MELBOURNE, Australia – Chris Maher has spent decades as a physiotherapist and clinical researcher and knows firsthand how difficult it can be to treat back pain. The causes of the condition are often complex or uncertain, and treatments can be ineffective or even harmful.
So when he heard that a group of researchers, including scientists at Harvard, were claiming that back pain could be relieved by prescribing placebos — pills with no active ingredient — he was concerned the claims were exaggerated. “It all seemed like snake oil to me,” he said.
for dr. Maher, a professor at the University of Sydney’s School of Public Health, is just one example of a disturbing trend in modern medicine. In recent years, more and more researchers have argued that placebos are effective not only in pharmaceutical studies — their most common use — but also in clinical treatments prescribed to relieve conditions such as chronic pain, chronic fatigue, asthma and depression.
When new drugs are clinically tested, some participants with a health condition receive the real cure, while others receive an inactive control – a placebo. Curiously, some of those who received the placebo report still feeling better for a variety of reasons. These are called placebo effects.
Researchers have long been fascinated by the phenomenon’s apparent potential in treating a range of conditions. In studies, they argue that placebos have remarkable, if poorly understood, curative effects, even when patients are fully aware that they are taking inert pills. In studies, doctors report widespread use of placebos, especially for patients with complex conditions for which there is no clear cure.
But in a recent article in the Medical Journal of Australia, Dr. Maher said the medical community has become enthralled with the idea of ”considering placebos mysterious and highly effective,” even with little evidence of their efficacy in clinical care.
Much of the research, says Dr. Maher, has significant flaws that inflate the potency and reliability of placebos as therapies. These errors, he says, could further entrench the clinical use of placebos when proven treatments remain available, encouraging entrepreneurs trying to monetize the online sale of placebo pills.
“The idea that we can use placebos as a panacea for a range of health problems is really problematic,” he said. “It’s bad for science and bad for patients.”
Perhaps the most famous attempt to measure the power of placebos as a clinical treatment was undertaken by Henry Beecher, a pioneering American anesthesiologist. In the 1950s, he conducted a series of 15 studies, finding that 35 percent of 1,082 patients with various conditions experienced pain relief from placebos.
In the decades following Dr. Beecher, researchers investigated what caused this effect. Some suggested it was primarily psychological – a case of mind over matter – while others suggested a possible biological origin. Scientists found that naloxone, a drug developed for opioid overdose patients, partially prevented placebo effects, suggesting that the pain relief experienced after taking a placebo may be produced in part by opioid receptors in the central nervous system. activate the nervous system.
By the time Dr. Maher completed his training in physical therapy in the 1980s, Dr. Beecher’s afflictions were already ingrained in medical folklore, even leaking into popular culture.
dr. Maher recalls an M*A*S*H episode in which the medics filled capsules with sugar scraped from donuts to give to wounded soldiers after the morphine supply ran out. “Like everyone else, I just accepted that it could actually work,” he said.
His opinion changed after 2001, when two Danish researchers, Asbjorn Hrobjartsson and Peter C. Gotzsche, published an article in the New England Journal of Medicine claiming that medical studies had exaggerated placebo effects. They identified what they believed to be a flaw in the study design: Many failed to compare patients who had received placebos with a control group of patients who had not.
In such studies, the Danish researchers argued, it was impossible to know whether it was the placebo that worked or something completely different, such as natural healing. When they looked at studies that compared placebo groups to groups without treatment, they found that the placebo effect more or less disappeared.
The paper kicked off a debate about study design in placebo research. dr. Maher, who was then working in clinical research at the University of Sydney, was initially convinced that the Danish researchers had made a mistake. But when he and one of his students replicated their research, they got essentially the same result.
Still, Dr. Maher in the years that followed saw research describing the therapeutic benefits of placebos for a range of conditions: nausea, hypertension, rheumatoid arthritis and even Parkinson’s tremors.
Much of the more extraordinary research has come out of the program in Placebo Studies and Therapeutic Encounter at Harvard Medical School, an institute founded in 2011. The program’s director, Ted Kaptchuk, has published studies and editorials on the therapeutic potential of open-label placebos — those that are honestly described to patients as inert.
for dr. Maher this was a red flag. If placebos work at all, he said, it is through trickery, instilling an expectation of benefit in the patient’s mind. While going through the research, Dr. Maher argued that the reported benefits of open-label placebos were often artifacts of the same methodological flaw highlighted by the Danish researchers in 2001.
In one study, a team of researchers, including Professor Kaptchuk, reported that a three-week course of open-label placebo pills provided relief from back pain for the next five years. But, notes Dr. Maher in his editorial in the Medical Journal of Australia, the study authors followed up only participants who received the placebo, and did not have a control group that received nothing — a weakness recognized in the study.
In the elapsed time, Dr. Maher, the condition may have improved on its own or changed for various reasons. “In science, you can’t throw away half the data to meet your goal,” he said. “It’s more than naughty.”
Placebo studies with a good control group have become more common in the years since the Danish study, but Dr. Maher argues that the problem of poorly designed placebo studies is still widespread.
Professor Kaptchuk said he was talking to Dr. Maher agreed that placebos should never replace more effective treatments. “A placebo will never shrink a tumor or cure malaria,” he said. “But that doesn’t mean they can’t be effective for many symptoms.”
In his research on open-label placebos, he has found that they are most effective at providing some symptom relief in conditions that sometimes have no apparent physiological cause, such as chronic pain, chronic fatigue and irritable bowel syndrome.
Often those afflicted with these conditions go through an assortment of drugs before taking part in Professor Kaptchuk’s trials. “The people we see have failed mainstream treatment and are desperate,” he said. “What placebos seem to do is decrease the volume of some of their symptoms.”
Danielle Ofri, a primary care physician at Bellevue Hospital in New York, said she sometimes recommended a multivitamin — along with any needed medication and other lifestyle changes — to patients with complex cases. There is no evidence that such vitamin pills work, in a direct physiological sense. But dr. Ofri said many patients who took the pills from a caring and attentive doctor reported feeling healthier and more energetic.
“As long as I’m not ambiguous about prescribing it instead of the right medication, I think it’s okay to boost the patient’s optimism by giving them something to feel better,” she said.
Professor Kaptchuk and his colleagues are beginning to use brain imaging to better understand placebo effects, as many scientists interested in placebos have done before. It appears, said Professor Kaptchuk, that the effects may be associated with the release of neurotransmitters, such as endorphins and dopamine.
But he admits they’re just beginning to understand biology and many of his open-label studies have yet to be replicated. “People are right to be skeptical because there’s a lot we still don’t understand,” he said.
Professor Kaptchuk, who studied Chinese medicine before turning his attention to placebos, said he was hopeful that they could eventually provide some relief to the increasing number of people with chronic conditions — and even help broaden the scope of Western medicine. medicine. He argues that the answer to the mystery of placebos most likely lies in the compassionate encounter between doctor and patient – the ‘medical ritual’.
“There are few dramas as compelling and moving as when you go to the doctor,” he said.
dr. However, Maher believes that understanding the medical exchange in such terms is a regression to a culture in which doctors rely on their authority, rather than science, to treat the patient.
“They act like the placebo is a magic potion,” he said. “It’s a return to the dark age of medicine.”