Would you want to know if a medication you were taking was working as a placebo?

[say1988]

Depnds on how much codeine is in it. If there is a touch put in just so they can label it that way, but not enough to have any effect it is still a placebo. However, with the amount of acetaminophen in it even if there was effectively no coedeine it still isn't a placebo, but just ineffective for that case.
For what is actually an example, while most cough syrups (children's in particular) contain some medicinal ingredients, including those known to help the symptoms in larger quantities, it is of negligable amounts, making the medication nothing more than a placebo.

 

[Neonanocyborgasm]

Why? It is justas likely (if not moreso) a failure of medical science.

If you have the option of suffering without hope of a cure or having symptoms mitigated by dangerous and extremely expensive narcotics without hope of a cure or having symptoms mitigated by a completely safe and cheap placebo without hope for a cure which would you choose? I know which one I would and I wouldn't call my doctor a failure for doing it.

That's not what a placebo is. It's not a pain reliever. A drug that relieves pain is still performing its intended pharmacologic effect on pain receptors in the central nervous system. A placebo is a fake that is disguised as a real drug, whose effects only come because the patient believes it. It is a trick, and as good as snake oil.

Further, the original point was you were prescribed a drug that medical science believed worked and only discovered that is was equivalent to a placebo after the fact. You can't fault a doctor for prescribing based on what the scientific community tells him.

That's different. There have been drugs on the market that were later proven to be no better than placebo, and in some cases much worse, but at the time they were prescribed, the known evidence was that they weren't placebos. And it seemed unbeknownst to everyone, and not a matter of deception; just a mistake.

There was a recent drug called drotrecogin that was pulled from the market because a follow-up study came out that showed it was no better than placebo and perhaps even worse, as it had pharmacologic effects that were simply not therapeutic. But the origin study, performed 10 years ago, showed opposite effects, so for years, doctors were using it.

In this case it's more like an SSRI once believe to be effective, later shown to not be.

Which SSRI?

 

[Cutlass]

This makes no sense.

Codeine is not a placebo. Maybe it wasn't enough in your specific case, but codeine or any other opiate analgesic isn't meant to be a placebo.

It just didn't have any noticeable affect

 

[say1988]

That's not what a placebo is. It's not a pain reliever. A drug that relieves pain is still performing its intended pharmacologic effect on pain receptors in the central nervous system. A placebo is a fake that is disguised as a real drug, whose effects only come because the patient believes it. It is a trick, and as good as snake oil.

How is that relevant to what i posted?
A placebo can be an effective pain reliever (or manage any number of symptoms), this is an established fact.

Lets say you have severe chronic pain, and there is no way to cure you of it, so symptom management is the only option.
Your doctor knows that the only effective, medicinal treatments of the symptom are dangerous (nasty side effects, addiction, etc) narcotics, you don't.
You have the choice of suffering severe pain all the time or taking dangerous narcotics regularly.
Wouldn't you appreciate the option of your doctor prescribing this little pill with few side effects that relieves your pain? I sure would. Do you care that it is medicinally relevant? Nope, as the goal is symptom control I am just looking for results. What if it doesn't work? You find out pretty fast and your doctor moves on to narcotics, this type of thing happens all the time.

If the doctor said this would cure some underlying disease, then I would have an issue. If it is just symptom management I would be perfectly happy. Parents do it all the time for their children (i.e. "let me kiss it better").

 

[Tani Coyote]

I think placebos are a great way to get some tangible benefits without all the costs of medicine. Of course, if actual medicine is available, it should be used first before giving placebos. Placebos should come secondary, a bit like faith healing - both can have powerful effects on one's mood and condition in the right circumstances, but actual medicine should be taken first.

If I was on a placebo and was getting good benefits, I wouldn't want to know otherwise.

Like my peptobismol. It likely doesn't actually help me any by taking it; indeed, my wooziness could very well be the product of my mind. But it helps me out a lot and doesn't run the risk of addiction or serious harm unless I'm guzzling a bottle of it a day.

 

[Neonanocyborgasm]

How is that relevant to what i posted?

You don't seem to understand the difference between a placebo and an analgesic. An analgesic is not a fake drug. It really does relieve pain, and doctors who prescribe tell the truth by stating that it will only remove the pain. A placebo is nothing but a trick.

A placebo can be an effective pain reliever (or manage any number of symptoms), this is an established fact.

Not an effective reliever. Placebo only works by a psychological effect, not physiologic. If it is relieving anything, it is the patient's imagined symptoms with an imagined drug.

