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One thing that I have always struggled with is “placebo medicine”. Believe it or not, there is a lot of it around. Placebos are medications that are given to yield a therapeutic benefit that has nothing to do with the chemicals within the pill or effect of the device. The medicine has no curative power by itself. The classic is the sugar pill. Someone suffers from a self limited problem, say the common cold, and requests “medicine”. An inert or powerless pill is given, and yet the illness resolves. Another example is the child who skins her knee and the pain is improved by a parent’s kiss or a band-aid. While the treatment has no power by itself, an improvement is experienced. It works because you think it works, but, if you do a carefully controlled study, there is no or very little treatment effect. No treatment effect has been found with cough suppressants or antihistamines/nasal congestion. Is it “all in your head”? The answer is more complicated that it seems.
Dr. Paul Offit’s book, Do You Believe in Magic? deals with placebos and medical hucksters, both modern and historical, in some depth. It is a fascinating book that I wholeheartedly recommend. He discusses the power of placebos and the body’s reaction to conditioning. Just as Pavlov’s dog learned to salivate whenever a bell was rung, your body can change your immune system and pain regulation if it is properly trained or conditioned. Wounded soldiers who were given saline injections during wartime shortages instead of the morphine pain medicine, not only thought they felt less pain, they did feel less pain. Is this fraud or not? If you benefit from a treatment because you anticipated the benefit, would you feel deceived? Is hope worth purchasing? My own thought is that it depends.
First, it depends on the problem. If the problem is a dangerous one which has proven beneficial treatment, it goes without saying that to withhold such a treatment is criminal. If, however, the problem is not curable or heals on its own, it may be the only treatment that may be reasonable.
The second factor that it depends on is the person. People approach disability, loss of function, and pain differently. For some, it is an obstacle to overcome, a challenge. These people do not need a placebo to help them through their recovery. For others, it is an insurmountable, overwhelming, gloomy prison. The ritual of the placebo may be necessary to reduce the fear of the problem which may be blown out of proportion.
In practice, first approach physical problems and the people attached to them from an educational standpoint. They need help them in understanding their injury and what different treatment options offer them. Is a particular treatment supportive (ice, heat, anti-inflammatory medication) or curative (protection, exercise, surgery)? What are the risks and the benefits?Afterward, some are reassured when they know that their body can heal these things on its own. Others look bewildered. The explanations are re-enforced and questions answered.. They often reply, “Isn’t there something that I can do?” From the standpoint of something curative, there is often not much that gives more than pain relief. These people often need the comfort or the distraction of the placebo.
In order to be effective, placebos must be delivered in a specific manner. Like faith healers or witch doctors, this healing is a ritual. First, the treatment must be specific. An order of treatment is necessary that is sufficiently complicated to require some practice and concentration. If a side-effect is common, this may enhance the placebo. Secondly, the treatment needs to be frequent enough to disrupt the normal routine. Third, it has to be expensive in some way. Certainly, financial cost ethically should be minimized (a doctor should not get rich selling placebos!), but if it is too easy to obtain, or common, or painfree, the effect may be reduced. It is helpful if the placebo has some kind of pain relieving effect-such as ice, heat, ultrasound, wrapping, salt baths, etc, or side-effect, such as euphoria with narcotics. Fourth, the treatment must be delivered with confidence and seriousness and with concern for the person. Beneficial effects have been recorded in 30-60% of cases
I will have to admit that my effectiveness as a doctor probably suffers because I am not a good actor or salesman. It’s just too hard to convince someone of a treatment that I don’t wholehearted believe in. It feels insincere. I’m not sure if I should be proud of this reservation or not.
What do you think? What place does placebo medicine have in the treatment of bone and joint problems? Send me your thoughts. firstname.lastname@example.org.
-Brett Fink, MD.
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