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Blease C, Colagiuri B, Locher C. Replication crisis and placebo studies: rebooting the bioethical debate. JOURNAL OF MEDICAL ETHICS 2023; 49:663-669. [PMID: 36609361 DOI: 10.1136/jme-2022-108672] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Accepted: 12/30/2022] [Indexed: 06/17/2023]
Abstract
A growing body of cross-cultural survey research shows high percentages of clinicians report using placebos in clinical settings. One motivation for clinicians using placebos is to help patients by capitalising on the placebo effect's reported health benefits. This is not surprising, given that placebo studies are burgeoning, with increasing calls by researchers to ethically harness placebo effects among patients. These calls propose placebos/placebo effects offer clinically significant benefits to patients. In this paper, we argue many findings in this highly cited and 'hot' field have not been independently replicated. Evaluating the ethicality of placebo use in clinical practice involves first understanding whether placebos are efficacious clinically. Therefore, it is crucial to consider placebo research in the context of the replication crisis and what can be learnt to advance evidence-based knowledge of placebos/placebo effects and their clinical relevance (or lack thereof). In doing so, our goal in this paper is to motivate both increased awareness of replication issues and to help pave the way for advances in scientific research in the field of placebo studies to better inform ethical evidence-based practice. We argue that, only by developing a rigorous evidence base can we better understand how, if at all, placebos/placebo effects can be harnessed ethically in clinical settings.
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Affiliation(s)
- Charlotte Blease
- General Medicine and Primary Care, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
- Digital Psychiatry, Department of Psychiatry, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Ben Colagiuri
- School of Psychology, University of Sydney, Sydney, New South Wales, Australia
| | - Cosima Locher
- Department of Consultation-Liaison Psychiatry and Psychosomatic Medicine, University Hospital Zurich, Zurich, Switzerland
- Psychology, Plymouth University, Plymouth, UK
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Gainsburg I, Pauer S, Abboub N, Aloyo ET, Mourrat JC, Cristia A. How Effective Altruism Can Help Psychologists Maximize Their Impact. PERSPECTIVES ON PSYCHOLOGICAL SCIENCE 2023; 18:239-253. [PMID: 35981321 DOI: 10.1177/17456916221079596] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Although many psychologists are interested in making the world a better place through their work, they are often unable to have the impact that they would like. Here, we suggest that both individuals and psychology as a field can better improve human welfare by incorporating ideas from effective altruism, a growing movement whose members aim to do the most good by using science and reason to inform their efforts. In this article, we first briefly introduce effective altruism and review important principles that can be applied to how psychologists approach their work, such as the importance, tractability, and neglectedness framework. We then review how effective altruism can inform individual psychologists' choices. Finally, we close with a discussion of ideas for how psychology, as a field, can increase its positive impact. By applying insights from effective altruism to psychological science, we aim to integrate a new theoretical framework into psychological science, stimulate new areas of research, start a discussion on how psychology can maximize its impact, and inspire the psychology community to do the most good.
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Affiliation(s)
- Izzy Gainsburg
- Ross School of Business, University of Michigan
- John F. Kennedy School of Government, Harvard University
| | - Shiva Pauer
- Department of Social Psychology, University of Amsterdam
| | | | - Eamon T Aloyo
- Institute of Security and Global Affairs, Leiden University
| | | | - Alejandrina Cristia
- Laboratoire de Sciences Cognitives et de Psycholinguistique, Département d'Etudes Cognitives, École Normale Supérieure (ENS)/Ecole des Hautes Études en Sciences Sociales (EHESS)/Centre National de la Recherche Scientifique (CNRS), Paris Sciences et Lettres (PSL)
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Blease C, DesRoches CM. Open notes in patient care: confining deceptive placebos to the past? JOURNAL OF MEDICAL ETHICS 2022; 48:572-574. [PMID: 34702766 DOI: 10.1136/medethics-2021-107746] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/15/2021] [Accepted: 10/19/2021] [Indexed: 06/13/2023]
Abstract
Increasing numbers of health organisations are offering some or all of their patients access to the visit notes housed in their electronic health records (so-called 'open notes'). In some countries, including Sweden and the USA, this innovation is advanced with patients using online portals to access their clinical records including the visit summaries written by clinicians. In many countries, patients can legally request copies of their records; however, open notes are different because this innovation offers patients rapid, real-time access via electronic devices. In this brief report, we explore what open notes might mean for placebo use in clinical care. Survey research into patient access to their clinical notes shows that increased transparency enhances patients' understanding about their medications and augments engagement with their care. We reflect on the consequences of access for placebo prescribing, particularly for the common practice of deceptive placebo use, in which patients are not aware they are being offered a placebo. In addition, we explore how open notes might facilitate placebo and nocebo effects among patients. Bridging placebo studies with medical ethics, we identify a range of empirical research gaps that now warrant further study.
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Affiliation(s)
- Charlotte Blease
- General Medicine and Primary Care, Harvard Medical School, Boston, Massachusetts, USA
- Division of General Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Catherine M DesRoches
- Division of General Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
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Bedford T, Kisaalita N, Haycock NR, Mullins CD, Wright T, Curatolo M, Hamlin L, Colloca L. Attitudes Toward a Pre-authorized Concealed Opioid Taper: A Qualitative Analysis of Patient and Clinician Perspectives. Front Psychiatry 2022; 13:820357. [PMID: 35401245 PMCID: PMC8987573 DOI: 10.3389/fpsyt.2022.820357] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2021] [Accepted: 02/23/2022] [Indexed: 11/18/2022] Open
Abstract
Standard opioid tapers tend to be associated with increased patient anxiety and higher pain ratings. Pre-authorized concealed opioid reductions may minimize expectations such as fear of increased pain due to the reduction of opioids and, prolong analgesic benefits in experimental settings. We recently observed that patients and clinicians are open to concealed opioid tapering. However, little is known about the "why" behind their attitudes. Based on this lack of data, we analyzed qualitative responses to survey questions on patients' and clinicians' acceptance of a concealed opioid reduction for chronic pain. Seventy-four patients with a history of high dose opioid therapy and 49 clinicians completed a web-based questionnaire with open-ended questions examining responses to two hypothetical clinical trials comparing a concealed opioid reduction pre-authorized by patients vs. standard tapering. We used content analysis based on qualitative descriptive methodology to analyze comments from the patients and clinicians. Five themes were identified: informed consent; anxiety; safety; support; and ignorance is bliss, or not. These themes highlight the overall positive attitudes toward concealed opioid tapers. Our findings reinforce the importance of patient-centered care and are expected to inform the design of clinical trials from both the patient and clinician perspective. This qualitative study presents patients' and clinicians' attitudes toward hypothetical scenarios for a trial of pre-authorized reduction of opioids. The findings indicate positive attitudes and the relevance of engaging patients with effective decision-making processes.