Lets say you have severe chronic pain, and there is no way to cure you of it, so symptom management is the only option.
Your doctor knows that the only effective, medicinal treatments of the symptom are dangerous (nasty side effects, addiction, etc) narcotics, you don't.
You have the choice of suffering severe pain all the time or taking dangerous narcotics regularly.

This is not a real situation. Chronic pain is treated with opioid analgesics. They do not all have "nasty side effects" and even when they do, there are so many to choose from that you will always be able to find one that is tolerable. There are also other drugs that can be given to manage the side-effects. You also are woefully ignorant of the addictive potential of narcotics. They are only addictive when abused for euphoria, not when used for therapeutic gain. That is evidence established from at least 10 years ago in clinical trials. Only the old doctors who forgot to read up on "the latest" medical evidence from years ago are still under the delusion that prescribing one drop of morphine will transform an addict. What is more is that a placebo will never be effective for real pain. No matter how hard you try to trick someone into believing that the snake oil they're using is a pain reliever, those damned pain receptors just keep getting set off and the patient still suffers. A placebo would only work if the patient was a mental case and only imagined pain that wasn't there. (I have used placebo in this way as a test to see if a patient was faking symptoms this way.) A significant amount of patients with real diseases do have some imagined symptoms, but that is no excuse to avoid treating them with real drugs rather than placebo.

Wouldn't you appreciate the option of your doctor prescribing this little pill with few side effects that relieves your pain?

In fact, placebos have no side effects, because they're... fake!

Nope, as the goal is symptom control I am just looking for results. What if it doesn't work?

See above. Analgesics ARE symptom control, but the difference there is that the doctor doesn't try to trick the patient. The drugs actually do work even if the patient doesn't know what he's getting.

 

[say1988]

Not an effective reliever. Placebo only works by a psychological effect, not physiologic. If it is relieving anything, it is the patient's imagined symptoms with an imagined drug.

I take placebo. I am no longer in pain. It effectively relieved the pain. It is an effective pain reliever.
Considering most pain is just your brain interpreting signals a placebo just stops the brain from registering the pain. How is it any different where and how you break the link?
Unless you are arguing that the placebo effect simply doesn't exist.

In fact, placebos have no side effects

Which, if it has the same effect, makes it better than every drug on the market.

 

[emzie]

Which SSRI?

It's my impression, though you would be much better situated to know otherwise, that meta analysis of SSRIs showed them to not be statistically significant in treating depression... that their perceived success came from publishing bias.

 

[El_Machinae]

Part of the infodump!

Firstly, placebo is known to be quite effective in relieving pain. This means that, in some cases, the patient's perception of suffering is reduced. Because a LOT of medical demand is for symptom relief, then placebo can be quite effective in benefiting a patient.

One thing that's probably intuitive is that you can get different intensities of placebo. You can even test for what components of a placebo treatment are most effective. For example, in Kaptchuk et al (2008), patients came to receive sham acupuncture along with some TLC for irritable bowel syndrome. Now, IBS changes in intensity over time, so some patients spontaneously recover. This group endeavored to see what was more effective in providing relief: acupuncture or the acupuncture & TLC

As you can see, sham acupuncture ("limited") increased the odds of the patient perceiving relief. Sham acupuncture & TLC ("augmented") was even more effective.



This is not really a surprise. What blew me away was a recent paper is that there were different ways to inhibit placebo effect, based on how the placebo effect was being generated. It's been known for ~30 years that 'naloxone' (an opiod inhibitor) inhibits the placebo effect from morphine. But 2011 had a cool paper too.

In this experiment, they would get the subjects to resist expermental pain for as long as they could. On day 2 & 3 they gave the subjects morphine. On day 4, they thought they were getting morphine but either got naloxone or saline. You'll see that the expectation of morphine was enough to blunt pain, but naloxone blocks the ability to derive benefit from saline after morphine


In their more recent paper (behind a paywall, sorry) that group showed that you can generate a similar effect with non-opoid painkillers (e.g., tylenol), but naloxone doesn't inhibit this benefit. But inhibiting something else (using a different drug) will block the non-opiod placebo effect.

So, there's actual neuroanatomical correlates for placebo, and (in fact) there are multiple types!

Finally (for this post, there's actually a ton of really cool stuff), a great portion of modern analgesics get their benefit from the placebo effect. If the patient is aware they're getting a painkiller, the painkiller is more effective at relieving suffering than if they don't know they're getting it. This paper shows that if the patient realises that painkiller is being placed into the IV, they receive quite a bit more relief than if the IV is dosed with painkiller by an automated system that doesn't inform the patient.

The 'actual' analgesic effect is augmented by the placebo effect.

