Atheists....the Next Generation!
Kepler, Newton, Galileo, and God

The Death and Rebirth of the Placebo

For just a brief moment, there was no placebo; there was no such thing. Just for a day. Placebo had its 15 minutes of antifame. And then the day passed, placebos resurfaced, and they've ruled ever since, just as before.

That day was May 24, 2001, and the front page read Survey Finds Placebo Effect Imaginary. From the Associated Press:

"One of the most strongly held beliefs in medicine, that dummy pills or other sham treatments greatly help many patients, has been called into question by Danish researchers who found little or no "placebo effect" in dozens of studies."

Those Danes had looked at study after study after study in which the experimental new drug was compared to the look-alike dummy pill, the placebo. If the new drug was any good, test results beat that of the placebo. But where researchers bothered to include a third group receiving neither drug nor placebo, the Danes found that that group fared about the same as the placebo group. In other words, people sometimes get better all by themselves! They sometimes do, in fact, just about as often as those who received the placebo.

I spoke to a few people involved in pharmaceuticals. They hadn't read the paper and hadn't heard of the survey and didn't believe me. A few days later, I googled "placebo." Conventional wisdom ruled once again. My article was buried many pages back. It took forever to find it. (But you can find it here.) Nobody ever touched the subject again.

I suspect placebo is a notion too good and too lucrative to let die. After all, when you're testing your new drug for efficacy and you can't wait to urge people to ask their doctors if it's right for them, you want it to seem like it has teeth. If it's so much better than the placebo and the placebo is so much better than nothing.....well, you've got some powerful stuff. But if the gap between nothing and placebo collapses, then your drug is not so effective as you thought. Better to keep that gap intact: broad shoulders for all new meds to stand on!

The fact is big pharma pushes a lot of drugs on us. We (in the USA) spent $2.7 billion on prescription drugs in 1960. By 2002 it was $162 billion. There were 600 prescription drugs to choose from in 1960. By 2002 it was 9000. Plus 4000 over-the-counter. Are we that much sicker that we need all those meds? Or conversely, are we that much healthier now that we have them?

And where did this term "meds" come from anyway? They're medicines, dammit! Isn't "meds" a sneaky con attempt to make them seem warm and fuzzy, friendly-like?...every day you take your meds just like you take your tea, or chocolate.

 

That's why when Pop goes to the doctor and the doctor "puts him on" this or that drug, Pop tells him to forget it. Either that or because he's a stubborn cuss. But it's hard to tell someone 85 who's in perfect health that he'd be so much better if he'd just be gobble down more pills. It's a standing joke with us. I meet him in the doctors office, after his yearly physical. (it took forever to get him to agree to those, and he only did so for insurance reasons) "What do ya think, Pop?" I ask, "Want me to get a wheelbarrow for all your pills?" "HA!" he says, "that'll be the day! No pills!"

Most people, overawed by our age's slobbering idolization of science and the doctor's high-priest membership of that discipline, obediently swallow anything they're told to. Not Pop. "Your blood pressures too high," the doctor says, reading his machine. "I want you to take these beta-blockers." "What I'll do," Pop says, "is buy one of those machines myself and see if I can get the blood pressure down with diet and exercise. If I can't, then I'll think about your beta-blockers." He's been able to do exactly that, aided with an immediate drop in blood pressure that comes just from not being in the doctor's office, where we're all at our hypochondriac worst.

Yeah, the old boy thinks that if you steer clear of drugs then one day you'll die in your sleep or drop in your tracks. And isn't that what we all want? A graceful exit when we go. But if you gobble down every pill someone pushes at you, you'll waste away slowly sans dignity in a nursing home. Who's to say he's wrong?

***********************

Tom Irregardless and Me       No Fake News but Plenty of Hogwash

Defending Jehovah’s Witnesses with style from attacks... in Russia, with the ebook ‘Dear Mr. Putin - Jehovah’s Witnesses Write Russia’ (free).... and in the West, with the ebook ‘TrueTom vs the Apostates!’ (free)

Comments

mud_rake

"I suspect placebo is a notion too good and too lucrative to let die."

