Great summary of placebo effect(s), amusing, sharp and provocative. A great way to spend three minutes!

Here's an article from a blog called PRACTICAL ETHICS (Ethics in the News) at the University of Oxford. It's pretty unfriendly to homeopathy, which we think isn't quite as cut and dried a domain of practice as the author, Bennett Foddy, assumes. Brian, one of our founders, is happy to advise on both homeopathic and placebo regimes. That's one point where we differ substantially with Foddy, and at least some of the literature does as well. Buying placebos from Boots, government subsidised or not, makes at least the 'pleasing the practitioner' script impossible. ("Pleasing the practitioner" is the idea that a patient's trust in the authority of an expert induces the placebo effect.)

You know you've made it when they run a story on Fox News. Forget Harvard (where the groundbreaking placebo study took place that allowed patients to KNOW they were trialling placebos). The Harvard study told participants the 'medication' they were taking was inert, however it 'would engage the mind-body and self healing thing'.

Marc Siegel, from something called the 'Fox News Medical A-Team', comments on video here.

In other news, the more mainstream Wall Street Journal comments on the research here and here.

A simple sugar pill may help treat a disease -- even if patients know they're getting fake medicine.

The finding, reported online Wednesday in the journal PloS One, may point the way to wider -- and more ethical -- applications of the well-known "placebo effect."

"The conventional wisdom is you need to make a patient think they're taking a drug, you have to use deception and lies," said lead author Ted Kaptchuk, an associate professor of medicine at Harvard Medical School. And, Kaptchuk added, it seems many doctors do this: In one report, as many as half of rheumatologists and internists surveyed said they had intentionally given patients ineffective medication in the hopes it would have a positive result.

Kaptchuk, however, wondered whether the deception was needed. When he first tried to persuade fellow researchers to explore a sort of "honest" placebo, "they said it was nuts," he said. After all, didn't the whole effect hinge on people believing they were getting real treatment?

Patients were easier to enlist. "People said, 'Wow, that's weird' and we said, 'Yeah, we think it might work.'"

The researchers enrolled 80 people suffering from irritable bowel syndrome, explaining the experiment while framing it positively -- they called it a novel "mind-body" therapy.

Half the patients were given a bottle with the word "placebo" printed on it. The pills it held, they were told, were like sugar pills. The patients were told they didn't even need to believe in the placebo effect, but had to take the pills twice daily.

The other half were given no treatment at all.

At the end of the three-week trial, 59 percent of the patients taking the placebo said their symptoms had been adequately relieved, far outstripping the 35 percent in the non-treatment group.

"We were all taken aback," Kaptchuk said. "We triple-checked the data before we decided it was real."

Read the research paper at Plos One: Placebos without Deception: A Randomized Controlled Trial in Irritable Bowel Syndrome

The placebo effect is a pervasive, albeit misunderstood, phenomenon in medicine. In the UK, over 60% of doctors surveyed said they had prescribed placebos in regular clinical practice. In a recent Times Magazine article, 96% of US physicians surveyed stated that they believe that placebo treatments have real therapeutic effects.

Work on the placebo effect received an intellectual boost when the Harvard Placebo Study Group was founded at the beginning of 2001. This group is part of the Mind-Brain-Behavior Initiative at Harvard University, and its main characteristic is the interdisciplinary approach to the placebo phenomenon. The group is made up of 8 members: Anne Harrington (Historian of Science at Harvard), Howard Fields (Neuroscientist at Univ. of California in San Francisco), Dan Moerman (Anthropologist at Univ. of Michigan), Nick Humphrey (Evolutionary Psychologist at London School of Economics), Dan Wegner (Psychologist at Harvard), Jamie Pennebaker (Psychologist at Univ. of Texas in Austin), Ginger Hoffman (Behavioral Geneticist at Harvard) and Fabrizio Benedetti (Neuroscientist at Univ. of Turin). The main objective of the group is two-fold: to devise new experiments that may shed light on the placebo phenomenon and to write papers in which the placebo effect is approached from different perspectives.

 

 

 

We were fascinated to see a story on Australia's ABC News about recent research into the placebo effect. Pain researcher Damien Finniss, from Sydney's Royal North Shore Pain Management and Research Institute, has published a paper in The Lancet on the phenomenon of the placebo effect. The ABC story makes two points which in our view have not received sufficient attention, namely:

* that the placebo effect is engaged even when a patient is aware s/he is receiving placebo (the 'no-blind test'); and
* that responsible practitioners consider the agency of placebo in the course of treatment.

Consistent with other researchers we've read, Finniss and his colleagues are concerned with ethical issues in practitioner-client relationships in consideration of conscious engagement with the placebo effect. This is what we'd expect from responsible researchers and health professional. At the same time, we're aware of anecdotal evidence and some research (contained elsewhere in this blog) that in any case there is widespread 'de facto' use of placebos in general practice and elsewhere, as for example in the presciption of an antiobiotic in the treatment of a viral condition.

It sounds counter-intuitive, but it seems that placebos are geting 'stronger' ... or more to the point, the placebo effect is increasingly recognised as touching the heart of the overall process of healing and the nature of wellness. A fascinating article on this dynamic phenomenon in Wired magazine - looks like the debate is going mainstream!

And lest we forget ... there's money at stake. Big money.

One for those who can't start the day without a caffeine hit. ;-)

Amazing placebo experiment with knee surgery - points to the finding that there can be 'grades' in the placebo effect - big pills are more effective than small pills, coloured pills more effective than white ones, inert injections more effective than pills, and sham surgery more effective than any of them.
Of course, at Universal Placebos we feel it sufficient to stay with our modest, aesthetically pleasing, small white sugar pills, in doses of three. That's enough.

