PERSPECTIVES OF THE PLACEBO PHENOMENON: General Medical Effectiveness and Human Biology: Placebo Effects in the Treatment of Ulcer Disease

What Can the Chemical Hold?: The Politics of Efficacy in the Psychedelic Renaissance

Drawing from ethnographic research with psychedelic therapists and researchers, this article explores political tensions between two sources of efficacy within psychedelic therapy: the self and the chemical. At times researchers and therapists emphasize the specificity of chemical effects in relationship to the neurobiology of particular diagnoses. And at other times they foreground the self as the true source of an experience which is not tied to that same biochemistry. Anthropologists have long emphasized that efficacy is a historically and socially embedded category and practice. Those conversations have new valence in light of recent theorization of the chemicals as material-semiotic structures shaped by their experimental contexts. This article argues that while the empirical claims embedded in these two efficacies can and do mutually include each other, a fundamental political tension remains between the efficacious ends envisioned by each. As clinical trials develop these drugs as therapeutic agents, they do so through linking the specific effects of the chemical to particular diagnostic populations, which may enfranchise these chemicals, but not all their efficacies.

Trusting the Dentist—Expecting a Leap of Faith vs. a Well-Defined Strategy for Anxious Patients

This article aimed to set into perspective the unique aspects of trust within the dentist–patient relationship by exploring the literature as well as historical aspects of dentistry in the association between trust/distrust and patient anxiety. In order to characterise this uniqueness, the assumptions for trusting in dentistry are compared and contrasted with other professions using a conceptual analysis. The professions of medicine, sociology, psychology, nursing and dentistry were check listed according to the tenets of a concept analytical approach reported by Hupcey et al., in 2001. Recommendations for patient/person-centred care, as opposed to dentist-centred care, that would improve trust are specified according to the literature. These include empowering patients, practicing active listening, empathy and relationship building that might benefit dental patients in relation to the perceived risks of anxiety or induced pain. It was concluded that global distrust of dominating dentists must give way to person-centred professional strategies so that dentists and patients can tackle their dental anxiety-trust challenges, both in the public’s image of the dental profession and in clinical relationships. Future directions would be to explore incentives for dentists to change to patient/person-centred care.

Polluting pharmaceutical atmospheres: Compulsion, resistance, and symbolism of buprenorphine in Norway

This article offers a counter narrative to the current ethnographic studies on treatment with buprenorphine, in which notions of promised and experienced normality dominate. In some countries, introduction of buprenorphine led to a perceived “normalisation” of opioid substitution treatment, and this new modality was well received. However, in Norway the response has been almost the opposite: patients have reacted with feelings of disenfranchisement, failure, and mistrust. Based on ethnographic fieldwork in Norway, this article offers comparative insight into local experiences and subjectivities in the context of the globalisation of buprenorphine. By outlining the ethnographic description of the pharmaceutical atmosphere of forced transfers to buprenorphine-naloxone, I show that the social history of the medication is as significant as its pharmacological qualities for various treatment effects. An analysis of the reactions to this treatment modality highlights the reciprocal shaping of lived experiences and institutional forces surrounding pharmaceutical use in general and opioids in particular.

Placebo orthodoxy and the double standard of care in multinational clinical research

It has been almost 20 years since the field of bioethics was galvanized by a controversial series of multinational AZT trials employing placebo controls on pregnant HIV-positive women in the developing world even though a standard of care existed in the sponsor countries. The trove of ethical investigations that followed was thoughtful and challenging, yet an important and problematic methodological assumption was left unexplored. In this article, I revisit the famous "double standard of care" case study in order to offer novel consideration of the placebo orthodoxy that underlies much of the ethical debate. This majority view found in medical research is that placebo-controlled trials are methodologically superior to comparative trials that use active controls. I challenge this orthodoxy and argue that lives were unnecessarily lost in these trials as a result. Furthermore, current HIV research on vaccines and microbicides is now poised to repeat the error of subscribing to the placebo orthodoxy.

Questioning the methodologic superiority of 'placebo' over 'active' controlled trials

A resilient issue in research ethics is whether and when a placebo-controlled trial (PCT) is justified if it deprives research subjects of a recognized treatment. The clinicians' moral duty to provide the best available care seems to require the use of 'active' controlled trials (ACTs) that use an established treatment as a control whenever such a therapy is available. In another regard, ACTs are supposedly methodologically inferior to PCTs. Hence, the moral duty of the clinical researcher to use the best methods will favor PCTs. In this target article, I analyze the three reasons for believing that ACTs are inferior to PCTs namely: 1) ACTs lack 'assay sensitivity'; 2) ACTs do not measure absolute effect size; and 3) ACTs require more participants; and I contend that none are acceptable. Consequently the tension between clinical and research ethics dissolves: the moral duty of the clinician to avoid PCTs is unopposed by methodological considerations.