Finally, we have some clues as to where in our neuroanatomy we generate our placebo effect. Like I said, different placebos can be blocked by inhibiting certain types of receptors. But, as well, if we 'inhibit' the dorsolateral prefrontal cortex using transcranial magnetic stimulation (another totally awesome technology) you can prevent someone from getting the placebo benefit without increasing their pain sensitivity. They don't become sissier, they just don't get placebo benefit.

 

[El_Machinae]

And then, as a random piece of placebo trivia

http://www.psychologytoday.com/blog...know-its-fake-the-strength-the-placebo-effect

The 80 IBS patients were randomly selected to receive either no treatment (the control condition) or a pill they were told was inactive "like a sugar pill" without any medication in it. Patients in the placebo condition were also told about the placebo effect and that such inactive sugar pills have been shown to produce significant mind-body self-healing processes. The placebo pills were marked with clear labels that read "placebo pills" so that there would be no confusion and so that patients would be constantly reminded that they pills they were taking were placebo pills 2 times a day. Amazingly, the placebo effect was still found to be present.

At the end of 3 weeks of treatment, participants in the placebo group reported significantly greater improvement in their symptoms

 

[emzie]

And then, as a random piece of placebo trivia

http://www.psychologytoday.com/blog...know-its-fake-the-strength-the-placebo-effect

I linked to the paper in the first few posts. Other studies have shown a similar result, but they were even smaller than the 80something IBS patients.

 

[Atlas14]

What sort of illnesses are we talking about? Caner? Common cold?

The body is relatively good at healing itself provided it receives proper nourishment and care. I realize there is data to support the claim that placebos are effective, even in some cases where the patient knew that is what was being administered, however I would want to know exactly what I was being given.

I'd ultimately want a real drug...I am too skeptical of things that don't seem logical.

 

[Neonanocyborgasm]

I take placebo. I am no longer in pain. It effectively relieved the pain. It is an effective pain reliever.

Ok. Continue to confuse analgesia with the placebo effect.

Considering most pain is just your brain interpreting signals a placebo just stops the brain from registering the pain. How is it any different where and how you break the link?

That's how opioid analgesics work. They block the signals transmitting pain. Placebo just tricks you so you produce the same effect naturally. Maybe if you were to study meditation and yoga for a lifetime, you could convince yourself that the stab wound isn't really there, but for 99% of the rest of the world, that's just not a viable option.

Unless you are arguing that the placebo effect simply doesn't exist.

Oh it exists alright.

It's my impression, though you would be much better situated to know otherwise, that meta analysis of SSRIs showed them to not be statistically significant in treating depression... that their perceived success came from publishing bias.

That's incorrect. What has been debunked is that any one SSRI is more effective than any other for treating depression, which is a claim by many pharmaceutical companies to advance their product.

Firstly, placebo is known to be quite effective in relieving pain. This means that, in some cases, the patient's perception of suffering is reduced. Because a LOT of medical demand is for symptom relief, then placebo can be quite effective in benefiting a patient.

As I don't have access to the full text of these articles, I can't comment on their validity. But what is certain is that adjunctive modalities have been used to treat chronic pain for years, because pain affects emotion and functional states even when the feeling of pain is effectively treated with opioids. That's not surprising considering that some of the opioid receptors mediate the emotional response to pain, and not just its sensation. The opposite effect, euphoria, can be produced by administering opioids, especially in the painless state. I interpret this as suggesting that many patients do not receive a dose of medication sufficient to treat their pain, because, as my previous post mentioned, there are still old physicians who are afraid of turning their patients into addicts with one drop of morphine (as if a patient with terminal cancer cares).

So I don't disbelieve in the placebo effect. It's just not an effective way to treat "real" pain.

And as for Irritable Bowel Syndrome, it is a psychiatric illness according to most authorities. I'm not surprised at all that giving no treatment was effective.

 

[say1988]

Ok. Continue to confuse analgesia with the placebo effect.

Are you saying that a medically inert substance that mitigates pain is not a placebo?

That's how opioid analgesics work. They block the signals transmitting pain. Placebo just tricks you so you produce the same effect naturally

So a placebo will have the same end result and far smaller chance of side-effects (yes, placebos do have side effects, via the same means as any other effect). Sounds like a good deal to me.

 

[El_Machinae]

So, like Mise mentioned upthread, the placebo effect has been getting stronger over the years. This has made finding pain medications more and more difficult, because placebo is a fairly significant part of most treatments. In order to show 'statistical significance' you need to deal with two issues - variance, and effect size. Pain management has wild variance, and so what makes a drug 'viable' in market testing is how much of a boost it gives compared to a placebo. The less the relative boost, the greater number of test subjects you need to show effect. Logically, it would make the most sense to try to limit the placebo effect in patients when trying to discover a new drug, but it's hard.