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Affiliation(s)
- Theresa Bedford
- 711 Human Performance Wing, En Route Care, Wright Patterson Air Force Base, OH, United States
| | - Nkaku Kisaalita
- Mental Health Service Line, Orlando Veterans Affairs Healthcare System, Orlando, FL, United States
| | - Nathaniel R Haycock
- Department of Pain and Translational Symptom Science, School of Nursing, University of Maryland, Baltimore, MD, United States
| | - C Daniel Mullins
- Department of Pharmaceutical Health Services Research, School of Pharmacy, University of Maryland, Baltimore, MD, United States
| | - Thelma Wright
- Department of Anesthesiology, School of Medicine, University of Maryland, Baltimore, MD, United States
| | - Michele Curatolo
- Department of Anesthesiology & Pain Medicine, School of Medicine, University of Washington, Seattle, WA, United States
| | - Lynette Hamlin
- Uniformed Services University of the Health Sciences, Graduate School of Nursing, Bethesda, MD, United States
| | - Luana Colloca
- Department of Pain and Translational Symptom Science, School of Nursing, University of Maryland, Baltimore, MD, United States.,Department of Anesthesiology, School of Medicine, University of Maryland, Baltimore, MD, United States.,Center to Advance Chronic Pain Research, University of Maryland, Baltimore, MD, United States
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Locher C, Buergler S, Frey Nascimento A, Kost L, Blease C, Gaab J. Lay perspectives of the open-label placebo rationale: a qualitative study of participants in an experimental trial. BMJ Open 2021; 11:e053346. [PMID: 34408060 PMCID: PMC8375733 DOI: 10.1136/bmjopen-2021-053346] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
OBJECTIVES To analyse participants' concepts about the open-label placebo (OLP) effect; to explore their views about the discussion points that are applied in conventional OLP trials and to examine their experiences of taking part in an OLP trial. DESIGN A qualitative study using thematic analysis of semistructured interviews that were nested within a randomised controlled trial investigating experimental OLP analgesia (registered at ClinicalTrials.gov: NCT02578420). PARTICIPANTS 30 healthy adults who took part in the randomised controlled trial. RESULTS Participants mostly conceptualised placebo as something that is inert and requires deception in order to be effective. Interviewees used a broad definition of placebos, going beyond a conventional notion of sugar pills. In contrast to the conventional OLP rationale, participants seldom emphasised classical conditioning as a mechanism of placebo effects, stressing a variety of other well-established components through which placebos might be therapeutic, whereas the conventional OLP disclosures state that 'a positive attitude helps but is not necessary', participants in our study applied other attitudes, such as 'it's worth a try'. When asked about their experiences during the trial, the majority emphasised that the concept of OLP was completely novel to them. Participants were rather sceptical about the efficacy of the intervention. CONCLUSION Integrating lay perspectives into the scientific rationale of OLP treatments might enhance the plausibility and credibility of the rationale in ethical treatments. TRIAL REGISTRATION NUMBER NCT02578420.
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Affiliation(s)
- Cosima Locher
- Department of Consultation-Liaison Psychiatry and Psychosomatics, University Hospital Zurich, Zurich, Switzerland
- Division of Clinical Psychology and Psychotherapy, Faculty of Psychology, University of Basel, Basel, Switzerland
- Faculty of Health, University of Plymouth, Plymouth, UK
| | - Sarah Buergler
- Division of Clinical Psychology and Psychotherapy, Faculty of Psychology, University of Basel, Basel, Switzerland
| | - Antje Frey Nascimento
- Division of Clinical Psychology and Psychotherapy, Faculty of Psychology, University of Basel, Basel, Switzerland
| | - Linda Kost
- Division of Clinical Psychology and Psychotherapy, Faculty of Psychology, University of Basel, Basel, Switzerland
| | - Charlotte Blease
- General Medicine and Primary Care, Harvard Medical School, Boston, Massachusetts, USA
| | - Jens Gaab
- Division of Clinical Psychology and Psychotherapy, Faculty of Psychology, University of Basel, Basel, Switzerland
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Bedford T, Adediran T, Haycock NR, Mullins CD, Medeiros M, Wright T, Curatolo M, Hamlin L, Colloca L. Patient and Provider Acceptability of a Patient Preauthorized Concealed Opioid Reduction. PAIN MEDICINE 2021; 22:1651-1659. [PMID: 33674821 DOI: 10.1093/pm/pnaa454] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
OBJECTIVE Limited research of how to best taper opioids brings about an ethical and clinical dilemma. Experiments using overt and concealed administration of opioids have demonstrated the benefits of a concealed reduction to eliminate negative expectations and prolong analgesic benefits. This may allow for opioid tapering without significant increases in pain. Based on this, we investigated patient and provider acceptance of a concealed opioid reduction for chronic pain. METHODS We conducted a cross-sectional survey via REDcap with 74 patients, who are currently taking or have taken high dose opioids, and 49 providers using a validated questionnaire based on two hypothetical clinical trials comparing a patient preauthorized concealed opioid reduction vs standard tapering. RESULTS We found that patients and providers have positive attitudes toward a concealed reduction of opioid dosages. More than 60% of providers and patients surveyed viewed the hypothetical clinical trial as helpful to reduce pain, side effects, and withdrawal symptoms. Sixty-one percent of patients and 77.6% of providers recognized that there would be differences in pain relief depending upon which group the hypothetical participants would be enrolled in. CONCLUSIONS Patients and providers appear to understand the benefits of a concealed opioid reduction. Our findings support future randomized controlled trials that compare concealed and overt opioid tapering in patients with chronic pain. More research is needed to understand the difference in attitudes between research and clinical practice and to test the acceptability of a concealed reduction following a participation in an active clinical trial.
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Affiliation(s)
- Theresa Bedford
- Uniformed Services University of the Health Sciences, Graduate School of Nursing, Bethesda, Maryland, USA
| | - Timileyin Adediran
- Department of Epidemiology and Human Genetics, School of Medicine, University of Maryland, Baltimore, Maryland, USA
| | - Nathaniel R Haycock
- Department of Pain and Translational Symptom Science, School of Nursing, University of Maryland, Baltimore, Maryland, USA
| | - C Daniel Mullins
- School of Pharmacy, University of Maryland, Baltimore, Maryland, USA
| | - Michelle Medeiros
- School of Pharmacy, University of Maryland, Baltimore, Maryland, USA
| | - Thelma Wright
- Department of Anesthesiology, School of Nursing, University of Maryland, Baltimore, Maryland, USA
| | - Michele Curatolo
- Department of Anesthesiology & Pain Medicine, University of Washington, School of Medicine, Seattle, USA
| | - Lynette Hamlin
- Uniformed Services University of the Health Sciences, Graduate School of Nursing, Bethesda, Maryland, USA
| | - Luana Colloca
- Department of Pain and Translational Symptom Science, School of Nursing, University of Maryland, Baltimore, Maryland, USA.,Department of Anesthesiology, School of Nursing, University of Maryland, Baltimore, Maryland, USA.,Center to Advance Chronic Pain Research, University of Maryland, Baltimore, Maryland USA
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Colloca L, Kisaalita NR, Bizien M, Medeiros M, Sandbrink F, Mullins CD. Veteran engagement in opioid tapering research: a mission to optimize pain management. Pain Rep 2021; 6:e932. [PMID: 34104838 PMCID: PMC8177869 DOI: 10.1097/pr9.0000000000000932] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2021] [Revised: 04/10/2021] [Accepted: 04/17/2021] [Indexed: 02/01/2023] Open
Affiliation(s)
- Luana Colloca
- Departments of Pain and Translational Symptom Science
- Anesthesiology, School of Nursing, University of Maryland, Baltimore, MD, USA
- Center to Advance Chronic Pain Research, University of Maryland, Baltimore, MD, USA
| | - Nkaku R. Kisaalita
- Mental Health Service Line, Orlando Veterans Affairs Medical Center, Orlando, FL, USA
| | - Marcel Bizien
- Veterans Affairs Cooperative Studies Program, Clinical Research Pharmacy, Coordinating Center, Albuquerque, NM, USA
- College of Pharmacy, University of New Mexico, Albuquerque, NM, USA
| | - Michelle Medeiros
- Pharmaceutical Health Services Research Department, School of Pharmacy, University of Maryland, Baltimore, MD, USA
| | - Friedhelm Sandbrink
- Department of Neurology, Washington DC Veterans Affairs Medical Center, Washington DC, USA
- Department of Neurology, George Washington University, Washington DC, USA
| | - C. Daniel Mullins
- Pharmaceutical Health Services Research Department, School of Pharmacy, University of Maryland, Baltimore, MD, USA
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Khullar V, Rahnama'i MS, Veit-Rubin N, Cardozo L, Wein AJ. Can we harness the placebo effect to improve care in lower urinary tract dysfunction? ICI-RS 2019. Neurourol Urodyn 2020; 39 Suppl 3:S80-S87. [PMID: 32311166 DOI: 10.1002/nau.24351] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2020] [Accepted: 03/26/2020] [Indexed: 11/09/2022]
Abstract
The proposal "Can we harness the placebo effect to improve care in lower urinary tract dysfunction?" was discussed at the International Consultation on Incontinence-Research Society (ICI-RS) 2019 meeting. The placebo effect can change the treatment outcome whether the treatment is an active treatment or placebo. The total active treatment outcome is a combination of the placebo and the active treatment effect which is seen in placebo-controlled trials. The placebo effect plays an important role in the treatment of lower urinary tract dysfunction in overactive bladder, bladder pain syndrome, and stress urinary incontinence. In clinical practice, a number of factors can be employed to use the placebo effect to maximize its effect on patients receiving an active treatment, such as having the same environment for review such as the same appointment time, same room, and same clinician. Clinicians should also be aware of the nocebo effect which is increased with an overemphasis on side effects or negative outcomes.