Trust but verify: the interactive effects of trust and autonomy preferences on health outcomes

Patients' trust in their physicians improves their health outcomes because of better compliance, more disclosure, stronger placebo effect, and more physicians' trustworthy behaviors. Patients' autonomy may also impact on health outcomes and is increasingly being emphasized in health care. However, despite the critical role of trust and autonomy, patients that naïvely trust their physicians may become overly dependent and lack the motivation to participate in medical care. In this article, we argue that increased trust does not necessarily imply decreased autonomy. Furthermore, patients with high levels of trust and autonomy preferences are most likely to have the best health outcomes. We propose a framework for understanding simultaneous trust and autonomy preferences and for recognizing their interactive effects on health outcomes in the dynamic medical encounter. This framework argues that policy makers and health care providers should make efforts to foster not only patients' trust but also their preferences for autonomy and thus gain the best position for achieving health-related goals.

Predictors and non-predictors of symptom relief in dyspepsia consultations in primary care

OBJECTIVE

We aimed to evaluate if the course of dyspepsia is influenced by medical consultation in primary care.

DESIGN, SETTING AND PATIENTS

Australian general practitioners (n = 27) recruited 157 dyspeptic patients, of whom 94 were eligible for follow-up. Dyspepsia, comorbidity, quality of life, emotional status, locus of control and consultation satisfaction were measured at baseline and follow-up (mean 3 months).

MAIN OUTCOME MEASURE

Response was defined as improvement of dyspepsia over time on the Nepean Dyspepsia Index score.

RESULTS

Dyspepsia improved in 82% (n = 77). There was no significant change in non-gastrointestinal symptoms. Half were worried or stressed by their symptoms, and 85% wanted reassurance, a need that (univariately) differentiated responders from non-responders (p = 0.02). Most patients seen in primary care with dyspepsia improved. If the doctor believed it was likely that the patient would follow their recommendations, the patient was nearly five times as likely to be a responder (OR 4.9, 95% CI 1.2-19.0). The only other significant predictor was acid suppression therapy (OR 3.5, 95% CI 1.1-10.9).

CONCLUSION

Most primary care visits for dyspepsia are followed by improvement, which may be predicted in part by indicators of patient compliance. Prescription of acid suppression therapy may also improve outcome in dyspepsia.

Clinical attrition due to biased preclinical assessments of potential efficacy

Unless it is carefully controlled, bias often distorts the results of clinical trials, usually exaggerating the magnitude of true efficacy. For that reason, procedures to limit bias have been mandated by the FDA when assessing efficacy in clinical trials. The present review shows that the effects of bias in preclinical studies are at least as large as in clinical trials, and since bias is not usually controlled in preclinical proof of concept studies, compounds that actually have little or no therapeutic potential may often be advanced into clinical trials. This possibility is supported by the fact that lack of efficacy is the single biggest reason why compounds fail in the clinic. The shift to target-based discovery during the last 10-15 years may have further increased the effects of bias on preclinical assessments of potential efficacy, and contributed to the continuing decline in clinical success rates. Procedures are available to control for bias during preclinical assessments of potential efficacy, and their use could dramatically increase clinical success rates and substantially reduce the costs of drug discovery and development.

Circular instead of hierarchical: methodological principles for the evaluation of complex interventions

BACKGROUND

The reasoning behind evaluating medical interventions is that a hierarchy of methods exists which successively produce improved and therefore more rigorous evidence based medicine upon which to make clinical decisions. At the foundation of this hierarchy are case studies, retrospective and prospective case series, followed by cohort studies with historical and concomitant non-randomized controls. Open-label randomized controlled studies (RCTs), and finally blinded, placebo-controlled RCTs, which offer most internal validity are considered the most reliable evidence. Rigorous RCTs remove bias. Evidence from RCTs forms the basis of meta-analyses and systematic reviews. This hierarchy, founded on a pharmacological model of therapy, is generalized to other interventions which may be complex and non-pharmacological (healing, acupuncture and surgery).

DISCUSSION

The hierarchical model is valid for limited questions of efficacy, for instance for regulatory purposes and newly devised products and pharmacological preparations. It is inadequate for the evaluation of complex interventions such as physiotherapy, surgery and complementary and alternative medicine (CAM). This has to do with the essential tension between internal validity (rigor and the removal of bias) and external validity (generalizability).