And, sometimes a treatment has been designed off of 'real science' (in that we assume a condition can be fixed through intervention, so we do the intervention) and then 'gotten lucky' in that it defeated placebo in initial trials. It then becomes the standard treatment. Later on, we realise that placebo had become the *better* treatment than the actual treatment. There're two main surgeries for arthroscopic surgery for knee osteoarthritis : lavage and debridement. Something like $3 billion per year is spent on these surgeries. So, placebo as a therapy becomes important when it's more effective than the specialised treatment.


We have to worry about the placebo effect in Parkinson's Disease and using stem cell transplants. The stem cell transplant is effective (and needs to be improved), but when we ask patients whether they thought they received the stem cells or placebo, the placebo effect was much stronger than the treatment effect.

Actual surgery (lower is better)


Perceived surgery (lower is better)


So, you can see that in science placebo is a frustrating distraction (unless you're studying placebo), but in medicine it's a powerful tool in the toolkit. Because of the 'nocebo' effect (the negative symptoms caused by placebo), a physician has to manage how they use the placebo, and because patient suffering is a primary measure, it should probably be studied more. Pubmed has over 150 articles on nocebo, so there's a base of science for access. Notably, if the patient is familiar with the negative side effects of a treatment, then placebo is more likely to generate those adverse side effects.

One of the holy grails in placebo research will be to identify the phenotype of people more likely to receive placebo benefit. If that can be found, then the science can go much faster (they'll be excluded from trials) and medicine can improve too (because placebo can be a go-to therapy for them). One of the easiest placebos to generate is to prescribe a sub-clinical dose of a medication for their disease, because the patient is getting the right 'medicine' but at a dose where it's only the placebo they're responding to.

 

[Neonanocyborgasm]

Are you saying that a medically inert substance that mitigates pain is not a placebo?

Inert substances aren't actually doing anything. That's why they're called inert. What they are doing is tricking your brain to produce its own natural analgesics, called endorphin and encephalin, producing the same effect. Rarely, however, will they ever be produced in sufficient quantity to treat pain effectively. Another aspect of the placebo effect is purely psychological. Some people are mentally deranged and imagine all sorts of symptoms that aren't there. If they can imagine them there, they can be tricked to imagine them not there with a fake drug.

So, like Mise mentioned upthread, the placebo effect has been getting stronger over the years.

What you are confusing is the effect of placebo and the use of randomized clinical trials. What you have to appreciate is that evidence based medicine, applied from randomized clinical trials, is fairly new. Until about the 1970's (that's new to medicine, which is very conservative), much of medicine was based on "authoritative" opinion and few claims were subjected to rigorous scientific challenge. Many practices and drugs have been abandoned because, when actually subjected to placebo as a competitor, were found no better and sometimes worse.

The placebo effect has not been increasing over time. What you cited for me is standard in medical literature because all randomized clinical trials strive to compare to placebo or "sham". And every so often, one finds that the fake intervention is as effective, and sometimes even more effective, than the so-called "therapeutic." That doesn't make placebo an effective treatment. It just proves that the "therapy" is a fraud and doesn't deserve to be used. The list of drugs that have been abandoned as being no better than placebo is long, and most never make it to market because they are discredited in pre-market trials. One recent one, as I said, is drotrecogin, used to treat severe sepsis for 10 years, which, in a recent large scale trial, was found no better than placebo, and perhaps even worse in some respects. Digoxin is another drug that once used to be used for almost every ailment, but is now limited only as a antiarrhythmic.

The fact that you can pull off pretty amazing trickery with the use of placebo is not news.

 

[El_Machinae]

Naw, there's a generally acknowledged trend that the placebo effect is growing over the last 3 decades. Big Pharma is conducting proprietary research on this topic, because figuring out how to decrease the placebo effect will reduce other research costs. As well, the rising effect of placebo has brutalised cost-benefit analysis of clinical trials, because the placebo effect rises in between initial trials and the decision to fund phase III trials. It's fundamentally harder to prove efficacy if the placebo effect is high (or a major portion of the treatment effect).

And I fundamentally disagree that placebo is not an important point of therapy. If placebo is better than best-practices at relieving pain, then it justifies using placebo. The best example is using sham acupuncture in Germany: it was cheaper AND more effective than best practices. If placebo is shown to provide symptomatic benefit to the patient, to improve their quality of life, then it should be considered.

It's not just pain where placebo is important. Parkinson's can be alleviated with placebo. Depression, too.