One of the rare studies into the action of the placebo effect in 'non-blind' clinical trials was undertaken by Lee C. Park and Uno Covi at the Johns Hopkins University School of Medicine in 1964. 'Non-blind' means that patients were informed that the pills they were issued were totally inert, that they were placebos, and in this case they were also assured that despite this the pills would be of benefit to them. The study concluded:'The primary finding is that patients can be willing to take placebo and can improve despite disclosure of the inert content of the pills; belief in pill as drug was not a requirement for improvement.'

(Some first-hand reports on our Testimonials page.)

Ref. L. C. Park, U. Covi, Nonblind Placebo Trial - An Exploration of Neurotic Patients' Responses to Placebo When Its Inert Content Is Disclosed, Archives of General Psychiatry, April 1965, Vol. 12, pp. 336-345

Typically, as people experiencing dis-ease, we want to know whether a therapy works. We are less concerned to know how it works, just whether it works.Just how the placebo effect comes about is unresolved, despite the burgeoning research effort. Theories include:

• Benefit from attention – we respond positively because we receive enhanced and focused attention from a practitioner

• Stimulus response – like Pavlov’s dogs, we respond somatically to the suggestion which accompanies the administration of a therapy because we have experienced benefit from such therapy in the past

• Beliefs, expectations, and the attribution of meaning – as with stimulus-response, our assumptions and expectations about the efficacy of a therapy conditions a somatic response: the higher our expectations, the greater our response

• Relationship with therapist – we respond positively to positive relations with our therapist

• Pleasing the therapist – in our effort to be ‘good patients’, we respond positively to our therapist’s expectations (1)

It is reasonable to say that there is no scientific consensus on how it works. In general, most agree that the placebo effect (and its reverse, the nocebo effect, where negative reactions are experienced) operates in the borderland between the ‘mind’ and ‘body’ constructions assumed by conventional medicine. And while conventional medical science has little to offer us by way of explanation, our subjective experience of the placebo effect needn’t baffle us.

Michael Jospe, a professor at the California School of Professional Psychology who has studied the placebo effect for more than 20 years, points out that all people experience physiological reactions to anticipation and stress--something like the fight-or-flight response--that help them to survive and cope. When you step out of your office and a spider jumps out at you, Jospe analogizes, "you'll get a fright and have a physiological reaction. And the next time you go out that way, the thought that it could happen again can produce a physiological reaction before you even open the door." So, he says, the relationship between a thought and a negative psychophysiological reaction like fear is something we experience daily.

That goes for positive associations, too, Jospe continues. "The placebo effect is part of the human potential to react positively to a healer. You can reduce a patient's distress by doing something which might not be medically effective." It's like kids and Band-Aids, Jospe says. "When you put a Band-Aid on a child and it has stars or comics on it, it can actually make the kid feel better by its soothing effect, though there's no medical reason it should make the child feel better." (2)

Refs(1) Mayo Clinic - Consumer Health Tips and Products, Placebo Effect: Harnessing Your Mind’s Power to Heal, December 30, 2003, (2) Tamar Nordenberg, The Healing Power of Placebos, US Food and Drug Administration

‘I will follow that system of regimen which, according to my ability and judgment, I consider for the benefit of my patients, and abstain from whatever is deleterious and mischievous.’ Hippocratic Oath (1)

There is a large and burgeoning literature on the phenomenon of the ‘placebo effect’, that is, the tendency of people experiencing illness to improve through an engagement with a medically inactive remedy, ranging from sham surgery to administration of an inert injection or oral medication.
Most recently this literature is inspired by the increasing use of antidepressant medications in the treatment of major depressive disorders (MDD’s), where ‘fewer than half of the depressed patients who receive active medications in psychiatric trials show clinically significant improvement’ and where placebo medication has been shown to be effective in up to 70% of cases. (2)

Apart from MDD’s, people taking placebos often report reduction in pain, healed ulcers, eased nausea and even disappearing warts. The literature rarely denounces the existence of a placebo effect; disagreement and controversy arises most often in understanding how it comes about, and more importantly, how it might be used.

It can be argued that the foundation of modern western medicine resides in the distinction between ‘mind’ and ‘body’, the former understood as a philosophical construction which places it outside the realm of medical practice (unless seen, in the psychiatric model, as a function of the brain and nervous system), the latter as a kind of sophisticated machine. This machine can ultimately be understood analytically, through an understanding of its functional components and their complex interactions.

The placebo effect disrupts this assumption of a mind-body boundary, especially where conventional medicine relates it dismissively to complementary and alternative medicines (CAM’s): ‘You may think that such-and-such was effective, but it was only a placebo effect.’ This misses the point. To dismiss, say, homeopathy as ‘merely a placebo’ is not to dismiss it at all, since there is a tacit recognition that there is in fact a placebo effect, that in a greater or lesser degree, the thing actually works.

The fact that it works outside the reductionist and analytical paradigm is the real issue. Put this way, it is not an argument about therapies, but an argument about prestige and power, played out socially, culturally, politically and economically.

Refs:
(1) Hippocratic Oath
(2) Richard Entsuah, Phil Vinall, Potential Predictors of Placebo Response: Lessons From a Large Database. Drug Information Journal. Ambler: 2007. Vol. 41, Iss. 3; pg. 315, 16 pgs