SUMMARY

Instead of an Evidence Hierarchy, we propose a Circular Model. This would imply a multiplicity of methods, using different designs, counterbalancing their individual strengths and weaknesses to arrive at pragmatic but equally rigorous evidence which would provide significant assistance in clinical and health systems innovation. Such evidence would better inform national health care technology assessment agencies and promote evidence based health reform.

The Ethics and Science of Placebo-Controlled Trials: Assay Sensitivity and the Duhem–Quine Thesis

The principle of clinical equipoise requires that, aside from certain exceptional cases, second generation treatments ought to be tested against standard therapy. In violation of this principle, placebo-controlled trials (PCTs) continue to be used extensively in the development and licensure of second-generation treatments. This practice is typically justified by appeal to methodological arguments that purport to demonstrate that active-controlled trials (ACTs) are methodologically flawed. Foremost among these arguments is the so called assay sensitivity argument. In this paper, I take a closer look at this argument. Following Duhem, I argue that all trials, placebo-controlled or not, rely on external information for their meaningful interpretation. Pending non-circular empirical evidence that we can trust the findings of PCTs to a greater degree than the findings of ACTs, I conclude that the assay sensitivity argument fails to demonstrate that placebo-controlled trials are preferable, methodologically or otherwise, to active-controlled trials. Contrary to the intentions of its authors, the fundamental lesson taught by the assay sensitivity argument is Duhemian: the validity of all clinical trials depends on external information.

Placebo effect in the treatment of duodenal ulcer

AIMS

To assess whether frequency of placebo administration is associated with duodenal ulcer healing.

METHODS

A systematic literature review of randomized clinical trials was undertaken. 79 of 80 trials that met the inclusion criteria. The pooled 4 week placebo healing rate of all duodenal ulcer trials that employed a four times a day regimen was compared with the rate obtained from trials with a twice a day regimen.

RESULTS

The pooled 4 week healing rate of the 51 trials with a four times a day regimen was 44. 2% (805 of 1821 patients) compared with 36.2% (545 of 1504 patients) in the 28 trials with a twice a day regimen (difference, 8.0% [equal effects model]; 95% confidence interval, 4.6% to 11.3%). Depending on the statistical analysis, the rate difference ranged from 6.0% (multivariable random effects model) to 8.0% (equal effects model). A number of sensitivity analyses showed comparable differences between the two regimens. Most of these sensitivity analyses were not significant, probably because a number of trials were excluded resulting in a loss of power.

CONCLUSIONS

We found a relation between frequency of placebo administration and healing of duodenal ulcer. We realize that the comparison was based on nonrandomized data. However, we speculate that the difference between regimens was induced by the difference in frequency of placebo administration. A better knowledge of various placebo effects is required in order to make clinically relevant assessments of treatment effects derived from placebo-controlled trials.

Auditory Integration Training: The Magical Mystery Cure

Since its introduction in this country at the beginning of the decade, auditory integration training (AIT) has generated enthusiasm in parents and some clinicians, and harsh criticism by others. AIT has been promoted as a non-invasive treatment for auditory disorders that are believed to lead to attention and behavior problems. It has been particularly popular as a treatment for autism. Although parents cite numerous anecdotal reports of treatment success, many professionals frown on AIT's widespread practice prior to undergoing scientific scrutiny. The reasons for cautious evaluation of AIT prior to implementation in clinical practice are reviewed, along with a brief summary of current research findings.

Doctors' attitudes towards empirical data--a comparative study

In the assessment of the effects of medical technologies, the focus is most often on the quality of the empirical data. In order to shed light on the question whether medical researchers are really so empirically oriented we conducted the following study. 600 questionnaires were sent by mail to three groups, selected at random: 1) pre-clinical researchers; 2) clinical researchers who received research grants from The Swedish Medical Research Council; and 3) general practitioners. The questionnaire was built around three cases concerning the assessment of the effects of: a) H-2-receptor antagonists, b) coronary by-pass surgery and c) the homeopathic treatment of hay fever. The results indicate that there are rather small differences in how the three groups assessed the three technologies and larger differences within one and the same group concerning different cases. The tendency is that the more one considers that empirical data should be assessed independent of theoretical considerations, the higher are the demands which are placed on the quality and quantity of the empirical documentation, and vice-versa.