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Affiliation(s)
- Vik Khullar
- Urogynaecology Department, St Mary's Hospital, Imperial College London, London, UK
| | - Mohammad S Rahnama'i
- Department of Urology, University Hospital Maastricht, Maastricht, The Netherlands
| | - Nikolaus Veit-Rubin
- Department of Obstetrics and Gynecology, Medical University of Vienna, Vienna, Austria
| | - Linda Cardozo
- Department of Urogynaecology, Kings College Hospital, London, UK
| | - Alan J Wein
- Department of Urology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
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Friesen P. Placebos as a Source of Agency: Evidence and Implications. Front Psychiatry 2019; 10:721. [PMID: 31708807 PMCID: PMC6824097 DOI: 10.3389/fpsyt.2019.00721] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2019] [Accepted: 09/09/2019] [Indexed: 12/11/2022] Open
Abstract
Bioethical discussions surrounding the use of placebos in clinical practice have long revolved around the moral permissibility of deceiving a patient if it is likely to benefit them. While these discussions have been insightful and productive, they reinforce the notion that placebo effects can only be induced through deception. This paper challenges this notion, looking beyond the paradigmatic clinical encounter involving deceptive placebos and towards many other routes that bring about placebo effects. After briefly describing the bioethical terrain surrounding the deceptive use of placebos in clinical practice, section 1 offers an examination of the various mechanisms known to contribute to placebo effects: classical conditioning, expectations, affective pathways, open-label placebo treatments, and additional factors that do not fall easily into a single category. The following section explores how each of these routes can be harnessed to bring about clinical benefits without the use of deception. This provides grounding for reconceiving of the placebo effect as a clinical tool that is not always in conflict with patient autonomy and can even be seen as a source of agency. In the final section, implications of the shift away from seeing placebos as necessarily deceptive are discussed. These include the necessity of looking beyond the clinical encounter and mainstream medicine as the primary sites of placebo responses, how important acknowledging the limits of placebo effects will be when we do so, as well as the difficulties of disentangling agency, responsibility, and blame within medicine.
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Affiliation(s)
- Phoebe Friesen
- Biomedical Ethics Unit, Social Studies of Medicine, McGill University, Canada
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Friesen P, Blease C. Placebo effects and racial and ethnic health disparities: an unjust and underexplored connection. JOURNAL OF MEDICAL ETHICS 2018; 44:774-781. [PMID: 29936435 DOI: 10.1136/medethics-2018-104811] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/15/2018] [Revised: 05/07/2018] [Accepted: 05/17/2018] [Indexed: 06/08/2023]
Abstract
While a significant body of bioethical literature considers how the placebo effect might introduce a conflict between autonomy and beneficence, the link between justice and the placebo effect has been neglected. Here, we bring together disparate evidence from the field of placebo studies and research on health inequalities related to race and ethnicity, and argue that, collectively, this evidence may provide the basis for an unacknowledged route by which health disparities are exacerbated. This route is constituted by an uneven distribution of placebo effects, resulting from differences in expressions of physician warmth and empathy, as well as support and patient engagement, across racial and ethnic lines. In a discussion of the ethical implications of this connection, we argue that this contribution to health disparities is a source of injustice, consider ways in which these disparities might be ameliorated and suggest that this conclusion is likely to extend to other realms of inequality as well.
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Affiliation(s)
- Phoebe Friesen
- Philosophy Department, CUNY Graduate Center, New York City, New York, USA
- Ethox Centre, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Charlotte Blease
- Program in Placebo Studies, General Medicine and Primary Care, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
- School of Psychology, University College Dublin, Dublin, Ireland
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The Ethics of Placebo Effects in Clinical Practice and Research. INTERNATIONAL REVIEW OF NEUROBIOLOGY 2018; 139:463-484. [DOI: 10.1016/bs.irn.2018.07.031] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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Ballou S, Kaptchuk TJ, Hirsch W, Nee J, Iturrino J, Hall KT, Kelley JM, Cheng V, Kirsch I, Jacobson E, Conboy L, Lembo A, Davis RB. Open-label versus double-blind placebo treatment in irritable bowel syndrome: study protocol for a randomized controlled trial. Trials 2017; 18:234. [PMID: 28545508 PMCID: PMC5445390 DOI: 10.1186/s13063-017-1964-x] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2017] [Accepted: 04/29/2017] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Placebo medications, by definition, are composed of inactive ingredients that have no physiological effect on symptoms. Nonetheless, administration of placebo in randomized controlled trials (RCTs) and in clinical settings has been demonstrated to have significant impact on many physical and psychological complaints. Until recently, conventional wisdom has suggested that patients must believe that placebo pills actually contain (or, at least, might possibly contain) active medication in order to elicit a response to placebo. However, several recent RCTs, including patients with irritable bowel syndrome (IBS), chronic low back pain, and episodic migraine, have demonstrated that individuals receiving open-label placebo (OLP) can still experience symptomatic improvement and benefit from honestly described placebo treatment. METHODS AND DESIGN This paper describes an innovative multidisciplinary trial design (n = 280) that attempts to replicate and expand upon an earlier IBS OLP study. The current study will compare OLP to double-blind placebo (DBP) administration which is made possible by including a nested, double-blind RCT comparing DBP and peppermint oil. The study also examines possible genetic and psychological predictors of OLP and seeks to better understand participants' experiences with OLP and DBP through a series of extensive interviews with a randomly selected subgroup. DISCUSSION OLP treatment is a novel strategy for ethically harnessing placebo effects. It has potential to re-frame theories of placebo and to influence how physicians can optimize watch-and-wait strategies for common, subjective symptoms. The current study aims to dramatically expand what we know about OLP by comparing, for the first time, OLP and DBP administration. Adopting a unique, multidisciplinary approach, the study also explores genetic, psychological and experiential dimensions of OLP. The paper ends with an extensive discussion of the "culture" of the trial as well as potential mechanisms of OLP and ethical implications. TRIAL REGISTRATION ClinicalTrials.gov, identifier: NCT02802241 . Registered on 14 June 2016.
