA says something is ethical (or not) doesn’t make it so.
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What, don’t you check out the colour of the curtains and whether the wallpaper is still orange, brown and beige?!
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“Slightly more subtle, in the past I have had a doctor use the “if you do not take this medicine as prescribed, you
could die” exhortation.”
So did I, for an emergency asthma medication. Which is why, no matter how terrible I felt, I never, ever took it. Rather than make an error on taking the follow-up tapered dosage.
Somehow I doubt that was the effect the doctor and pharmacist wanted their warning to have.
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Its a difficult issue, ethically prqctically and economically (for both private providers and patients) in many ways. However, positively if we can enhance meaning ,facilitate a persons own process of restitution and understand what may move a person towards this state than this has to be a good thing? Spaces and places where treament takes place for example have been studied by the Rheumatologist Esther Sternberg. Often complex cases of distress and disabilty are shunted into stark clnical rooms with rushed appointments (this was my experience of several pain clinics).
I fully endorse pain managment , enhancing self efficacy and minimising disability. However in Neils terms a few ‘kisses’ probably will not go amiss. A good narrative which looks at a patients journey dealing occupational therapy following an elbow fracture and secondary neurogenic pain is the Sociologist Ann Oakley’s Fracture. The response Ann obtained through the enhanced treatment effect cultivated by the acupuncturist (environment ,demenour , care ) was in stark contrast to the orthopaedic clinic . People often seek care, reasurance and an ‘individualised’ approach –this is often lacking in many protocol led clinics.
I disagree with the post that suggest placebo and nocebo are of no clinical importance. For many people nocebo is a feature of many health care interactions and according to Benedetti may have strong negative physiological consequencies. As biomechancial explanations of pain are dominant many people are told or interpret the results of tests,scans etc in often maladpative ways ….you have the spine of a 70 year old often leads to catastrophisation and disability for example.
I think for some people ‘chi’ used as a metaphorical explanation is not too bad… metaphors used wisely may indeed enchance meaning and downregulate threat. I suggest tai chi and use the principles all the time–it does not mean that I think chi,prana etc are ‘real’ but perhaps these metaphors may improve a persons self image /intereoception (especially if they learn to do things themself) .The danger perhaps is if these things are relied upon too much …..’Peddlars of false hope’ …yes a big problem and it is easy for those in the scientific medicla community to sit on a pedastal casting stones on CAM etc when many interventions offered by the medical profession offer little and in many cases are iatrogenic. I would have no problem suggesting certain ‘woo’ therapies offered by some caring people I know over and above an interventional pain clinc or rheumatology clinic for example . Allowing a stressed out person with often complex social issues a little respite seems fine in some circumstances . It may be a better use of resources than the mri/ct multiple health professional pharmacology route which tends to be a frequent occurrence.
Sometimes I just think we live in a overly medicalised culture and placebo treatments will just evolve to meet the demands of the population seeking care and attention!
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Hmmm, more food for thought Ian! But if we can learn about what it is about these nonscientific interactions that is helpful then surely we can transplant this into evidence-based practice? That’s part of the reason I’m teaching 5th year medical students about psychosocial ‘yellow flags’, so they can develop awareness and then skills to be compassionate and to listen – hopefully when they graduate these skills will remain with them and they’ll be far more capable of providing appropriate individualised attention.
The problem with using words like ‘chi’ is that they are tied up in a belief system with all the same problems inherent in the biomedical system – like unintended nocebic effects. And while we may acknowledge them as being metaphoric, I’m not so sure that patients will, and there are most definitely practitioners who do believe in these things literally. The combination of an enthusiastic, passionate, caring person who genuinely believes in something mystical is undoubtedly powerful. You see while I think there are definitely some woo peddlars who are fully aware of the lack of effectiveness of their approach, there are many more who are genuine in their belief – even though it is only a belief – and the expectations they engender simply because they’re passionate are possibly a good part of their ‘success’. Wouldn’t it be fabulous if that same passion and instilling of hope was delivered by someone who is using evidence-based practice?
