The Collison Newsletter August 2014

 

                         THE  PLACEBO  EFFECT*   

 

Placebo: a medicine or procedure prescribed for the psychological benefit to the patient rather than for any physiological effect. The word 'placebo' is derived from the Latin placebo, "I shall please".

 

A placebo is a simulated or otherwise medically ineffectual treatment for a disease or other medical condition intended to deceive the recipient. When a patient given a placebo treatment has a perceived or actual improvement in a medical condition, this phenomenon is called the placebo effect.

 

There are many definitions of placebo, and the following are given (from www.thefreedictionary.com/placebo) to provide a more complete picture of this interesting topic.

 

"A substance containing no medication and prescribed or given to reinforce a patient's expectation to get well.

An inactive substance or preparation used as a control in an experiment or test to determine the effectiveness of a medicinal drug."

 

"An inactive substance or other sham form of therapy administered to a patient usually to compare its effects with those of a real drug or treatment, but sometimes for the psychological benefit to the patient through his believing he is receiving treatment."

 

"A substance having no pharmacological effect but given to placate a patient who supposes it to be a medicine.

A pharmacologically inactive substance or sham procedure administered as a control in testing the efficacy of a drug or course of action."

 

A placebo has also been defined as "a substance or procedure .... that is objectively without specific activity for the condition being treated". Under this definition, a wide variety of things can be placebos and exhibit a placebo effect. Pharmacological substances administered through any means can act as placebos. Medical devices such as ultrasound can act as placebos. Sham surgery, sham acupuncture, either with sham needles or on fake acupuncture points, have all exhibited placebo effects.

 

The physician has even been called a placebo. It has been shown that patient recovery can be increased by words that suggest the patient "would be better in a few days" and, if the patient is given a treatment, that "the treatment is the ideal for him and will certainly make him better". Negative words such as "I am not sure that the treatment I am going to give you will have any effect" almost ensure that the treatment will not work (the nocebo effect). Good rapport is a guarantee to a placebo response. Rapport is a close and harmonious relationship in which the people or group concerned understand each other's feelings or ideas and communicate well. The relationship is especially one of mutual trust and emotional affinity. This is the basis of the therapeutic value of the good old-fashioned bedside manner.

 

Placebos are widely used in medical research and medicine: placebos are given as control treatments, and depend on the use of measured deception. Common placebos include inert tablets, sham surgery and other procedures based on false information. The double-blind cross-over with a placebo is the ‘gold standard’ of drug research. In such a study neither the researcher nor the patient knows which (numbered) pill is the active one or the placebo: half way through the trial, the medications are reversed. It is generally accepted and believed that, without such a study showing that the drug works better than a placebo, the drug does not work at all.

 

In one common placebo procedure, unlike the double-blind cross-over study referred to above, a patient is given an inert pill, told that it may improve his/her condition, but not told that it is in fact inert. Such an intervention may cause the patient to believe the treatment will change his/her condition; and this belief may produce a subjective perception of a therapeutic effect (causing the patient to feel their condition has improved) or an actual improvement in their condition. As indicated above, this phenomenon is known as the placebo effect.

 

The use of words like "sham" and "fake", and the concepts of dishonesty, false information and deception may sound wrong, unethical and in one sense, very negative. This is not so. To illustrate the purpose of procedures etc that are called sham and fake, let us consider sham surgery and sham acupuncture in more detail.

 

Sham surgery, also called placebo surgery, is a faked [false information, deception, dishonesty] surgical intervention that omits the step thought to be therapeutically necessary. In clinical trials of surgical intervention, sham surgery is an important scientific control. This is because it isolates the specific effects of the treatment as opposed to the incidental effects caused by the anaesthetic, the incisional trauma, pre- and post-operative care and the patient's perception of having had a regular operation. Thus sham surgery serves an analogous purpose to placebo drugs (the double-blind cross over studies, as already mentioned, being the 'gold standard').

 

In a number of situations, sham-controlled surgeries have identified interventions that are useless, but had been believed by the medical community to be helpful based on studies without the use of sham surgery. To give but one example:

J. B. Moseley and co-workers published in the New England Journal of Medicine in 2002 their results of the studies they carried out as orthopaedic surgeons on the effect of arthroscopic surgery on osteoarthritis of the knee. There were two treatment groups (with active intervention) and a third group, the sham-operated control group. They found that patients in the treatment groups did no better than the control group (where a small incision, as for the treatment groups, was made in the skin, but nothing more was done). The fact that all three groups improved equally points to the possible placebo effect in certain surgical interventions.

 

Sham acupuncture is used as a control in scientific studies that test the efficacy of acupuncture in the treatment of various illness or disorders. To give an example:

H. H. Moffet published in The Journal of Alternative and Complimentary Medicine in 2009 the following conclusion from his studies: "Sham acupuncture may be as efficacious as true acupuncture, especially when superficial needling was applied to non-points."

 

Understandably, such studies and conclusions are disturbing to those who have trained and practice as acupuncturists, and for those who receive such therapy. However, this is the way in which effective therapeutic interventions can be proven.

 

The placebo effect is a pervasive phenomenon. In fact, it is part of the response to any active medical intervention .... hence the physician being a placebo.

 

The placebo effect is highly variable in its magnitude and reliability: it is typically strongest in measures of subjective symptoms such as pain, and typically weak-to-nonexistent in objective measures such as blood pressure.

 

The placebo effect points to the importance of perception in the brain's role in physical health: it is related to perceptions and expectations of the patient. If the substance is viewed as helpful, it can heal, but, if it is viewed as harmful, it can cause negative effects, which is known as the nocebo effect.

 

So often, "what you expect, is what you get".  Motivation may contribute to the placebo effect. If you intend to get better, you are more likely to respond to therapy in a positive way, whatever the therapy may be.

 

Technically a placebo is not supposed to have any effect but, correctly used, by harnessing the power of placebos it is possible to boost the effectiveness of a range of medical treatments.

 

The power of the subconscious mind has been detailed in my November 2013 newsletter The Power of the Subconscious Mind, and it is suggested that it be read in conjunction with this newsletter.

 

There is much research as to what happens in the brain as part of the placebo effect. There is no doubt as to the reality of the placebo effect, and used intelligently and correctly, better outcomes from therapy will result.

Conclusion 

To quote Dr Damian Finniss  (Clinical Senior lecturer of the University of Sydney,  working in the Northern Clinical School of Pain Management and Research, Royal North Shore Hospital, Sydney):

 

"We need to realise that there are very specific biological pathways that are activated in the therapeutic encounter and ritual, and therefore once we start to learn more about them, I think the onus is going to be on clinicians, or certainly the next generation of clinicians, to think about the way in which they deliver the treatments they deliver and perhaps not just focus on the technical aspects of the treatments alone."

 

The placebo effect is a broad term that includes many non-interventional or invasive elements in medical therapy including:

·        A suggestion by the healer (doctor, health practitioner)

·        Patient's belief in the competence of the healer.

·        Patient's expectations and hope for recovery.

·        The healer's manner (showing attention, care, affection, sincerity, knowledge).

·        The rituals and theatre involved in the delivery of the therapy, including technical jargon, special uniforms, medical gadgetry, treatment room set-up and the like.

 

 

*Copyright 2014: The Huntly Centre.

Disclaimer: All material in the huntlycentre.com.au website is provided for informational or educational purposes only. Consult a health professional regarding the applicability of any opinions or recommendations expressed herein, with respect to your symptoms or medical condition.

Back to the list  Print friendly version