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Affiliation(s)
- Sarah Ballou
- Department of Medicine, Division of Gastroenterology, Beth Israel Deaconess Medical Center, 330 Brookline Avenue, Boston, MA 02215 USA
| | - Ted J. Kaptchuk
- Program in Placebo Studies, Beth Israel Deaconess Medical Center/Harvard Medical School, 330 Brookline Avenue, Boston, MA 02215 USA
- Department of Global Health and Social Medicine Harvard Medical School, 641 Huntington Avenue, Boston, MA 02115 USA
| | - William Hirsch
- Department of Medicine, Division of Gastroenterology, Beth Israel Deaconess Medical Center, 330 Brookline Avenue, Boston, MA 02215 USA
| | - Judy Nee
- Department of Medicine, Division of Gastroenterology, Beth Israel Deaconess Medical Center, 330 Brookline Avenue, Boston, MA 02215 USA
| | - Johanna Iturrino
- Department of Medicine, Division of Gastroenterology, Beth Israel Deaconess Medical Center, 330 Brookline Avenue, Boston, MA 02215 USA
| | - Kathryn T. Hall
- Program in Placebo Studies, Beth Israel Deaconess Medical Center/Harvard Medical School, 330 Brookline Avenue, Boston, MA 02215 USA
- Division of Preventive Medicine, Brigham and Women’s Hospital/Harvard Medical School, 900 Commonwealth Avenue, Boston, MA 02215 USA
| | - John M. Kelley
- Program in Placebo Studies, Beth Israel Deaconess Medical Center/Harvard Medical School, 330 Brookline Avenue, Boston, MA 02215 USA
- Department of Psychology, Endicott College, 376 Hale Street, Beverly, MA 01915 USA
| | - Vivian Cheng
- Department of Medicine, Division of Gastroenterology, Beth Israel Deaconess Medical Center, 330 Brookline Avenue, Boston, MA 02215 USA
| | - Irving Kirsch
- Program in Placebo Studies, Beth Israel Deaconess Medical Center/Harvard Medical School, 330 Brookline Avenue, Boston, MA 02215 USA
| | - Eric Jacobson
- Department of Global Health and Social Medicine Harvard Medical School, 641 Huntington Avenue, Boston, MA 02115 USA
| | - Lisa Conboy
- Program in Placebo Studies, Beth Israel Deaconess Medical Center/Harvard Medical School, 330 Brookline Avenue, Boston, MA 02215 USA
- Department of Medicine, Division of General Medicine and Primary Care, Beth Israel Deaconess Medical Center, 330 Brookline Avenue, Boston, MA 02215 USA
| | - Anthony Lembo
- Department of Medicine, Division of Gastroenterology, Beth Israel Deaconess Medical Center, 330 Brookline Avenue, Boston, MA 02215 USA
- Program in Placebo Studies, Beth Israel Deaconess Medical Center/Harvard Medical School, 330 Brookline Avenue, Boston, MA 02215 USA
| | - Roger B. Davis
- Program in Placebo Studies, Beth Israel Deaconess Medical Center/Harvard Medical School, 330 Brookline Avenue, Boston, MA 02215 USA
- Department of Medicine, Division of General Medicine and Primary Care, Beth Israel Deaconess Medical Center, 330 Brookline Avenue, Boston, MA 02215 USA
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Abstract
Placebos are often used by clinicians, usually deceptively and with little rationale or evidence of benefit, making their use ethically problematic. In contrast with their typical current use, a provocative line of research suggests that placebos can be intentionally exploited to extend analgesic therapeutic effects. Is it possible to extend the effects of drug treatments by interspersing placebos? We reviewed a database of placebo studies, searching for studies that indicate that placebos given after repeated administration of active treatments acquire medication-like effects. We found a total of 22 studies in both animals and humans hinting of evidence that placebos may work as a sort of dose extender of active painkillers. Wherever effective in relieving clinical pain, such placebo use would offer several advantages. First, extending the effects of a painkiller through the use of placebos may reduce total drug intake and side effects. Second, dose-extending placebos may decrease patient dependence. Third, using placebos along with active medication, for part of the course of treatment, should limit dose escalation and lower costs. Provided that nondisclosure is preauthorized in the informed consent process and that robust evidence indicates therapeutic benefit comparable to that of standard full-dose therapeutic regimens, introducing dose-extending placebos into the clinical arsenal should be considered. This novel prospect of placebo use has the potential to change our general thinking about painkiller treatments, the typical regimens of painkiller applications, and the ways in which treatments are evaluated.
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Osemeke NP, Hart OC, Cosmas NM, Ohumagho IA. Geriatric Prescription in a Nigerian Tertiary Hospital. J Basic Clin Pharm 2017; 8:20-24. [PMID: 28104970 PMCID: PMC5201059 DOI: 10.4103/0976-0105.195086] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Objectives: To assess the medications prescribed for elderly inpatients on specific days during hospital admission with a view to detecting areas of irrational prescription. Methods: It was a prospective study of all patients aged 65 years and above admitted to the medical wards of a Nigerian tertiary hospital over a 12-month period. The World Health Organization/International Network of Rational Use of Drugs (WHO/INRUD) drug use indicators were used to assess drug prescriptions on various days of admission. Results: A total of 1513 patient encounters involving 345 patients aged between 65 and 92 years were assessed on hospital days 1, 3, 5, 7, 14, and 28. The average number of medicines per encounter ranged from 6.1 ± 2.5 on hospital day 1 to 7.8 ± 2.4 on hospital day 28. This difference was statistically significant (F = 14.42; P < 0.05). The percentage of encounters with an antibiotic prescribed ranged from 50.4% on hospital day 1 to 62.9% on hospital day 28 while the percentage of encounters with an injection prescribed decreased from 72.8% on hospital day 1 to 50.0% on day 28. Conclusions: This study suggests some degree of irrational prescribing as evident by the high average number of medicine per encounter and the high percentages of encounters with an antibiotic or injection prescribed. However, there is a need to develop standard values for the WHO/INRUD indicators based on the recently published national treatment guidelines for common elderly diseases which will serve as yardsticks to assess elderly inpatients prescriptions using WHO/INRUD core indicators in future studies.
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Affiliation(s)
- Nwani Paul Osemeke
- Department of Medicine, Clinical Pharmacology and Therapeutics Unit, Nnamdi Azikiwe University Teaching Hospital, Nnewi, Nigeria
| | - Onwukwe Chikezie Hart
- Department of Medicine, Endocrine Unit, Nnamdi Azikiwe University Teaching Hospital, Nnewi, Nigeria
| | - Nwosu Maduaburochukwu Cosmas
- Department of Medicine, Neurology Unit, Nnamdi Azikiwe University Teaching Hospital, Nnewi, Anambra State, Nnewi, Nigeria
| | - Isah Ambrose Ohumagho
- Department of Medicine, Clinical Pharmacology and Therapeutics Unit, University of Benin Teaching Hospital, Benin City, Edo State, Nigeria
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Petkovic G, Charlesworth JEG, Kelley J, Miller F, Roberts N, Howick J. Effects of placebos without deception compared with no treatment: protocol for a systematic review and meta-analysis. BMJ Open 2015; 5:e009428. [PMID: 26610763 PMCID: PMC4663432 DOI: 10.1136/bmjopen-2015-009428] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
INTRODUCTION Placebos have long provided a robust control for evaluating active pharmacological preparations, but frequently demonstrate a variable therapeutic effect when delivered in double-blinded placebo-controlled trials. Delivery of placebos as treatment alone has been considered unethical, as it has been thought that deception is essential for their effect. However, recent evidence suggests that clinical benefit can be derived from placebos delivered without deception (unblinded/open-label) manner. Here, we present a protocol for the first systematic review and meta-analysis of studies of the effects of non-deceptive placebos compared with no treatment. METHODS AND ANALYSIS This protocol will compare the effect of placebos delivered non-deceptively to no treatment. It will also assess the methods of delivery used for non-deceptive placebos. Studies will be sought through relevant database searches and will include those within disease settings and those among healthy controls. To be included, trials must include both non-deceptive (open-label) placebo and no treatment groups. All data extraction and analysis will be conducted by two independent reviewers. The analysis will evaluate any differences in outcome measures between the non-deceptive placebo and no treatment groups. Outcome measures will be the clinically-relevant outcomes detailed in the primary papers. The delivery methods, such as verbal instructions, which may provide positive expectations and outcomes, of non-deceptive placebos will also be assessed. Each study will be comprehensively assessed for bias. Subgroup analyses will identify any discrepancies among heterogeneous data. ETHICS AND DISSEMINATION This review does not require ethical approval. The completed review will be widely disseminated by publication and social media where appropriate. This protocol has been registered on PROSPERO (2015:CRD42015023347).
