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Placebo effect is real, and complicated

Many over-the-counter cold medications are clinically useless, yet we regularly take them when we are sick. Doing "something" makes us feel better.

This article was originally posted in the Montreal Gazette.

There is an interesting ethical debate to be had about the use of placebos in medicine. As a general rule, doctors do not prescribe placebos to patients in the sense they will not lie to the patient and prescribe them a sugar pill. That requires an act of deception that would not be considered acceptable in this day and age. But a study in the journal JAMA Pediatrics suggested that there was a way to use placebos in an ethical fashion — by telling patients they were getting placebos.

When people hear the term placebo, they generally think of sugar pills. But the term is actually broader and can encompass a variety of things. A survey of 1,200 U.S. physicians found that about half prescribed “placebos” to their patients and nearly two-thirds felt the practice was ethically permissible. But few prescribed sugar pills to deceive their patients. Their “placebos” were usually vitamins, over-the-counter analgesics, or antibiotics for obviously viral illnesses.

Notwithstanding the issue of inducing microbial resistance from the overuse of antibiotics, these therapies were essentially harmless but useless for the patient’s main problem. As such they were considered placebos — that is, medically ineffective but possibly useful for making the patient feel better.

People sometimes take the placebo response to mean that the body can heal itself or that patients are being tricked into not complaining. But the placebo response is more complicated and actually encompasses a number of different phenomena.

Most diseases vary in severity over time (arthritis sufferers can have good days and bad). Many people will spontaneously get better even without therapy (your urinary tract infection will often improve on its own, but it may just scar your kidneys a bit without proper treatment). Statistical concepts like “regression to the mean” can explain why lab values tend to improve on repeated measurement. Simply being enrolled in a clinical trial means your condition may get better in the placebo group because you are getting better quality care and closer follow-up from the research team. And for some people the simple act of doing “something” is reassuring.

The study in JAMA Pediatrics seems to have capitalized on just such a sentiment. The crossover randomized trial enrolled 30 young people with irritable bowel syndrome or functional abdominal pain to usual care or open-label placebo. No deception was involved and patients knew the liquid suspension they received had no active medicinal ingredients. With each patient serving as their own control, during the three weeks when they received the placebo their pain scores improved and they needed less additional antispasmodic medication.

This study suggests an interesting if controversial approach to treating conditions like functional abdominal pain where the causes are complex and few practical treatments exist. There is an adage in medicine that not every symptom is a disease, not every disease has a treatment and not every treatment is a cure.

We all fall into this trap routinely. Many over-the-counter cold medications are clinically useless and yet we all regularly take them when we get sick. When we are sick, we all feel better when we do “something” because doing “nothing” is generally intolerable. In particular, when it comes to children, as in this study, a major variable is the parents and their approach. Things that make parents feel better tend to make children feel better too.

I see why people might advocate for open-label (without deception) placebos for chronic non-fatal medical problems where no good treatment exists, but I have two issues with placebos, even open-label placebos, as a treatment strategy: They are not necessarily benign and they cost money.

When I see the many bottles of vitamins, supplements and minerals people take for no clear reason, I feel compelled to point out how much money they would save every month if they stopped buying them.


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