Conversation as placebo

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Last Sunday there was an interesting opinion piece in the New York Times titled ‘The Conversation Placebo‘. Here is a quick summary. It starts with the, now commonly accepted, issue of pain costs and opioid use:

‘… pain costs America up to $635 billion annually. The pain remedies developed by the pharmaceutical are only modestly effective, and they have side effect ranging from nausea and constipation to addiction and death.” 

And then opens into an honest reflection on client/patient interaction:

What is often overlooked is that the simple conversation between doctor and patient can be as potent an analgesic as many treatments we prescribe.”

“A substantial portion of ‘healing’ comes from the communication and connection with the patient”

As health professions begin to realise the power of the words they choose, and the fact it is them that says them, questions arise. What if we allowed a patient to believe a placebo was effective, because the belief from the conversation us could provide the impact?

“There are some who argue it is unethical to promote placebos to patients. But increasingly, many say it is unethical not to give placebos a try in situations where patients are not getting relief from traditional means (and where it could not cause harm or replace a necessary treatment).”

What are your thoughts? Is it ethical to encourage (or not discourage) a known placebo (i.e. vitamins) when is it likely to be effective and not harmful?

“… if it helps without causing harm, then it’s legitimate medicine.”

 – Hayley Leake

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5 Responses to “Conversation as placebo”

  1. Marcel

    Hi,

    I think I posted this earlier: Kaptchuk et al 2010 “Honest” placebos and IBS
    where it is shown that placebo can have significant results/effects even if it is known the medication ie pill is a placebo ! (59% of patients who knowingly took sugar pills reported adequate relief )

    May I add that (if reproducable) 59% adequate relief of pain in persistent pain problems is pretty impressive for “sugar in a pill” ,… I wonder if there is any treatment (IBS or other “comparable” persistant pain problems) that has been proven to have better results then this?

    “Placebos: Honest fakery

    Jo Marchant
    Nature (14 July 2016)

    In April, Ted Kaptchuk addressed hundreds of physicians and scientists at the Behind and Beyond the Brain symposium in Porto, Portugal. Within minutes, ripples of laughter were spreading around the conference hall.

    Kaptchuk, a researcher at Harvard Medical School in Boston, Massachusetts, was showing the audience a cartoon in which a doctor hands over a prescription note. “I want you to take this placebo,” says the white-coated medic to her bemused patient. “If your condition doesn’t improve, I’ll give you a stronger one.” The chuckles were a response to the absurdity of openly treating a patient with fake pills. By definition, placebos have no active ingredient, so the idea that someone might benefit from knowingly taking one — let alone that different placebos could have different effects — seems nonsensical. But Kaptchuk invited his audience to take the scene seriously. Honest placebos can work, he insisted. And some placebos really are stronger than other

    Learning nothing

    Placebos influence expectation: how good or bad we think our pain is going to be. This expectation is influenced by what we’re told about a treatment and also its nature — invasive treatments (such as surgery or acupuncture) often elicit larger placebo responses than interventions that seem more modest (such as pills). Social factors including the attitude of the practitioner can also influence patients’ symptoms4, 5. What’s now coming to light, however, is that placebo responses can also be learned. Just as Russian physiologist Ivan Pavlov discovered that dogs salivate in response to a buzzer associated with food, similar mechanisms are thought to drive placebo responses previously assumed to rely purely on conscious expectation.

    Kaptchuk is going one step further. For conditions such as chronic pain, for which placebo effects are large, drugs aren’t very effective and taking them can have downsides (see page S4), he suggests sometimes ditching medication altogether and openly giving placebos.

    He made headlines in 2010 with a placebo study for irritable bowel syndrome (IBS) in which patients were told that they were receiving a sugar pill. “Historically, the assumption has been that deception or concealment is necessary for placebos to work,” Kaptchuk says. “My logic was that maybe we could tell patients upfront that placebos may work and tell them to give it a try.” The results were startling: 59% of patients who knowingly took sugar pills reported adequate relief from their symptoms, compared with 35% in the no-treatment group — better than most IBS drugs, he adds. “I was very surprised by the results,” says Kaptchuk, “even though I hoped it would work.”

    https://www.ncbi.nlm.nih.gov/pubmed/21203519?dopt=Abstract&holding=npg

    http://www.nature.com/nature/journal/v535/n7611_supp/full/535S14a.html

    Reply
  2. davidbutler0noi

    I always find placebo to be a fascinating circular topic. It can be hard to define and I get around that by thinking of it as ‘brainpower’. You could insert ‘brainpower’ or ‘brainpower powder’ into the above discussions and they would still make sense. ? Vitamins as brain power enhancing substances in the right context.

    Cheers

    David

    Reply
  3. Nico pauly

    I ambassade Physiotherapist and I do do so many things that might have placebo effects. Like explain pain, convincing pain is not always what MRI shows, doing non evidence based techniques but explaining what it does in the nervous system. The more my way of approaching pain in words, acts and advises are giving a placebo effect the better for the patient because it does not harm and has not the collateral damage like lots of evidence based drugs.

    Reply
  4. Marcel

    Next to placebo. It’s probably a good thing to be aware of the unintended “nocebo” (that might “lurk” around)

    “The power and value of placebo and nocebo in painful osteoarthritis
    Dieppe et al, Osteoarthritis and Cartilage 24(11) · June 2016

    Placebo and nocebo effects are positive or negative outcomes resulting from the human interactions and contexts in which healthcare consultations take place. Subtle changes in behaviours and the environments in which consultations take place can have major effects on pain and other symptoms being experienced by people with OA.

    Nocebo effects are particularly powerful, leading to many health-care professionals (HCPs) causing unintended harm to their clients.”

    https://www.researchgate.net/publication/304340398_The_power_and_value_of_placebo_and_nocebo_in_painful_osteoarthritis

    Reply

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