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Affiliation(s)
- Grace Petkovic
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | | | - John Kelley
- Psychiatry Department, Massachusetts General Hospital/Harvard Medical School, Boston, Massachusetts, USA
- Psychology Department, Endicott College, Beverly, Massachusetts, USA
| | - Franklin Miller
- Department of Bioethics, Clinical Center, National Institutes of Health, Bethesda, Maryland, USA
| | - Nia Roberts
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Jeremy Howick
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
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When and why placebo-prescribing is acceptable and unacceptable: a focus group study of patients' views. PLoS One 2014; 9:e101822. [PMID: 25006673 PMCID: PMC4089920 DOI: 10.1371/journal.pone.0101822] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2014] [Accepted: 06/12/2014] [Indexed: 01/18/2023] Open
Abstract
Background Surveys of doctors suggest that they use placebos and placebo effects clinically to help patients. However, patients' views are not well-understood. We aimed to identify when and why placebo-prescribing in primary care might be acceptable and unacceptable to patients. Methods A purposive diverse sample of 58 English-speaking adults (18 men; aged 19–80 years) participated in 11 focus groups. Vignettes describing doctors prescribing placebos in primary care were used to initiate discussions. Data were analyzed inductively. Results Participants discussed diverse harms and benefits of placebo-prescribing for individual patients, carers, healthcare providers, and society. Two perspectives on placebo-prescribing were identified. First, the “consequentialist” perspective focused on the potential for beneficial outcomes of placebo-prescribing. Here, some participants thought placebos are beneficial and should be used clinically; they often invoked the power of the mind or mind-body interactions. Others saw placebos as ineffective and therefore a waste of time and money. Second, the “respecting autonomy” perspective emphasized the harms caused by the deceptive processes thought necessary for placebo-prescribing. Here, participants judged placebo-prescribing unacceptable because placebo-prescribers deceive patients, thus a doctor who prescribes placebos cannot be trusted and patients' autonomy is compromised. They also saw placebo-responders as gullible, which deterred them from trying placebos themselves. Overall, the word “placebo” was often thought to imply “ineffective”; some participants suggested alternative carefully chosen language that could enable doctors to prescribe placebos without directly lying to patients. Conclusions Negative views of placebos derive from beliefs that placebos do not work and/or that they require deception by the doctor. Positive views are pragmatic in that if placebos work then any associated processes (e.g. mechanisms, deception) are deemed unimportant. Public education about placebos and their effects is warranted and research to identify optimal ways of harnessing placebo effects in clinical practice is needed.
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Moerman DE. Society for the Anthropology of Consciousness Distinguished Lecture: Consciousness, “Symbolic Healing,” and the Meaning Response. ANTHROPOLOGY OF CONSCIOUSNESS 2012. [DOI: 10.1111/j.1556-3537.2012.01061.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Avins AL, Cherkin DC, Sherman KJ, Goldberg H, Pressman A. Should we reconsider the routine use of placebo controls in clinical research? Trials 2012; 13:44. [PMID: 22540350 PMCID: PMC3404895 DOI: 10.1186/1745-6215-13-44] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2011] [Accepted: 04/27/2012] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Modern clinical-research practice favors placebo controls over usual-care controls whenever a credible placebo exists. An unrecognized consequence of this preference is that clinicians are more limited in their ability to provide the benefits of the non-specific healing effects of placebos in clinical practice. METHODS We examined the issues in choosing between placebo and usual-care controls. We considered why placebo controls place constraints on clinicians and the trade-offs involved in the choice of control groups. RESULTS We find that, for certain studies, investigators should consider usual-care controls, even if an adequate placebo is available. Employing usual-care controls would be of greatest value for pragmatic trials evaluating treatments to improve clinical care and for which threats to internal validity can be adequately managed without a placebo-control condition. CONCLUSIONS Intentionally choosing usual-care controls, even when a satisfactory placebo exists, would allow clinicians to capture the value of non-specific therapeutic benefits that are common to all interventions. The result could be more effective, patient-centered care that makes the best use of both specific and non-specific benefits of medical interventions.
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Affiliation(s)
- Andrew L Avins
- Northern California Kaiser-Permanente Division of Research, 2000 Broadway, Oakland, CA 94612, USA.
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Abstract
Psychoanalysis, psychodynamic psychotherapy, and the other talking cures claim to help clients acquire insight into their selves. With insight, the unruly forces that govern lives and that make people strangers to themselves finally come to be understood and rendered subject to conscious control. These insights, it is claimed, are true, and fit the facts like a key fits a lock; they are not merely coherent fictions or confabulated cause-and-effect stories designed to please clients. But is this credible? The argument developed here is that some of the therapeutic changes in the talking cures are functions of placebos that rally the mind's native healing powers in much the same way that placebo pills rally the body's native healing powers and that some of these placebos are insight placebos. The talking cures rightfully claim that it is only talking with others that unlocks the soul and opens it up to ways of self-knowing and to caring for self that would otherwise be unavailable, but they fail to acknowledge the presence of placebo effects, and they operate with restrictive models of dialogue that may unintentionally encourage placebo effects and cognitive suggestibility.
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Affiliation(s)
- David A Jopling
- Department of Philosophy, York University, Toronto, Ontario, Canada.
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Miller FG, Colloca L. The placebo phenomenon and medical ethics: rethinking the relationship between informed consent and risk-benefit assessment. THEORETICAL MEDICINE AND BIOETHICS 2011; 32:229-243. [PMID: 21479794 DOI: 10.1007/s11017-011-9179-8] [Citation(s) in RCA: 55] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
It has been presumed within bioethics that the benefits and risks of treatments can be assessed independently of information disclosure to patients as part of the informed consent process. Research on placebo and nocebo effects indicates that this is not true for symptomatic treatments. The benefits and risks that patients experience from symptomatic treatments can be shaped powerfully by information about these treatments provided by clinicians. In this paper we discuss the implications of placebo and nocebo research for risk-benefit assessment and informed consent.
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Affiliation(s)
- Franklin G Miller
- Department of Bioethics Clinical Center, National Institutes of Health, Building 10, Bethesda, MD 20892-1156, USA.
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Colloca L, Miller FG. Harnessing the placebo effect: the need for translational research. Philos Trans R Soc Lond B Biol Sci 2011; 366:1922-30. [PMID: 21576150 PMCID: PMC3130404 DOI: 10.1098/rstb.2010.0399] [Citation(s) in RCA: 85] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Laboratory research recently has greatly enhanced the understanding of placebo and nocebo effects by identifying specific neuromodulators and brain areas associated with them. However, little progress has been made in translating this knowledge into improved patient care. Here, we discuss the limitations in our knowledge about placebo (and nocebo) effects and the need for translational research with the aim of guiding physicians in maximizing placebo effects and minimizing nocebo effects in their routine clinical practice. We suggest some strategies for how, when and why interventions to promote beneficial placebo responses might be administered in the clinical setting.
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Affiliation(s)
- Luana Colloca
- National Center for Complementary and Alternative Medicine (NCCAM), National Institutes of Health, Bethesda, MD, USA.
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Ferentzi E, Köteles F, Bárdos G. The use of placebos in medical practice. A questionnaire survey among GPs of Hungary. ACTA ACUST UNITED AC 2011. [DOI: 10.1556/cemed.5.2011.2.2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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Abstract
If placebos have been squeezed out of medicine to the point where their official place in in clinical trials designed to identify their own confounding effect, the placebo effect nevertheless thrives in psychotherapy. Not only does psychotherapy dispose of placebo effects that are less available to medicine as it becomes increasingly technological and preoccupied with body parts, but factors of the sort inhibiting the use of placebos in medicine have no equivalent in psychology. Medicine today is disturbed by the placebo effect in a way psychotherapy is not. Psychotherapy does not have to grapple with such a disconcerting paradox as successful sham surgery, and unlike those physicians who once pretended to treat the patient's body while actually attempting to treat the mind, the psychotherapist can treat the mind in all frankness. Perhaps it is because psychotherapy is less burdened by doubts about the placebo effect that it was able to come to its aid when it was orphaned by medicine. It is vain to expect something with so long a history as the placebo effect to disappear from the practices of healing.
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Miller FG, Colloca L. The legitimacy of placebo treatments in clinical practice: evidence and ethics. THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2009; 9:39-47. [PMID: 20013499 DOI: 10.1080/15265160903316263] [Citation(s) in RCA: 106] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Abstract
Physicians commonly recommend 'placebo treatments', which are not believed to have specific efficacy for the patient's condition. Motivations for placebo treatments include complying with patient expectations and promoting a placebo effect. In this article, we focus on two key empirical questions that must be addressed in order to assess the ethical legitimacy of placebo treatments in clinical practice: 1) do placebo treatments have the potential to produce clinically significant benefit? and 2) can placebo treatments be effective in promoting a therapeutic placebo response without the use of deception? We examine evidence from clinical trials and laboratory experiments bearing on these two questions. The conclusion is reached that based on currently available evidence, it is premature to judge whether placebo treatments are ethically justifiable, with the possible exception of acupuncture for pain relief.