...as is the placebo effect of religiosity?

tom sheepandgoats

No, as in the sense the post speaks of.

mud_rake

My answer/comment was to enhance the idea of 'placebo effect.' After all, religion is all in the brain as is the placebo effect of drugs [or non drugs.]

plonka

Hey Tom. When I went to your blogger profile, I didn't see a blog so I assumed you didn't have one. Wrong again... Oh well...:)

I'm not so sure it's quite so conspiratorial. There are degrees to which people are prepared to believe. Placebos don't work for sceptics like me who can barely believe their own eyes, let alone what someone tells them.

Any decent trial concerning the placebo effect will revolve around the fact that all participants believe they are getting the real thing and not the placebo.

This is why I said it was an interesting field. Tell them they're getting the placebo and you have nowhere near the same results. It doesn't work for everyone, but belief is the key, or so it seems so far.

tom sheepandgoats

"I'm not so sure it's quite so conspiratorial"

I'm not either. It's a suspicion, that's all. A strong belief in placebo certainly does help in the marketing of pharmaceuticals.

dikkii

Hi Tom,

I'm not sure if this is actually news.

Clinical trials have involved testing stuff against placebos for years because, wait for it, placebos don't do anything.

Consequently, we can say that if something is tested and does better than a placebo, no matter if it's only better by a small margin, we can then say it works to some small degree.

Great example - sticking needles into the skin of a patient works better than a placebo at releasing a small release of endorphins. On the other hand, it doesn't work as well as exercise, sex, some drugs etc.

We know this because needle-sticking was tested against a placebo in double blind testing. And we also know from years of study exactly how much endorphins are released by the other ones.

Consequently, for double blind testing, placebos are the best control device we have because they don't do anything.

Incidentally, your point about doctors pushing drugs at every opportunity doesn't meet with my experience.

I've lost count of the number of times various doctors have said to me, "Improve your diet and exercise," and nothing else. No drugs, surgery or anything else gets prescribed or recommended.

If your pop has a doctor that just prescribes drugs and nothing else (and I would suspect this is not the case - I know the revised Hippocratic Oath pretty well), I would suggest that your pop immediately changes doctors.

Party on!

tom sheepandgoats

Dikkii:

I don't think that's the point of the article. Studies you refer to measure 1) the tested treatment or drug against 2) the placebo. The ones who receive the placebo generally register some improvement. It is assumed that their improvement is due to thinking they have received something beneficial. This article, and my post, question that assumption.

Yes, I agree with you, the placebo clinically does nothing. But people believe it will, so goes the placebo theory, and therein lies the explanation for their improvement. However, if you throw in a third group, a group to whom absolutely nothing is done, a group who is not even aware of a study going on, then you find that group improves at a equivalent pace to the placebo group. In other words, many conditions are self-limiting, the body tends to repair itself, and much, sometimes all of the placebo group's improvement would have taken place had they never participated in the study.

Don't chalk their improvement up to the power of belief, the article is saying. Because the general populace with the same condition gets better at the same rate.

dikkii

The placebo effect, as I understand it, has been long hypothesised as really a bunch of other "effects" rolled into one:

Patient was getting better anyway
Chronic illness usually happens in waves
Confirmation bias
Regressive fallacy
Misattribution
Subjective validation
Loads more.

The study you've referred to really only dissociates the placebo effect from all of these, and concludes that it really has no effect - which would appear to validate all clinical trials involving drugs developed by big pharma. They use placebos as the control device, after all.

