Relieving pain using dose-extending placebos

Placebos are often used by clinicians, usually deceptively and with little rationale or evidence of benefit, making their use ethically problematic. In contrast with their typical current use, a provocative line of research suggests that placebos can be intentionally exploited to extend analgesic therapeutic effects. Is it possible to extend the effects of drug treatments by interspersing placebos? We reviewed a database of placebo studies, searching for studies that indicate that placebos given after repeated administration of active treatments acquire medication-like effects. We found a total of 22studies in both animals and humans hinting of evidence that placebos may work as a sort of dose extender of active painkillers. Wherever effective in relieving clinical pain, such placebo use would offer several advantages. First, extending the effects of a painkiller through the use of placebos may reduce total drug intake and side effects. Second, dose-extending placebos may decrease patient dependence. Third, using placebos along with active medication, for part of the course of treatment, should limit dose escalation and lower costs. Importantly, provided that nondisclosure is pre-authorized in the informed consent process and that robust evidence indicates therapeutic benefit comparable to that of standard full-dose therapeutic regimens, introducing dose-extending placebos into the clinical arsenal should be considered. This novel prospect of placebo use has the potential to change our general thinking about painkiller treatments, the typical regimens of painkiller applications, and the ways in which treatments are evaluated

Are Sham Acupuncture Interventions More Effective than (Other) Placebos? A Re-Analysis of Data from the Cochrane Review on Placebo Effects

Background and Objective: A recent Cochrane review on placebo interventions for all kinds of conditions found that `physical placebos' (which included sham acupuncture) were associated with larger effects over no-treatment control groups than `pharmacological placebos'. We re-analyzed the data from this review to investigate whether effects associated with sham acupuncture differed from those of other `physical placebos'. Methods: All trials included in the Cochrane review as investigating `physical placebos' were classified as investigating either (sham) acupuncture or other physical placebos. The latter group was further subclassified into groups of similar interventions. Data from the Cochrane review were re-entered into the RevMan 5 software for meta-analysis. The primary analysis was a random-effects analysis of trials reporting continuous outcomes of trials that used either sham acupuncture or other physical placebos. Results: Out of a total of 61 trials which reported a continuous outcome measure, 19 compared sham acupuncture and 42 compared other physical placebos with a no-treatment control group. The trials re-analyzed were highly heterogeneous regarding patients, interventions and outcomes measured. The pooled standardized mean difference was -0.41 (95% confidence interval -0.56, -0.24) between sham acupuncture and no treatment and -0.26 (95% CI -0.37, -0.15) between other physical placebos and no treatment (p value for subgroup differences = 0.007). Significant differences were also observed between subgroups of other physical placebos. Conclusion: Due to the heterogeneity of the trials included and the indirect comparison our results must be interpreted with caution. Still, they suggest that sham acupuncture interventions might, on average, be associated with larger effects than pharmacological and other physical placebos

Prescribing Placebos

The use of placebos in medicine is an area of ethical questioning, but we often do not consider the effect of placebos on daily life. One’s preconceptions on the outcomes of exercise physically affect health. Studies show being aware of the advantages of exercise is beneficial to aspects of health such as blood pressure, blood glucose levels, and depression. This article analyzes how the placebo effect applies to exercise and how it can be taken advantage of to improve health outcomes

Informed consent and placebo effects: a content analysis of information leaflets to identify what clinical trial participants are told about placebos

BackgroundPlacebo groups are used in randomised clinical trials (RCTs) to control for placebo effects, which can be large. Participants in trials can misunderstand written information particularly regarding technical aspects of trial design such as randomisation; the adequacy of written information about placebos has not been explored. We aimed to identify what participants in major RCTs in the UK are told about placebos and their effects.Methods and FindingsWe conducted a content analysis of 45 Participant Information Leaflets (PILs) using quantitative and qualitative methodologies. PILs were obtained from trials on a major registry of current UK clinical trials (the UKCRN database). Eligible leaflets were received from 44 non-commercial trials but only 1 commercial trial. The main limitation is the low response rate (13.5%), but characteristics of included trials were broadly representative of all non-commercial trials on the database. 84% of PILs were for trials with 50:50 randomisation ratios yet in almost every comparison the target treatments were prioritized over the placebos. Placebos were referred to significantly less frequently than target treatments (7 vs. 27 mentions, p<001) and were significantly less likely than target treatments to be described as triggering either beneficial effects (1 vs. 45, p<001) or adverse effects (4 vs. 39, p<001). 8 PILs (18%) explicitly stated that the placebo treatment was either undesirable or ineffective.ConclusionsPILs from recent high quality clinical trials emphasise the benefits and adverse effects of the target treatment, while largely ignoring the possible effects of the placebo. Thus they provide incomplete and at times inaccurate information about placebos. Trial participants should be more fully informed about the health changes that they might experience from a placebo. To do otherwise jeopardises informed consent and is inconsistent with not only the science of placebos but also the fundamental rationale underpinning placebo controlled trials