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Affiliation(s)
- Franklin G Miller
- Department of Bioethics Clinical Center, National Institutes of Health, Bethesda, MD 20892-1156, USA.
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Köteles F, Fodor D, Cziboly Á, Bárdos G. Expectations of drug effects based on colours and sizes — The importance of learning. ACTA ACUST UNITED AC 2009. [DOI: 10.1556/cemed.3.2009.1.9] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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Tilburt JC, Emanuel EJ, Kaptchuk TJ, Curlin FA, Miller FG. Prescribing "placebo treatments": results of national survey of US internists and rheumatologists. BMJ 2008; 337:a1938. [PMID: 18948346 PMCID: PMC2572204 DOI: 10.1136/bmj.a1938] [Citation(s) in RCA: 172] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/03/2022]
Abstract
OBJECTIVE To describe the attitudes and behaviours regarding placebo treatments, defined as a treatment whose benefits derive from positive patient expectations and not from the physiological mechanism of the treatment itself. DESIGN Cross sectional mailed survey. SETTING Physicians' clinical practices. PARTICIPANTS 1200 practising internists and rheumatologists in the United States. MAIN OUTCOME MEASURES Investigators measured physicians' self reported behaviours and attitudes concerning the use of placebo treatments, including measures of whether they would use or had recommended a "placebo treatment," their ethical judgments about the practice, what they recommended as placebo treatments, and how they typically communicate with patients about the practice. RESULTS 679 physicians (57%) responded to the survey. About half of the surveyed internists and rheumatologists reported prescribing placebo treatments on a regular basis (46-58%, depending on how the question was phrased). Most physicians (399, 62%) believed the practice to be ethically permissible. Few reported using saline (18, 3%) or sugar pills (12, 2%) as placebo treatments, while large proportions reported using over the counter analgesics (267, 41%) and vitamins (243, 38%) as placebo treatments within the past year. A small but notable proportion of physicians reported using antibiotics (86, 13%) and sedatives (86, 13%) as placebo treatments during the same period. Furthermore, physicians who use placebo treatments most commonly describe them to patients as a potentially beneficial medicine or treatment not typically used for their condition (241, 68%); only rarely do they explicitly describe them as placebos (18, 5%). CONCLUSIONS Prescribing placebo treatments seems to be common and is viewed as ethically permissible among the surveyed US internists and rheumatologists. Vitamins and over the counter analgesics are the most commonly used treatments. Physicians might not be fully transparent with their patients about the use of placebos and might have mixed motivations for recommending such treatments.
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Affiliation(s)
- Jon C Tilburt
- Department of Bioethics, National Institutes of Health, Bethesda, MD 20892, USA.
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Enwere OO, Falade CO, Salako BL. Drug prescribing pattern at the medical outpatient clinic of a tertiary hospital in southwestern Nigeria. Pharmacoepidemiol Drug Saf 2008; 16:1244-9. [PMID: 17868193 DOI: 10.1002/pds.1475] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
PURPOSE Assessment of drug use patterns with World Health Organization (WHO) Drug Use Indicators is becoming increasingly necessary towards promoting rational drug use in the developing countries. This study aimed at assessing the drug prescription pattern at the Medical Outpatient Clinic (MOP), University College Hospital, Ibadan, using some WHO core drug use indicators. METHODS One thousand four hundred and forty-seven patient encounters were reviewed prospectively over a 2-month period. Data were collected from patient case files immediately following consultation in each of the seven subspecialty clinics at the MOP. Prescribed medications were then reviewed for some drug use indicators including cost of medications. Cost was based on the current hospital pharmacy drug-pricing list. RESULTS One thousand three hundred and seven (90.3%) prescriptions from 1447 patient encounters were reviewed. One hundred and forty (9.7%) encounters did not have prescriptions written out. The overall average number of drugs prescribed was 3.2 +/- 1.47. Average percentage of drugs prescribed by generic names was 49.5% +/- 31.2, while average percentage of drugs prescribed from the hospital essential drug list was 96% +/- 14.0. The average cost of medications to patients/day was N = 126.0 +/- 136.0 approximately $0.9 (USD). Results varied between subspecialties. CONCLUSION The low percentage prescription of drugs by their generic name is responsible for the high cost of drugs to patients. Drug use studies are a necessary tool for assessing prescribing patterns in hospitals, recognizing areas for improvement and improving drug prescribing practices in these facilities.
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Affiliation(s)
- O Okezie Enwere
- Department of Clinical Pharmacology, University College Hospital, Ibadan, Oyo State, Nigeria.
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Zhang Z, Wang Y, Wang Y, Xu F. Antiemetic placebo: Reduce adverse drug interactions between chemotherapeutic agents and antiemetic drugs in cancer patients. Med Hypotheses 2008; 70:551-5. [PMID: 17703892 DOI: 10.1016/j.mehy.2007.06.029] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2007] [Accepted: 06/24/2007] [Indexed: 11/24/2022]
Abstract
Cancer patients receiving chemotherapy often require a wide range of drugs to manage symptoms of their cancer. The adverse drug interactions are common in the field of medical oncology. Chemotherapy-induced nausea and vomiting (CINV) continues to have a considerable effect on the physical and psychological well-being of patients with cancer, despite significant advances in antiemetic drugs since the 1990s. Fortunately, evidence-based interventions suggested that to a certain extent antiemetic effects can be achieved by use of placebo appropriately. Placebo effect can be reinforced by conferring much meaning. Thus physician can replace antiemetic drugs with reinforced meaningful antiemetic placebo to get better prevention and treatment efficacy for CINV while reduce the unnecessary adverse drug interactions induced by antiemetic drugs and chemotherapeutic agents.
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Affiliation(s)
- Zhongyi Zhang
- Department of Clinical Pharmacology, Second Medical College, Southern Medical University, Guangzhou, China
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Hoop JG, Smyth AC, Roberts LW. Ethical issues in psychiatric research on children and adolescents. Child Adolesc Psychiatr Clin N Am 2008; 17:127-48, x. [PMID: 18036483 DOI: 10.1016/j.chc.2007.07.003] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Psychiatric research on children and adolescents is ethically justified by the need to reduce the burden that mental illnesses place on young people, their families, and society. Such research must be conducted with careful attention to the ethical principles of beneficence, justice, and respect for persons. Child and adolescent psychiatrists who collaborate on research trials or advise patients and families about research participation should consider nine domains when evaluating the ethical acceptability of particular protocols. These domains include scientific merit and design; expertise, commitment, and integrity; risks and benefits; confidentiality; participant selection and recruitment; informed consent and decisional capacity; incentives; institution and peer/professional review; and data presentation. Special ethical issues in child and adolescent psychiatry research concern the use of randomized, controlled treatment trials; the informed consent process for research involving adolescents; the therapeutic misconception; and conflicts of interest in physician referrals.
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Affiliation(s)
- Jinger G Hoop
- Department of Psychiatry and Behavioral Medicine, Medical College of Wisconsin, 8701 Watertown Plank Road, Milwaukee, WI 53226, USA.
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Köteles F, Bárdos G. Expectations of drug effects based on colour and size of tablets. ACTA ACUST UNITED AC 2007. [DOI: 10.1556/mental.8.2007.4.2] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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Abstract
Until recently, the gold standard for assessing the efficacy and effectiveness of new medications has been the placebo-control randomized clinical trial (RCT). However, there are serious ethical concerns about placing patients on a placebo when effective treatments exist. Further, if a new agent is tested only against a placebo, there is no guarantee that it is more effective, or even as effective, as an existing agent. For these and other reasons, ethicists and regulatory bodies have said that, under these circumstances, new drugs should be tested against an active agent. There are three types of such trials: superiority, equivalence, and non-inferiority. In superiority trials, the goal is to establish that the new drug is better (i.e., more effective, or with a more benign side-effect profile) than the standard. Because such trials require much larger sample sizes than placebo-control studies, and are rarely required to bring a drug onto market, they are rarely done. In equivalence trials, the aim is to show that the new and standard agents have similar degrees of effectiveness or adverse events. Due to sample size requirements, most studies of new drugs are non-inferiority trials, in which it is sufficient to demonstrate that the new drug is not significantly worse than the existing ones. However, there are methodological concerns with equivalence and non-inferiority trials, including (a) an inability to determine if the drugs were equally good or equally bad; (b) poorly executed trials with low power can be mistaken for "proving" equivalence or non-inferiority; (c) the equivalence interval is arbitrary; (d) successive non-inferiority trials may lead to a gradual reduction in effectiveness; and (e) often larger trials are necessary. The paper also discusses "add on trials." It is recommended that, even when existing drugs exist, trials should consist of at least three arms, one of which is a placebo. This paper briefly considers the ethics of placebo, and conditions are stated under which such studies can be conducted.