This isn’t a treatment dichotomy – either biomedical or mystical. Maybe a referral to an interventional pain clinic or a rheumatology clinic where only pharmacological or invasive treatments are recommended isn’t the best for someone with psychosocial concerns – but the alternative isn’t just to suggest palliative ‘woo’ input. There’s enough evidence to support the cognitive behavioural approach including ACT, CBT and others for a referral to an interdisciplinary pain management centre to be as wholistic as what the woo provenders say they are!
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Its late here and I have 2 weeks off now to head off to the wilds of the N Isles of Scotland ! Briefly I agree with you re evidence and in an ideal way this would be the best bet . Pragmatically however,the reality in the interventionist led clinics where I have worked , the dominant issues are psychosocial ‘distress’, iatrogenic disability, ‘trauma’ /ptsd issues etc etc . The spaces where ‘treatments’ occur tend not to be like the ones Sternberg recommends and treatment ‘acts’ tend on the whole to be unimodal . Pain management is not at all integrated or for that matter valued that much. I have read widely in these areas. I practice meditation , have learned to teach mindfulness principles and apply CBT principles daily. It is not that I do not value evidence , far from it! Minimal ‘treatment’ with the dominant message of education and self reliance is my approach. I think my main role and only real role actually in the GP clinic is to act as a health coach and demedicalise the vast majority of people with vague non specific ailments that get sent my way…Most if not all of the modalities that I was trained to use are placebo ……Touch and movement are the main things I ‘believe’ in —both are often lacking in many peoples lives –especially those in persistent pain . Touch as a form of empathic communication and education is different from a mechanist fix which may cause dependency and I try to avoid the latter…
ian
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Hi adiemusfree
Should have said I was making a general comment on the placebo/nocebo effect. I agree that it probably does have some clinically significant (though generally modest) effect with pain and nausea. But these are probably the only symptoms it does.
Also, achieving a reduction in levels of medication use is not necessarily direct evidence for placebo effect. It may be that standard levels for at least some medications are a bit too high to start with (erring a little on the high side to ensure a good effect, under dosing can be just as problematic as over dosing).
There is also the question of exactly what we mean by placebo effect. For example, it is hard to distinguish clearly between placebo and just simple distraction, or even tell if they are different processes. Obviously if you have some rewarding interactions going on, say with an old and much loved friend visiting for the first time in a while, then your neuro-psychology is going to be less swamped by pain (or other distressing symptoms you may have), simply due to it having other and pleasurable things to do, within limits of course.
Another issue is the short term nature of placebo effects. Might be fine to help get somebody through a bad hour or day, but beyond that its effect and value seems to rapidly diminish.
I used to have the conventional view of placebo, but since the solid meta-analytical work of over the last decade, I have become a lot more sceptical of its power and importance and its nature (though not its reality, I don’t doubt it exists in some form). At the very least, the claims made about it, including by mainstream medicine, need to be much more closely scrutinised and cut down to size. I have always been troubled by how casually various clinical presentations are characterised as some form of placebo/nocebo. It is just too convenient, and frankly lazy and sloppy clinical practice. We are seeing exactly these problems at the moment with a lot of claims about various forms of somatisation, (the flavour of the decade it sometimes seems). But these are diagnoses all too often based on little more than a lack of known organic disease, (coupled with some rather weak and selective inferences about usually subjectively measured psycho-social correlates). I hardly need point out the logical fallacy in that line of thinking, including the unfalsifiability of the diagnostic method, and the serious potential consequences for the patient if it is wrong (and it quite clearly often is). It has a long and troubled history, that does not look like ceasing any time soon.
OTOH, we have the Whitehall studies (among others) which clearly show that social ranking alone has a very measurable impact on overall health, including simple physical health. But this is only measurable at the population level, ie statistically. My big problem comes when we try to definitively ascribe placebo based processes to individual patients. Virtually impossible to be sure in the vast majority of situations, which rather reduces the value of such interpretations.