THE ANTHROPOLOGY OF PHARMACEUTICALS: A Biographical Approach

▪ Abstract  This review discusses pharmaceuticals as social and cultural phenomena by following their “life cycle” from production, marketing, and prescription to distribution, purchasing, consumption, and finally their efficacy. Each phase has its own particular context, actors, and transactions and is characterized by different sets of values and ideas. The anthropology of pharmaceuticals is relevant to medical anthropology and health policy. It also touches the heart of general anthropology with its long-time interest in the concepts of culture vs nature, symbolization and social transformation, and its more recent concerns with the cultural construction of the body and processes of globalization and localization. The study of transactions and meanings of pharmaceuticals in diverse social settings provides a particularly appropriate empirical base for addressing these new theoretical issues.

Placebo effects. Issues for clinical practice in psychiatry and medicine

Placebo effects are integral to everyday clinical practice; therefore, they should be well understood by all health care practitioners. Despite the rich literature on the topic, placebo effects receive only passing mention in major textbooks of psychiatry and medicine. The authors clarify the placebo construct and offer a selective review of its history, definitions, mechanisms, and relation to experimental methodology and statistics. Also considered are the concept of nocebo, variation in placebo response rates, and some economic and ethical problems with placebos in clinical trials. Directions are suggested for future research.

Placebo effect and randomized clinical trials

The achievement of optimal therapeutic results presupposes the use of appropriate treatment combined with maximal utilization of placebo effects. These aims may sometimes be difficult to satisfy in randomized clinical trials (RCTs). The question thus arises whether there is a conflict between the goals of therapy and those of experimental research; and if so, to what extent, and how is it handled in practice by clinicians and researchers. Various ethical problems have been discussed in several reports connected with RCTs. But we have found no discussion concerning the conflict between obtaining informed consent and promoting optimal placebo effects. Information about RCTs can be given in various ways. Sometimes appropriate information about RCTs to patients involves non-optimal utilization of placebo effects. This gives rise to ethical and methodological problems, which are discussed in this article.

Is the effect of alternative medical treatment only a placebo effect?

A common assertion about alternative medical technologies is that their results are solely built upon the placebo effect. The reason for this assertion is due to the facts that the placebo effect is perceived as an irrational quantity, and that the placebo effect is considered unspecific. If it is possible to rehabilitate the placebo effect by interpreting it as a specific effect, what consequences would it have for school medicine and the view of certain alternative medical technologies? To answer these questions it is necessary to investigate just what sort of phenomenon the placebo effect is, and what determines its dimensions.

Theoretical and empirical problems in the assessment of alternative medical technologies

Critical situations help to clarify and define otherwise indistinct and vague phenomena. The paradigm-collision which occurs when assessing alternative medical phenomena against the background of a medical school paradigm is analogous to a critical situation. An analysis of the conditions for such an appraisal has helped to highlight aspects which are not normally ascribed any great significance in the assessment of technology. It turns out that theoretical requirements, the specific concept and certain irrational elements play a large role in the assessment of medical and alternative medical technology. One conclusion is that in the appraisal of e.g. alternative medical technology, one must take into account these conditions for forming a judgement, as a basic requirement for an objective appraisal of the technology in question.

The Symbolic Power of the Modern Personal Physician: The Placebo Response under Challenge

The change in a patient's condition that results from the meaning or symbolism of the encounter with the physician, rather than from the pharmacologic properties of the interventions used, constitutes the placebo response. Placebo research suggests that the placebo response forms a part of virtually all healing encounters, and is not limited to circumstances in which a “dummy” pill is used. This suggests, in turn, that the placebo effect has been important in medicine throughout history, and that the modern physician has important elements in common with her “pre-scientific” predecessors. Historical analysis of the meaning of the healing encounter for physician and patient suggests that the personal physician, as symbolizing a human intermediary between the impersonal forces of science and the suffering patient, remains an important ingredient even in modern technological medicine. Contemporary forces toward depersonalization of medical care may threaten this dimension of treatment, but appropriate research may measure those elements of the physician encounter that most effectively promote a positive placebo response.

Principles of irrational drug therapy

Drugs are extensively used in medicine when they are unlikely to produce a benefit to the patient. In most instances this does no apparent harm to the patient but sometimes (for example, the extensive use of thorotrast) the results are tragic. Even when the patient is not injured, overuse of medicines is an undesirable and money-wasting behavioral pattern. Several factors relating to the social process of drug use which encourage overprescribing are discussed and the Principles of Irrational Drug Therapy are derived. These principles are presented as negative role models for the use of medicines in developing countries.