The Power of Placebo

In a recent issue of the New Yorker, long-time staff writer Michael Specter explored the nature of the placebo effect in medicine, primarily by describing the work of Ted Kaptchuk, who directs Harvard University’s Program in Placebo Studies and the Therapeutic Encounter (PiPS). The program’s mission is “to examine the placebo response and the implications of medical ritual, the patient-provider relationship, cultural context, and the power of imagination and hope in the healing process. Through endeavors in the clinical, basic, and social sciences, bioethics, the history of science and philosophy, PiPS seeks to elucidate, quantify, optimize and reaffirm the humanistic and more intangible dimensions of health care.”

Kaptchuk, who studied Chinese medicine in Macau and practiced acupuncture for many years, is arguing for a shift in contemporary medicine away from high-tech and pure science to a greater emphasis on healing. Having recently received funding from the National Institutes of Health, he and his colleagues are undertaking neuroimaging and molecular studies to understand the biological underpinnings of the placebo response.

In one study, he and his group acknowledged that a problem in directly exploring the placebo effect in a clinical setting was the use of deception — not letting patients and providers know of they are receiving an active drug or not. So they designed a randomized study in which patients with irritable bowel syndrome were given pills they were told were “an inert substance, like sugar pills” or no treatment. After 21 days, patients given the placebo had significantly different changes on global improvement scores (5 versus 3.9, P=0.002) and symptom severity (P=0.03).

In another study, patients with asthma were randomized to treatment with an albuterol inhaler, a placebo inhaler, sham acupuncture, or no treatment. The albuterol group experienced 20% improvement in forced expiratory volume in one second (FEV₁) measured on spirometry, and the other three groups all improved by 7%. However, when patients were asked if they felt better, 50% on albuterol reported improvements, as did 45% of those using the placebo inhaler, and 46% of those who had sham acupuncture, compared with only 21% of those who had no treatment (P<0.001). The researchers concluded that, while objective measures such as FEV1 are important in asthma care, “other outcomes such as emergency room visits and quality-of-life metrics may be more clinically relevant to patients and physicians.”

Specter concludes his article with a personal anecdote. He had been experiencing chest pain and was worried, being an overstressed middle-aged man, so went to his doctor, who conducted a careful examination. The physician told him he was fine, but needed to relax — and the pain simply disappeared. This was an example of “exactly the type of ritual that, according to Kaptchuk, will have to play a critical role in the future of American health care.

So what do you think should be the role of placebo — if any — in tomorrow’s medicine?

Original article: The Power of Placebo http://bit.ly/t39hKo from @medpagetoday

Placebo Effect Powerful in Asthma

This article was originally posted on Medpagetoday.com

Asthma inhalers have a real impact on airways, but the symptom relief isn't any greater than that achieved with placebos, researchers found.

Stable asthma patients reported the same degree of symptom improvement with inhalation of albuterol as occurred with a placebo inhaler or sham acupuncture (50%, 45%, and 46% improvement, respectively, P=NS) in a blinded pilot study led by Michael E. Wechsler, MD, of Harvard and Brigham and Women's Hospital in Boston.

All three were equally better than no treatment at all (21% improvement, P<0.001), they reported in the July 14 issue of the New England Journal of Medicine.

"Placebo effects can be clinically meaningful and can rival the effects of active medication in patients with asthma," the group concluded in the paper.

Yet the results also suggested that physicians need to keep a close eye on objective measures of asthma control, Wechsler and colleagues noted.

Albuterol had a strong objective effect on airflow, with a mean 20% improvement in forced expiratory volume in 1 second (FEV₁) -- nearly three times the 7% boost seen in all three other groups (P<0.001).

But "patients could not reliably detect the difference between this robust effect of the active drug and the effects of inhaled placebo and sham acupuncture," the researchers warned.

So "subjective improvement in asthma should be interpreted with caution and objective outcomes should be more heavily relied on for optimal asthma care," they recommended.

However, patients' subjective experiences are not wrong simply because they don't fit the objective facts of FEV₁ and actually should trump physician judgment in such symptom-defined conditions, Daniel E. Moerman, PhD, of the University of Michigan in Dearborn, argued in an accompanying editorial.

"It is the subjective symptoms that brought these patients to medical care in the first place," he wrote. "They came because they were wheezing and felt suffocated, not because they had a reduced FEV₁."

A treatment should be acceptable as long as it yields significant improvement for patients, has a reasonable cost, and doesn't have negative effects over the short or long term, Moerman suggested.

The study included 46 patients randomized to double-blind treatment with an albuterol inhaler, a placebo inhaler, sham acupuncture, or no intervention administered in a crossover design during a total of 12 sequential office visits three to seven days apart after a washout period for short- and long-acting bronchodilators.

The no-intervention group acted as a control for the placebo groups, which few prospective studies have tried, the researchers noted.

The most likely explanation for the greater efficacy of placebo was expectation of improvement as "the mere ritual of treatment may affect patients' self-monitoring and subjective experience of their disease," they wrote.

The study was limited by use of a nonvalidated subjective measure of asthma symptom improvement that didn't include a measure of worsening as well as by unknown generalizability to chronic asthma, the group cautioned.

Original article can be found here