Time to reflect on open-label placebos and their value for clinical practice

A systematic qualitative review of ethical issues in open label placebo in published research

Open-label placebos (OLPs), which are transparently administered inert treatments, have gained increasing attention in the research community. They have the potential to harness placebo effects without deceiving the patient. The purpose of this study was to examine and synthesize prior research discussing ethical issues in OLPs. A systematic qualitative literature review was conducted (last search on January 2023) across multiple databases (e.g., MEDLINE, Embase, PsycInfo) using keywords related to OLPs. Publications were screened and assessed for eligibility. Seventeen articles explicitly addressing OLP ethics were included. Data were extracted and thematically analyzed following established qualitative content analysis procedures. 37 distinct ethical issues were identified, grouped into five overarching themes: (1) Sociocultural and Contextual Factors, (2) Implementation and Logistics, (3) Informed Consent, (4) Patient Health Behavior and Dynamics, and (5) Therapeutic Relationship. Frequently mentioned concerns focused on uncertainty of OLP efficacy, the need for further research, and complexities of dose-extending OLPs. The effective integration of OLPs into healthcare necessitates thoughtful consideration and responsible communication. This analysis shows that demonstrating the efficacy of OLPs becomes pivotal for their widespread adoption, underscoring the necessity for additional research to validate their effectiveness. This review was pre-registered on January 26th, 2023, in the Open Science Framework Registry under the identifier: DOI https://doi.org/10.17605/OSF.IO/R6NKG .

Noble Humbug? Hard and soft laws on clinical placebo use

Despite the widespread historical and contemporary use of placebos in medicine, legal regulations addressing their administration remain limited in many countries. This paper examines the legal landscape of clinical placebo use, focusing on key jurisdictions such as France, Germany, Switzerland, the United Kingdom, and the United States. Given the ethical and legal complexities surrounding placebo use, a critical assessment of existing regulatory frameworks is essential. This study employs a multidisciplinary approach, analyzing both binding laws ("hard laws") and non-binding principles ("soft laws") related to placebo administration. Data were collected from legal statutes, health institution guidelines, and professional medical codes to map the regulatory environment governing placebos in different legal systems. The results indicate significant variations in how placebos are addressed legally. For instance in Germany and the UK, no specific laws regulate placebo use, but statutes on informed consent implicitly cover their administration. In the United States, the American Medical Association provides ethical guidelines permitting placebo use under strict conditions emphasizing patient welfare and transparency. Across all examined jurisdictions, unauthorized placebo use may lead to legal consequences such as medical fraud allegations or violations of patient rights. These findings highlight the need for explicit regulatory guidelines to ensure that placebo use adheres to ethical and legal standards. The growing acceptance of open-label placebos (OLPs), which demonstrate efficacy without deception, presents a potential avenue for aligning legal frameworks with evolving medical practices. Future regulatory developments should address the ethical and legal challenges associated with placebos, ensuring patient autonomy and informed consent remain central to their use in clinical practice.

Open label placebo for chronic low back pain: a systematic review and meta-analysis of randomized controlled trials

AIM

To assess the therapeutic potential of Open-Label Placebo (OLP) for chronic low back pain (CLBP).

MATERIALS & METHODS

A systematic literature search was conducted on 12 September 2024. Data extraction focused on follow-up and change-from-baseline data of the placebo or control groups. The effect sizes were calculated using the inverse variance statistical method.

RESULTS

A meta-analysis of four articles involving 171 OLP patients and 161 controls demonstrated a modest reduction in pain on the numerical rating scale (Mean difference = -0.62; 95% confidence interval: -1.09 to -0.14; p = 0.01; I2 = 31%). However, according to GRADE, the certainty of evidence for this finding is very low due to methodological limitations of the included studies and potential biases. These findings, even if small, suggest potential benefits of OLP for pain reduction, with clinical relevance of the effect size being important depending on the clinical context and the patient's perspective.

CONCLUSIONS

OLP demonstrated a reduction in pain, with a slightly greater improvement observed during shorter intervention periods. However, the certainty of this evidence remains very low, indicating that these findings should be interpreted cautiously. Future clinical trials are needed to further explore the potential and limitations of this intervention.

PROTOCOL REGISTRATION

www.crd.york.ac.uk/prospero identifier is CRD42024568302.

Preoperative Anxiolysis and Treatment Expectation (PATE Trial): open-label placebo treatment to reduce preoperative anxiety in female patients undergoing gynecological laparoscopic surgery - study protocol for a bicentric, prospective, randomized-controlled trial

One of the most common concerns of patients undergoing surgery is preoperative anxiety, with a prevalence of up to 48%. The effects of preoperative anxiety continue beyond the preoperative period and are associated with more severe postoperative pain and poorer treatment outcomes. Treatment options for preoperative anxiety are often limited as sedatives cause side effects and their efficacy remains controversial. Placebo research has shown that optimization of positive treatment expectations, as can be achieved through placebo administration and education, has clinically relevant effects on preoperative anxiety, pain and treatment outcomes. As the administration of masked placebos raises ethical questions, clinical studies have increasingly focused on the use of open, non-deceptive placebo administration (open-label placebo, OLP). The use of OLPs to reduce preoperative anxiety and modify clinically relevant postoperative outcomes has not yet been investigated. This bicentric, prospective, randomized-controlled clinical trial (PATE Trial; German Registry for Clinical Studies DRKS00033221), an associated project of the Collaborative Research Center (CRC) 289 "Treatment Expectation", aims to alleviate preoperative anxiety by optimizing positive treatment expectations facilitated by OLP. Furthermore, this study examines a potential enhancement of these effects through aspects of observational learning, operationalized by a positive expectation-enhancing video. In addition, patient's perspective on the self-efficacy and appropriateness of OLPs prior to surgery will be assessed. To achieve these objectives, female patients will be randomized into three groups before undergoing gynecological laparoscopic surgery. One group receives the OLP with a positive rationale conveyed by a study physician. A second group receives the same intervention, OLP administration and rationale provided by a physician, and additionally watches a video on OLP presenting a satisfied patient. A third group receives standard treatment as usual (TAU). Outcome measures will be effects on preoperative anxiety and postoperative experience, particularly visceral and somatic postoperative pain. As the non-deceptive administration of placebos; when indicated; may yield positive outcomes without side effects, and as current treatment of preoperative anxiety is limited, evidence from clinical placebo research has the potential to improve outcomes and patient experience in the surgical setting.