This is best explained in this post here:

http://rockstarramblings.blogspot.com/2006/06/doggerel-14-it-works-through-placebo.html

And at the risk of sounding obtuse, I can't see the connection that you're drawing between the "placebo effect" and "big pharma". At no stage have you referred to big pharma selling placebos as a panacea, which I suspect you meant to put in somewhere. Is this correct?

tom sheepandgoats

My understanding is that the placebo effect is none of those things you have listed. It is one and one thing only: the power of belief to cure/improve. That believe stems from the subject imagining he's been given the real drug/treatment when in reality he's been given something innocuous. I think my notion of placebo, not yours, agrees with the Associated Press article cited. For example, item #1 on your list, 'Patient was getting better anyway' in no way measures the power of belief. Nor do the other terms. Though one or two of them are a little vague to me - I'm not quite sure what you mean by it. My fault, I'm sure, not yours.

Still, note the first sentence of the article: "One of the most strongly held beliefs in medicine, that dummy pills or other sham treatments greatly help many patients, has been called into question by Danish researchers who found little or no "placebo effect" in dozens of studies." Dummy pills or sham treatments plainly do not help people who were "getting better anyway" and nobody's ever imagined they did.

Frankly, your definition of placebo is completely new to me. I don't think it's accurate.

dikkii

Hi Tom.

You wrote:

"My understanding is that the placebo effect is none of those things you have listed. It is one and one thing only: the power of belief to cure/improve."

This is a gross oversimplification. This is also but one of the available hypotheses about how the placebo effect is supposed to work.

Largely, researchers cannot rely on an explanation like this one, because it begs questions such as, "How can neural biochemistry possibly effect the body's healing process?"

If you're suggesting that scientists have been relying on such a hypothesis, rest assured that it doesn't even meet the parsimony of the examples that I quoted in my previous comment.

Sadly, though, this is society's understanding of the placebo effect, and it completely (and sensationally) disregards all other available hypotheses of causes.

Wikipedia's entry is very good on this:

http://en.wikipedia.org/wiki/Placebo_effect#Isolation_of_causation

"That believe stems from the subject imagining he's been given the real drug/treatment when in reality he's been given something innocuous. I think my notion of placebo, not yours, agrees with the Associated Press article cited."

You're quite right, yet this is society's perception of the placebo effect and not science's.

May I remind you that placebo is a scientific term, not a media one.

"For example, item #1 on your list, 'Patient was getting better anyway' in no way measures the power of belief. Nor do the other terms."

Correct, but researchers have considered these to be better explanations of "the placebo effect" for years than "neural biochemistry did it."

Again, Wikipedia explains it better than me.

To be clear - the placebo effect is an observed/hypothesised effect. The explanation "belief did it" is not the effect - it is a possible explanation for this effect. You are co-mingling one possible (albeit improbable) cause with the effect itself.

"Still, note the first sentence of the article: "One of the most strongly held beliefs in medicine, that dummy pills or other sham treatments greatly help many patients, has been called into question by Danish researchers who found little or no "placebo effect" in dozens of studies." "

I suspect that the media covering this have made the same mistake as you in conflating cause and effect. The "widely held belief" as they describe is really only held outside of medicine. Scientists working within medicine have long been aware of all the other alternate explanations. And that's because they were the ones who came up with them!

"Frankly, your definition of placebo is completely new to me. I don't think it's accurate."

Partially, that's acceptable criticism, because I didn't word things terribly well.

On the other hand, I'll continue to draw your attention to Wikipedia's article, as well as Bronze Dog's post which I provided a link to in my previous comment. Conflating cause and effect is common amongst all of us.

And I'll add a final point: at no stage has there ever been any hard science supporting the assertion that observable responses to placebos are solely due to neural biochemical impulses. Science naturally supports the null hypothesis, so the claim that "belief did it" has never been widely supported.

Bronze Dog's post pretty much reflects the orthodox line on this.

tom sheepandgoats

Well, I dunno, Dikkii. This strikes me very much as revisionist thinking, a little analagous to how churches append the hellfire meaning to original language words that mean no such thing.

My understanding is that pretty much anyone can edit a Wikipedia definition, giving it the capacity to evolve quickly over time. I'd be happy to see a thirty year old definition of placebo agree with the definition you and Bronze Dog assign to it.