General Practitioners Attitudes towards Open-Label Placebos in Australia

This item is only available electronically.Objective: Multiple studies have found between 18-70% of medical professionals prescribe placebos, with general practitioners’ (GPs) reportedly being the highest prescribers. Even though placebos are common in clinical practice, patients and doctors alike have issues with the deceit involved, which is resolved with open-label placebos. The study looked at GPs attitudes towards traditional placebos and open-label placebos. Method: Participants were practising GPs in Australia (N = 54). The study involved an online questionnaire composed of four different sections; demographics, attitudes towards traditional placebos and open-label placebos, understanding towards open-label placebo mechanisms and usage, and any concerns or comments they had towards open-label placebos. Results: Differences found between traditional placebos and open-label placebos only involved GPs who were accepting of placebo interventions. GPs understanding of the underlying mechanisms being psychological and involving the patient/doctor relationship is in line with the current literature. The situational usage of open-label placebos in cases of non-specific or physical symptoms match with conditions commonly presented to GPs. The likelihood to prescribe open-label placebos did not appear to be influenced by demographic variables. The highest number of concerns and comments reported regarded patient acceptability and the lack of research in clinical practice. Conclusion: This exploratory analysis has constructed an overview of general practitioners’ attitudes towards placebos in Australia. Future research conducted with larger samples would be beneficial to evaluate demographic influences and the practicality of open-label placebos. This study indicated that open-label placebos are a viable treatment option in clinical practice pending further research.Thesis (B.PsychSc(Hons)) -- University of Adelaide, School of Psychology, 201

Asthma as a Model for Placebo Effects in Modern Medicine

Many a clinical intervention thrives on placebos. Lack of consensus — both definitional and methodological — however, contributes to general confusion and specious conclusions regarding the legitimacy and relevance of placebos in modern medicine. The apparent divergence between objective and subjective treatment outcomes, moreover, renders placebos clinically meaningless. Asthma provides a clinical model for studying placebos because it highlights how psychology works in concert with pharmacology. Here we examine placebos as valuable adjuncts to, rather than replacements for, pharmacological treatments

Impure placebo is a useless concept

Placebos are allegedly used widely in general practice. Surveys reporting high level usage, however, have combined two categories, 'pure' and 'impure' placebos. The wide use of placebos is explained by the high level usage of impure placebos. In contrast, the prevalence of the use of pure placebos has been low. Traditional pure placebos are clinically ineffective treatments, whereas impure placebos form an ambiguous group of diverse treatments that are not always ineffective. In this paper, we focus on the impure placebo concept and demonstrate problems related to it. We also show that the common examples of impure placebos are not meaningful from the point of view of clinical practice. We conclude that the impure placebo is a scientifically misleading concept and should not be used in scientific or medical literature. The issues behind the concept, however, deserve serious attention in future research.Peer reviewe

The use of pure and impure placebo interventions in primary care - a qualitative approach

Background: Placebos play an important role in clinical trials and several surveys have shown that they are also common in daily practice. Previous research focused primarily on the frequency of placebo use in outpatient care. Our aim was to explore physicians' views on the use of placebos in daily practice, whereby distinction was made between pure placebos (substances with no pharmacological effect, e.g. sugar pills) and impure placebos (substances with pharmacological effect but not on the condition being treated, e.g. antibiotics in viral infections or vitamins). Methods: We performed semi-structured interviews with a sample of twelve primary care physicians (PCPs). The interview addressed individual definitions of a placebo, attitudes towards placebos and the participants' reasons for prescribing them. The interviews were transcribed and analysed using qualitative content analysis. Results: The definition of a placebo given by the majority of the PCPs in our study was one which actually only describes pure placebos. This definition, combined with the fact that most impure placebos were not regarded as placebos at all, means that most of the participating PCPs were not aware of the extent to which placebos are used in daily practice. The PCPs stated that they use placebos (both pure and impure) mainly in the case of non-severe diseases for which there was often no satisfactory somatic explanation. According to the PCPs, cases like this are often treated by complementary and alternative therapies and these, too, are associated with placebo effects. However, all PCPs felt that the ethical aspects of such treatment were unclear and they were unsure as to how to communicate the use of placebos to their patients. Most of them would appreciate ethical guidelines on how to deal with this issue. Conclusions: Many PCPs seem to be unaware that some of the drugs they prescribe are classified as impure placebos. Perceptions of effectiveness and doubts about the legal and ethical aspects of the use of placebos by PCPs may discourage their application. Dissemination of guidelines and consensus papers may be one approach, but it has to be acknowledged that the topic itself is in conflict with the PCPs' perception of themselves as professional and reliable physicians

Placebos: Their Effectiveness in Medicine and Implementation in Health Care

Placebos are drugs that have no active therapeutic effect, yet they are often used in medicine. With a combination of physiological and neuroscientific factors, placebos can relieve a person of their symptoms even though they are not actually taking a real drug. As the cost of pharmaceuticals has risen astronomically in recent years, the need for an inexpensive, alternative to actual drugs has increased. In this review, placebos and their role in medicine will be analyzed. This will consist of a placebo’s function in pain management, usefulness in other areas of medicine, and the ethical dilemmas surrounding placebos. Future research of placebos is aimed at whether they should be separated based on their mechanism of action or based on the disease that is being treated