MEDICAL MATTERS: Placebos can work even on an aware patient, writes MUIRIS HOUSTON
FOLLOWING THE publication of the latest research into the placebo effect, we may be getting closer to a medical goal I would love to see achieved. I believe in the concept of doctor-as-drug and sometimes wish I had practised in an era when placebos were prescribed on a routine basis.
The word placebo comes from the Latin, meaning “I shall please”. By the early 19th century, it had acquired its modern medical meaning as something “given more to please than benefit the patient”. Traditionally this meant giving the patient a sugar tablet or an injection of water, but without telling them the treatment was inactive. Although it benefited the patient, the doctor was still engaging in subterfuge, something now discouraged by medical regulatory bodies throughout the world.
Can taking a placebo be effective even if the patient knows it is a placebo? The presumption has been that it could not, but now a new report suggests the opposite. Researchers from Harvard Medical School have shown that placebos are effective even when the patient is told what they are being given.
The researchers explained to 80 volunteers with irritable bowel syndrome (IBS) that half of them would receive no extra treatment and the other half would receive a placebo. They explained to participants that this was a sugar pill that had been found to “produce significant improvement in IBS symptoms through mind-body self-healing processes”. Patients were then randomly either assigned the pill – in a bottle clearly marked placebo – or told to continue their regular treatment for the condition.
When reassessed after 11 days, and again at 21 days, the patients given the placebo reported better pain relief and greater reduction in the severity of other symptoms than those who got no pill.
The authors concluded: “Placebos administered without deception may be an effective treatment for IBS. Further research is warranted in IBS, and perhaps other conditions, to elucidate whether physicians can benefit patients using placebos consistent with informed consent.”
In a separate study published some years ago, the same researchers looked at the effects of placebo acupuncture in three circumstances. One group of patients were placed on a waiting list and observed; another received “sham” acupuncture; a third received the “sham” acupuncture as well as 45 minutes of “quality time” with the doctor.
Some 3 per cent of the observation group reported an improvement in their symptoms, while 20 per cent who got sham acupuncture alone said they benefited. But four in 10 of those given both sham acupuncture and an extended patient-focused consultation reported the greatest relief of symptoms.
The doctors in this group inquired about the patients’ symptoms and their beliefs about them. They showed empathy and communicated their positive expectations about the treatment to the patient. The doctors in the brief sham acupuncture group told patients they had been asked not to talk about the experiment. The idea in this group was to try to replicate a medical consultation carried out under time limitations.
The fact that the extended consultation approach provided the greatest improvement in irritable bowel symptoms may be the key to the success of placebo use in both this study and the more recent research.
Certainly, the latest study challenges the conventional wisdom that placebo effects require “intentional ignorance”. The results suggest that harnessing placebo effects without deception is possible if doctors describe clearly what is known about placebo effects, encourage the patient to suspend disbelief, “sell” the inert treatment in a way that encourages a positive but realistic expectancy and direct the patient to adhere to the medical ritual of pill taking.
The results point to a strategy that might allow the ethical use of placebos consistent with evidence-based medicine. At the very least it has potential as a “wait and watch” strategy before drugs are used. For some disorders it may be appropriate for clinicians to recommend that patients try an inexpensive and safe placebo accompanied by careful monitoring. Might I now be able to ethically prescribe a placebo?