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Affiliation(s)
- David L Streiner
- Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada
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Koshi EB, Short CA. Placebo theory and its implications for research and clinical practice: a review of the recent literature. Pain Pract 2007; 7:4-20. [PMID: 17305673 DOI: 10.1111/j.1533-2500.2007.00104.x] [Citation(s) in RCA: 89] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Although placebo effect is a common phenomenon in medicine and research, its mechanisms are not well understood. With the advent of modern medicine, placebo became a symbol for an outdated, morally questionable practice implying deceit and paternalism. However, in recent years, there has been an increasing amount of rigorous research into the mechanisms of placebo response and placebo analgesia with most studies coming from the field of pain medicine. New theories on placebo mechanisms have shown that placebo represents the psychosocial aspect of every treatment and the study of placebo is essentially the study of psychosocial context that surrounds the patient. Therefore, its understanding is essential for researchers and all medical practitioners, particularly those dealing with patients suffering from pain, depression, and motor disorders. In this article, we review the theories on placebo mechanisms and discuss their implications for clinical practice and the design of clinical trials.
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Affiliation(s)
- Edvin B Koshi
- Pain Management Unit, Department of Anesthesia, Dalhousie University, Queen Elisabeth II Health Sciences Center, Halifax, Nova Scotia, Canada.
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Abstract
The discovery of the endogenous systems of analgesia has produced a large amount of research aimed at investigating their biochemical and neurophysiological mechanisms and their neuroanatomical localization. Nevertheless, the neurobiological acquisitions on these mechanisms have not been paralleled by behavioural correlates in humans--in other words, by the understanding of when and how these endogenous mechanisms of analgesia are activated. Until recent times one of the most studied behavioural correlates of endogenous analgesia was stress-induced analgesia, in which the activation of endogenous opioid systems is known to be involved. By contrast, today the placebo analgesic effect represents one of the best-described situations in which this endogenous opioid network is naturally activated in humans. Therefore, not only is placebo research helpful towards improving clinical trial design and medical practice, but it also provides us with a better understanding of the endogenous mechanisms of analgesia.
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Affiliation(s)
- F Benedetti
- Department of Neuroscience, Clinical and Applied Physiology Programme, University of Turin Medical School, Corso Raffaello 30, 10125 Turin, Italy.
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Abstract
Considerable progress has been made in our understanding of the neurobiological mechanisms of the placebo effect, and most of our knowledge originates from the field of pain and analgesia. Today, the placebo effect represents a promising model that could allow us to shed new light on mind-body interactions. The mental events induced by placebo administration can activate mechanisms that are similar to those activated by drugs, which indicates a similarity between psychosocial and pharmacodynamic effects. These new neurobiological advances are already changing our conception of how clinical trials and medical practice must be viewed and conducted.
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Affiliation(s)
- Luana Colloca
- Department of Neuroscience, Clinical and Applied Physiology Program, University of Turin Medical School, Corso Raffaello 30, 10125 Turin, Italy
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Colloca L, Lopiano L, Lanotte M, Benedetti F. Overt versus covert treatment for pain, anxiety, and Parkinson's disease. Lancet Neurol 2004; 3:679-84. [PMID: 15488461 DOI: 10.1016/s1474-4422(04)00908-1] [Citation(s) in RCA: 325] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
The recent introduction of covert administration of treatment to biomedical research has produced some interesting results, with many clinical and ethical implications. Concealed treatment has been used in people with nervous system conditions including pain, anxiety, and Parkinson's disease. The main finding is that when the patient is completely unaware that a treatment is being given, the treatment is less effective than when it is given overtly in accordance with routine medical practice. The difference between open and hidden administrations is thought to represent the placebo component of the treatment, even though no placebo has been given. The decreased effectiveness of hidden treatments indicates that knowledge about a treatment affects outcome and highlights the importance of the patient-provider interaction. In addition, by use of covert administration, the efficacy of some treatments can be assessed without the use of a placebo and associated ethical issues.
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Benedetti F. Placebos and Treatment of Pain. PAIN MEDICINE 2004. [DOI: 10.1111/j.1526-4637.2004.4046_3.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Affiliation(s)
- Kamal M F Itani
- Michael E. DeBakey Department of Surgery and the Houston VAMC, Houston, Texas, USA.
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40
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Abstract
OBJECTIVES The objectives of this medico-legal case report are to consider the current status of the use of placebos in pain medicine from clinical, ethical, and legal perspectives. The focus of the analysis is a particular case in which the deceptive use of placebo pain therapy on an adolescent gave rise to professional grievances filed by the patient's mother against the physician who ordered and several nurses who administered the placebo. The medical board declined to take disciplinary action against the physician, and disciplinary action by the board of registered nursing against the nurses was successfully challenged by two of the charged nurses in an administrative review. While there is a growing literature that challenges the need for or justification of the deceptive use of placebos, the practice continues and, as the case under consideration indicates, retains some influential supporters. DESIGN This is a case report from a community hospital. The patient, referred to here as KC, was an adolescent with migraine headaches. The substitution of a placebo (saline solution) for an opioid analgesic (morphine) was made during KC's treatment. RESULTS The patient's pain subsided sufficiently following the administration of a placebo to permit his discharge from the hospital. The subsequent discovery by the patient's mother of the deceptive use of a placebo prompted her to file charges of professional misconduct against the treating physician and three nurses with their respective professional licensing boards. The medical board declined to take disciplinary action against the physician, and the disciplinary action by the board of registered nursing was successfully challenged in a ruling by an administrative law judge following a hearing in which expert witnesses took conflicting positions on the acceptability of the deceptive use of a placebo. CONCLUSION While there is a developing literature that challenges the ethical legitimacy of the deceptive use of placebos in pain medicine, that literature has yet to be recognized as unqualifiedly setting the standard of care or of professionalism in medicine and nursing.
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Affiliation(s)
- Ben A Rich
- University of California, Davis School of Medicine, Sacramento, California 95817, USA.
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Ger LP, Chang CY, Ho ST, Lee MC, Chiang HH, Chao CS, Lai KH, Huang JM, Wang SC. Effects of a continuing education program on nurses' practices of cancer pain assessment and their acceptance of patients' pain reports. J Pain Symptom Manage 2004; 27:61-71. [PMID: 14711470 DOI: 10.1016/j.jpainsymman.2003.05.006] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
A hospital-based quasi-experimental (pretest and post-test) study was conducted in Kaohsiung Veteran General Hospital, Taiwan. This study was to evaluate a continuing education program (CEP) on nurses' practices of cancer pain assessment and their acceptance of patients' pain reports with respect to four types of misconceptions. A questionnaire was sent to on-duty nurses or head nurses with patient care responsibilities before the implementation of CEP (n=645) and six months after the program (n=630). The response rates were 92.6% and 91.3% for pretest and post-test surveys, respectively. The CEP was implemented in 8 weeks with four-repeated sessions of 4-hour lectures. A one-day workshop focused on cancer pain assessment and treatment was held 3 months after the four-repeated sessions. Several educational strategies and teaching materials were used in the CEP. The results showed that CEP made statistically significant yet moderate improvement in nurses' practices of pain assessment using pain rating scales (pretest 3.29+/-0.76 vs. post-test 3.48+/-0.75, P<0.001) and acceptance of patient's pain reports without misconceptions on addiction (3.12+/-0.80 vs. 3.39+/-0.90, P<0.001), phantom pain (3.91+/-0.96 vs. 4.07+/-0.92, P=0.005), and placebo testing (3.63+/-0.72 vs. 3.81+/-0.73, P<0.001), except on patient gender-age-related doubts (3.60+/-0.72 vs. 3.67+/-0.77, P=0.109). In order to achieve further improvement, additional follow-up CEP combined with a hospital-wide institutionalization of pain assessment should be promoted and implemented in the future.
