Even More Placebo Issues

This placebo study was reported on here and here. The results were somewhat surprising to me, that placebos worked even though the participants knew they were fake. I'm guessing now, but I wonder if the cultural ritual of taking pills is so powerful that the mere act of taking a pill, no matter its contents, encourages healing. And in the study, the participants were told that the "pills had been shown to be effective in clinical studies" even though they were inert. Which isn't the same as saying the pills are fake. Another observation is that it was canny of the researchers to use IBS, or "irritable bowel syndrome," since this condition is multi-factorial and subject to overall stress levels since there are so many nerve endings in the gut. It is also interesting that Ted Kaptchuk took on this study. He is an acupuncturist at Harvard and has done seminal work on the topic, authored "The Web That Has No Weaver," a basic explanation and text on acupuncture.
The acupuncture community, by necessity, is irrevocably involved in the discussion of placebo because our studies are scrutinized on every level for placebo bias. So I shouldn't be surprised that Kaptchuk would involve himself in this complicated topic. I would suggest, however, that all physicians should be interested in this topic given the poor track record of very popular and widely prescribed medications against placebo. (My next blog post will discuss the possible negative effects of cortisone injections for tendonitis, such as tennis elbow.)And there are many procedures which have never been challenged by a placebo procedure. And since the first tenet of the Hippocratic Oath is to do no harm, it is a phenomenon that deserves to be treated with respect.
The quote from Kaptchuk at the end of the article brings up questions, however.

“The magnitude of effect here is very large,” said the lead author, Dr. Ted J. Kaptchuk, a researcher at Beth Israel Deaconess Medical Center in Boston. The goal, he added, would be to develop a clinical strategy to use the placebo effect ethically, without lying to a patient.

Of course, we all want positive outcomes and would like to enhance any and all contributions to our therapeutic modality. But if one can't determine how much of any procedure IS actually placebo, it raises all sorts of questions for the practitioner, if not for the patient. If a large part of what the practitioner is doing is causing the patient to heal themselves, then it behooves them to do the safest option first, I would think. Then there's the whole other aspect of whether one would choose to practice a certain therapeutic modality if it really is all placebo. In my own case the answer would be an unequivocal "No." Of course there is some placebo in some patients when coming for acupuncture, but I suspect that there is much "nocebo" also. Nocebo is when the patients don't really think it will help, but will try anything. Fortunately, we know that acupuncture works on animals and babies, who aren't affected by placebo nor nocebo.

Here is the article from the NYTimes.

Perceptions: Positive Spin Adds to a Placebo’s Impact
By NICHOLAS BAKALAR

Can taking a placebo be effective even if the patient knows it is a placebo? A new report suggests the answer is yes.

In a study published online last week in the online journal PLoS One, researchers explained to 80 volunteers with irritable bowel syndrome that half of them would receive routine treatment and the other half would receive a placebo. They explained to all that this was an inert substance, like a sugar pill, that had been found to “produce significant improvement in I.B.S. symptoms through mind-body self-healing processes.” The patients, all treated with the same attention, warmth and empathy by the researchers, were then randomly assigned to get the pill or not.

At the end of three weeks, they tested all the patients with questionnaires assessing the level of their pain and other symptoms. The patients given the sugar pill — in a bottle clearly marked “placebo” — reported significantly better pain relief and greater reduction in the severity of other symptoms than those who got no pill. The authors speculate that the doctors’ communication of a positive outcome was one factor in the apparent effectiveness of the placebo.

“The magnitude of effect here is very large,” said the lead author, Dr. Ted J. Kaptchuk, a researcher at Beth Israel Deaconess Medical Center in Boston. The goal, he added, would be to develop a clinical strategy to use the placebo effect ethically, without lying to a patient.


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