At any rate, the "revised" meaning of the placebo effect seems to muddy the waters to such an extent that the term becomes meaningless. I see no reason to use a placebo as a baseline in studies if this new definition holds true; I would think merely comparing the drug to general population afflicted with this or that malady would be sufficient.

The study cited in my post was front page in the newspapers. Its authors were not without scientific credentials. Nobody that I know of made any attempt to refute it or explain that its underlying assumptions about the placebo effect was wrong. That in itself leads me to believe that your definition of placebo has largely evolved since.

At any rate, if the public so universally misunderstands the term, and if science is concerned about educating the public, there is something very obvious that they could do. Always keep track of, not two, but three groups:

1. those receiving the "real" thing
2. those receiving the sham or dummy treatment
3. those of the general population afflicted with the condition under observation who have no part in the study and preferably are unaware of it.

dikkii

Hi Tom,

I really, really, really apologise for the long comment.

"Well, I dunno, Dikkii. This strikes me very much as revisionist thinking, a little analagous to how churches append the hellfire meaning to original language words that mean no such thing."

I think you're being under-generous in your use of the term "revisionist". The effect is the same as it always has been: There is anecdotal evidence of people receiving placebos and getting better.

That's all "the placebo effect" is.

And I can't find a thirty year old definition, but this from 2002 Merriam-Webster's Medical Dictionary:

"Main Entry: placebo effect
Function: noun: improvement in the condition of a patient that occurs in response to treatment but cannot be considered due to the specific treatment used"

The possible explanations for this effect are the ones that are constantly evolving, but the one that says that it's due to belief has always violated Occam's Razor compared with other possible explanations.

"My understanding is that pretty much anyone can edit a Wikipedia definition, giving it the capacity to evolve quickly over time."

Quite right. It's a good thing that Wikipedia has a facility to see previous edits that are time and date stamped then, isn't it?

"At any rate, the "revised" meaning of the placebo effect seems to muddy the waters to such an extent that the term becomes meaningless."

This I disagree with. Revised or not, the Merriam-Webster definition above is plenty meaningful. And, 5 years on it hasn't changed. But I know what you mean - the problem is that this possible explanation has been conflated with the observed effect so many times that the layman cannot tell the two apart.

"I see no reason to use a placebo as a baseline in studies if this new definition holds true; I would think merely comparing the drug to general population afflicted with this or that malady would be sufficient."

I think more research needs to be done on this before we can arrive at that conclusion. The study itself suggested as much.

"Nobody that I know of made any attempt to refute it or explain that its underlying assumptions about the placebo effect was wrong."

This is non-sequitur in the context of the study. The study really only attempted to answer the question, "Does a placebo perform better than those who are not given any treatment?"

It was the media who interspersed the "belief" thing. I've been through about half a dozen news reports and in all instances, it has been the reporter who has brought this up. It only gets a mention in the actual study in passing.

And if you think that that's bad, you should read the report again. YOU missed all these other possible explanations for the placebo effect that were explicitly worded in the Associated Press story:

Researchers:
-reporting bias
-flawed research methodology
-patients would have gotten better with no treatment
-participating in a medical study induces patients to eat better, exercise more or otherwise pay more attention to their health.

Reporter:
-"...presumably because they believe they are getting an effective treatment."

At no stage does the reporter cite anything to back this rather broad assertion up. The reporter also makes a huge error with this line:

"The goal is to see if medicines being tested do more good than people's will to get better."

That is complete rubbish. The goal is to see if it works, period. Because a test is double blinded, wouldn't both groups of recipients display equivalent levels of belief if they don't know what's the pill and what's the placebo?

(Incidentally, the media has shown time and time again that they cannot report scientific information correctly. Take the term "theory" for example...)

Lastly, you wrote this:

"Always keep track of, not two, but three groups..."

Science is one step ahead of you. They do this already.

I'm so sorry that I went so long on this - this kind of misreporting makes me very angry. Scientific illiteracy is bad enough without articles like this making things worse.

longchamp gatsby

I’ve been visiting your blog for a while now and I always find a gem in your new posts.

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