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Affiliation(s)
- Luo-Ping Ger
- Department of Medical Education and Research, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
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Biller-Andorno N. The use of the placebo effect in clinical medicine--ethical blunder or ethical imperative? SCIENCE AND ENGINEERING ETHICS 2004; 10:43-50. [PMID: 14986770 DOI: 10.1007/s11948-004-0061-1] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/24/2023]
Abstract
The current debate in medical ethics on placebos focuses mainly on their use in health research. Whereas this is certainly an important topic the discussion tends to overlook another longstanding but nevertheless highly relevant question, namely if and how the placebo effect should be employed in clinical practice. This paper describes the way the placebo effect is perceived in modern medicine and offers some historical reflections on how these perceptions have developed; discusses elements of a definition of the placebo effect; and suggests some conditions under which making use of the therapeutic potential of the placebo effect can be ethically acceptable, if not warranted.
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Affiliation(s)
- Nikola Biller-Andorno
- Department of Medical Ethics and History of Medicine, University of Goettingen, Germany.
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Abstract
Because the "placebo effect" seems to result from "deception," it is often disparaged and despised. Rethinking this and realizing that these benefits flow largely from the meaning of medical encounters (and are far better understood as "meaning responses"); realizing that there need be no deception to elicit them and that they are often very desirable, engaging fundamental human biological pathways, puts the ethical dilemma in a new light. It seems unethical to avoid--to evade--coming to a full understanding of how meaning can so profoundly improve human well-being.
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Chuc NTK, Larsson M, Do NT, Diwan VK, Tomson GB, Falkenberg T. Improving private pharmacy practice: a multi-intervention experiment in Hanoi, Vietnam. J Clin Epidemiol 2002; 55:1148-55. [PMID: 12507680 DOI: 10.1016/s0895-4356(02)00458-4] [Citation(s) in RCA: 63] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
The objective of this study was to assess the effects of a multicomponent intervention on private pharmacy practice. From 641 private pharmacies in Hanoi, 68 pharmacies were randomly selected and matched into 34 pairs. Each pair consisted of a control and an intervention pharmacy. Three interventions were applied sequentially: Regulatory enforcement, Education, and Peer influence. Four tracer conditions were selected: uncomplicated acute respiratory infection (ARI), sexually transmitted disease (STD), requesting the prescription-only drugs prednisolone, and a short course of cefalexin. Practice was assessed through the Simulated Client Method (SCM). The intervention pharmacies improved significantly compared to the control pharmacies (P <.05) in all tracer conditions. For ARI, antibiotic dispensing decreased (P <.02) and questions regarding breathing increased (P <.01). For STD, advice to go to the doctor and dispensing the correct syndromic treatment increased (P <.01). Dispensing of prednisolone and cefalexin decreased (P <.01) and prescription requests increased (P <.01). Our conclusion is that it is possible to improve private pharmacy practice with a multicomponent intervention.
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Papakostas YG, Daras MD. Placebos, placebo effect, and the response to the healing situation: the evolution of a concept. Epilepsia 2001; 42:1614-25. [PMID: 11879377 DOI: 10.1046/j.1528-1157.2001.41601.x] [Citation(s) in RCA: 52] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
In spite of its impressive progress, medicine has been strongly criticized for relying on its modern biomedical tradition to the neglect of the psychosocial aspects of health. This neglect may account for patients' dissatisfaction and eventual use of alternative health approaches. The concept of placebo has sustained dramatic "protean" metamorphoses through the ages. For centuries, placebos have been regarded as powerful deceptive therapies. From the middle of the twentieth century, however, conventional medicine has used placebos as methodologic tools to distinguish the specific from the nonspecific ingredients in treatments. In modern medical research, the double-blind, placebo-controlled, randomized clinical trial has been established as the gold standard for the assessment of any new treatment. Recently a new trend regarding placebos seems to have emerged. The placebo and other nonspecific effects elicited by the "healing situation" have been independently subjected to scientific study. Progress in this area may promote useful clinical applications, enabling physicians to broaden their perspectives on the healing process. We present the historical changes of the concept of placebo and the ethical issues raised by their use.
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Affiliation(s)
- Y G Papakostas
- Department of Psychiatry, Athens University Medical School, Athens, Greece
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Abstract
The use of placebos in clinical trials, particularly in research with mentally ill people, has emerged as a subject of considerable controversy. We first outline ethical aspects of the primary scientific arguments for and against placebo use in research. Three examples of paradoxical aspects of the ethical use of placebos are discussed: involvement of relatively more vulnerable populations, use of apparently "less than standard" therapy, and the omission of information in placebo comparisons. In the current scientific and regulatory context, placebo use in psychiatric research may be necessary for scientific reasons, and when certain conditions are present, it may be justified on ethical grounds. Four key recommendations to facilitate the ethical use of placebos in research trials are presented. We conclude that placebo trials should be undertaken only after careful evaluation of alternative scientific strategies and, as with all human research, with great respect and genuine consideration for the individuals who choose to participate in these protocols.
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Affiliation(s)
- L W Roberts
- Department of Psychiatry, University of New Mexico School of Medicine, Albuquerque, New Mexico 87131-5326, USA
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Affiliation(s)
- D W Ramey
- Ramey Equine, Glendale, CA 91221, USA
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Affiliation(s)
- T C Manschreck
- Dr. John C. Corrigan Mental Health Center, 49 Hillside Street, Fall River, MA 02720, USA
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Weihrauch TR. [Placebo effect in clinical trials]. MEDIZINISCHE KLINIK (MUNICH, GERMANY : 1983) 1999; 94:173-81. [PMID: 10218354 DOI: 10.1007/bf03044850] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
BACKGROUND It is well known that placebos evoke a variety of effects in the human body. It is less known that placebo medication can produce adverse drug reactions (ADRs). METHOD The efficacy and, as the main topic, the tolerability were investigated from an international clinical data pool on placebo-controlled randomized multicenter studies of 5 different groups of indications. The therapeutic areas analyzed were neuropsychiatry (nimodipine, ipsapirone), cardiology (nisoldipine), metabolism (acarbose) and gastroenterology (hydrotalcit). RESULTS The placebo efficacy was evident and varied not only in comparison to 5 indication groups analyzed, but also within them. Placebo showed for example hardly an effect on the symptomatology of stroke patients with a severe neurological deficit in comparison to verum while there was a 50% improvement in symptoms following placebo application in patients with a mild stroke. In angina patients exercise tolerance increased under placebo by 10% (time to onset of ST segment depression and symptoms of angina) while verum showed a 22% improvement. In diabetes placebo had no effect as compared to baseline and to a verum on blood glucose and HbA1C. ADRs could be observed under placebo treatment. The frequency and kind of placebo-induced ADRs varied also between the indication groups, i.e. typical CV side-effects were observed in CV controls. The placebo ADR profile was similar to the reference drug also. Some ADRs were reported even more frequently under placebo than under verum, like "dry mouth" in patients with general anxiety status. CONCLUSIONS Placebo therapy is frequently effective and is not a "non-therapy". Placebo effects can be shown only by direct comparison with a "non-therapy". A placebo therapy is frequently accompanied by adverse drug reactions (ADRs) just as a verum therapy. Placebo ADRs are frequently illness- and verum-specific. Effects and ADRs of placebo therapy must be known, to judge the effect of verum medication in controlled clinical trials. The mechanisms of placebo effects are manifold (e.g. endorphine release, conditioned learning). Since placebo therapy outside of evidence-based medicine (use of drugs without proven efficacy = pseudoplacebos) may potentially also cause serious side effects, the use may not only be useless but also harmful.
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