Divemedic of the wonderfully named Confessions of a Street Pharmacist
responds to my criticism of the failure of pain management by someone who preaches that real medicine is evil.[1] –
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I attended a medical seminar that actually made a few valid points about placebo treatments, which included holistic medicine and “sugar pills.”
Alternative medicine treatments are also placebo treatments, but that oversimplifies things. In addition to placebo, alternative medicine depends on misdiagnosis, reversion to the mean, and spontaneous remission – not just placebo responses.
When we study treatments, we lump too much into the placebo responses.
We include misdiagnosed patients. If I did not have the illness, then I am found to still not have the illness, I did not get better. My diagnosis only became more accurate.
We include patients who will have reversion to the mean – they have deviated from the norm as much as they are going to, so they will only improve.
We include patients who will have spontaneous remission – they are starting to get better on their own.
Improvement does not mean the study drug did it and it does not mean the placebo did it.
These false response groups are in the treatment group and these false response groups are in the placebo group. They are not placebo effects and they are not drug effects.
What is due to placebo and what is due to misdiagnosis?
What is due to placebo and what is due to reversion to the mean?
What is due to placebo and what is due to spontaneous remission (the immune system at work)?
We need better studies to learn a lot more about these effects and about placebo effects.
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I have to say that a few good points were made, and I felt they were well grounded in science. For example, the lecturer pointed out that there are many cases where people being treated with placebo medications had better outcomes than people who received no treatment at all.
If we tell our children that we are kissing a boo boo to make it better, we are providing a placebo. We may only be distracting them from the injury, or the illness, until they get better, but having somebody care does seem to make a difference. Being distracted makes the time pass with less discomfort, but that is not magic.
Distraction is the absence of focusing on the illness, or the absence of focusing on the injury. Distraction is not healing.
Distraction is avoiding having the mind add stress to the condition.
And the big problem with placebos is that we tell someone that we are providing a treatment, when we are really deceiving them. We are confounding their expectations.
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. . . there are cases where the medication study group is said to be ‘no more effective than the placebo group.’
Those medications that are not shown to be better than placebo are medications that never should have been approved to begin with. Or they are medications that are not approved.
Failing to work better than placebo means that the medication is a placebo.
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This would lead one to believe that the power of the mind plays a part in patient outcome, and this should not be summarily dismissed or ignored.
Stress is a bad thing. The brain releases stress hormones. Interrupting that may be what placebos do best.
It is a mistake to give credit to placebo for things that we do not know.
What amount of harm is caused by placebo? If we do not know, then how can we recommend a placebo?
How can we claim to be ethical if we lie to patients?
How do we obtain informed consent for a placebo?
We do need to have a better understanding of what the benefits and harms are of placebo, just as with any other treatment. Until we do, it is not any better than any other new not well understood drug that people get excited about, even though we don’t know enough to make informed decisions.
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We all know that the nervous system plays a role in healing, through hormones like cortisol, and other factors that remain undiscovered.
We know that cortisol is harmful. Relaxation seems to decrease the release of cortisol, so the placebo effect may be just a decrease in the power of the mind to harm the body. A lot of the placebo effect may be just turning down the self-destruction of the body, not any actual healing.
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As medical practitioners, it is something that I feel we need to investigate. However, it is silly to wed ourselves to any treatment, unless that treatment is the one that is best suited to our patient’s care and recovery.
The way we learn what is best for patients is to study the response of patients to a treatment. If the treatment does not work in controlled circumstances, there is absolutely no reason to believe that some magic kicks in when we are not paying attention.
We need to know more about placebos, but exaggerating the usefulness of deceiving patients is not a good thing.
If we are supposed to obtain informed consent, what are the ethics of misleading patients?
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Footnotes:
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[1] What is a Holistic Pain Management Doctor?
Rogue Medic
Sat, 16 Jun 2012
Article
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