BTW, good blog. Very interesting, if often troubled area of medicine.
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Oops, messed up the formatting, as usual.
The reference I cited is
Cochrane Database Syst Rev. 2010 Jan 20;(1):CD003974.
Placebo interventions for all clinical conditions.
Hróbjartsson A, Gøtzsche PC.
http://mrw.interscience.wiley.com/cochrane/clsysrev/articles/CD003974/frame.html
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Ronny you make some great points. I’m still weighing up all the bits and pieces on placebo and I guess it’s a bit early to really apply it to daily clinica practice (although my feeling is that those ‘meaning responses’ are already influencing expectancies). I’m reflecting on Benedetti and Colloca’s work and the very ‘hard’ evidence they have found about endogenous opioid systems. I am truly wary of anyone pointing to an individual’s response as ‘placebo’ – although it’s incredibly tempting when one person I know received an invasive intervention, used the device 10 minutes a day for a month then stopped using it stating she was completely pain free. The device ordinarily is used intermittently throughout the day – but of course, this could be distress reduction with an external locus of control (ie the device controls) that she could push whenever she felt distressed, quite a powerful conditioning effect.
It’s plausible that along with the meaning response there are also situations in which conditioning occurs, as well as natural regression to the mean, reduced distress by ‘taking control’, and the occasional miraculous healing! Distraction, or working with attention management is still, IMHO, neurobiologically driven – in which case I’m really interested to know more about how this works.
I’m worried by your suggestion that clinical presentations without the presence of known organic disease being sloppy. Firstly, declaring my own hand here, what about fibromyalgia, and all the other central sensitisation syndromes? It’s pretty difficult to find objective ‘organic’ findings in mTBI and yet it produces profound disturbance of cognition, affect and behaviour especially in some vulnerable individuals. I personally think ‘somatization’ can represent the worst of the mind/body dichotomy that pain has neatly blurred. I wonder at the utility of diagnosis in these cases, and this is why I’d prefer to use a case formulation approach that develops specific hypotheses about how and why aspects of the individuals presentation are being maintained, and from this, treatment strategies can be developed. My concern about the ongoing search for a specific diagnosis is that the process itself is intrusive, can lead to iatrogenic disability (especially because the more obscure the diagnosis, the more high-tech the investigation – the more catastrophic the interpretation by the individual!), and delays in the person feeling ready to engage in living life well.
I think it’s important that placebo/nocebo isn’t thought of as ‘just psychological’ because to me it’s both, and the mechanisms are something we need to know more about and then harness as much as we can in clinical practice. But at the moment the best we can do is be mindful of the aspects we do know about, and ensure we are open and honest with our patients about what we do and don’t know.
Thanks for your thoughtful comments! Pain management is a passion of mine (in case you hadn’t guessed!)
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Hi Barbara,
I am afraid I don’t recognise your interpretation of the overall achievements of EBM. Massive steps forward in cancer survival rates, improved outcomes and disease control in Rheumatology, the fantastic record on vaccination all tell a different tale. Of course some therapies do not do so well – laminectomy is a good example and is being performed less in light of the evidence. In terms of CABG you seem to imply that CABG was compared to nothing when in the stuies that I am aware of it was compared to percutaneous coronary intervention – not a failure of evidence based medicine but a great example of progress in medicine and the development of equally effective but less invasive procedures. But I would be happy to see the reference source for your assertion. The “little evidence for medicine” argument is something of a fallacy . The oddest part of it is that this erroneous assertion then often leads to the beautiful idea that “therefore any old nonsense will do”. But that is a path that leads us backwards.
It is worth remembering that placebo effects are generally small, short lived and, beyond subjective outcomes, do not seem to have a strong impact on clinical results (see the Cochrane reference). Helping people to manage their symptoms better may well work via similar pathways as straightforaward placebos but it is not lying to them, selling them a story or a bottle of snake oil. As such I am comfortable with “rational hugs” but not prepared to make pretend with somebody’s symptoms.
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