Placebos in clinical care: a suggestion beyond the evidence, 2021, Maher et al

An article about the paper
Doctors Often Prescribe Placebos. But How Well Do They Work?
An Australian researcher argues that the medical community has enshrined placebos as “mysterious and highly effective” in clinical care on the basis of flawed research.

By Oscar Schwartz
The New York Times

Dec. 15, 2021
MELBOURNE, Australia — Having worked for decades as a physical therapist and a clinical researcher, Chris Maher knows firsthand how difficult it can be to treat back pain. The condition’s causes are often complex or uncertain, and treatments can be ineffective, even harmful.

So when he learned 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 that the claims were exaggerated. “It all just seemed like snake oil to me,” he said.

More at link: https://www.nytimes.com/2021/12/15/...linical-care.html?smid=tw-nythealth&smtyp=cur

 

Unfortunately, I cannot access NYT as I have already done so up to my limit.

The recent claim that placebos are effective, which I think stems form Harvard, is baloney, for sure.
The question is whether it is any more baloney than what this physio hands out. Maybe it is.

The flaw in the recent work relates to unblinding. A placebo may well be associated with some improvement, for various reasons, that may be much the same as for the test treatment - certainly if you are doing a blinded placebo-controlled trial.

But if you tell people they are getting a placebo the whole thing is unblinded. Moreover, paradoxically, the placebo suddenly becomes the 'test treatment' and will suffer from the very expectation bias that blinding and paces are intended to avoid.

Just like the BPS research there is a complete failure to understand how human nature affects experiments.

 

Ugh

“In his research on open-label placebos, he has found that they are most effective in providing some symptom relief in conditions that sometimes have no clear physiological cause, like chronic pain, chronic fatigue and irritable bowel syndrome.”

 

By Oscar Schwartz

Dec. 15, 2021
MELBOURNE, Australia — Having worked for decades as a physical therapist and a clinical researcher, Chris Maher knows firsthand how difficult it can be to treat back pain. The condition’s causes are often complex or uncertain, and treatments can be ineffective, even harmful.

So when he learned 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 that the claims were exaggerated. “It all just seemed like snake oil to me,” he said.

To Dr. Maher, a professor at the University of Sydney’s School of Public Health, this is just one example of a troubling trend in modern medicine. In recent years, an increasing number of researchers have made the case that placebos are effective not just in pharmaceutical trials — their most common use — but also in clinical treatments, prescribed to alleviate conditions like chronic pain, chronic fatigue, asthma and depression.

When new drugs undergo clinical testing, some participants with a health condition are given the real remedy while others are given an inactive control — a placebo. Strangely, some of those given the placebo still report feeling better for various reasons. These are called placebo effects.

Researchers have long been captivated by the phenomenon’s seeming potential in treating a range of ailments. In studies, they argue that placebos have notable, if poorly understood, healing effects even when patients are fully aware that they are taking inert pills. In surveys, doctors report wide use of placebos, especially for patients with complex conditions that have no clear treatment.

But in a recent paper in the Medical Journal of Australia, Dr. Maher argues that the medical community has become enthralled with the idea of “enshrining placebos as mysterious and highly effective,” even with little evidence of their efficacy in clinical care.

(excerpt)
continued . . .

 

. . .

Much of the more extraordinary research has come out of the Program in Placebo Studies and Therapeutic Encounter at Harvard Medical School, an institute established in 2011. The program’s director, Ted Kaptchuk, has published studies and written editorials about the therapeutic potential of open-label placebos — those that are honestly described to patients as inert.

For Dr. Maher, this raised a red flag. When placebos work at all, he said, it is through deception, creating an expectation of benefit in the patient’s mind. As he trawled through the research, Dr. Maher found that open-label placebos’ reported benefits were often artifacts of the same methodological error highlighted by the Danish researchers in 2001.

In one trial, a team of researchers, including Professor Kaptchuk, reported that a three-week course of open-label placebo pills offered relief from back pain over the next five years. But, Dr. Maher notes in his editorial in the Medical Journal of Australia, the study’s authors followed up only with participants who received the placebo, and did not maintain a control group who received nothing — a weakness acknowledged in the study.

In the elapsed time, Dr. Maher argues, the condition might have improved on its own, or changed for a variety of reasons. “In science you can’t throw away half the data to suit your purpose,” he said. “It’s beyond mischievous.”

Placebo studies that include a proper control group have become more common in the years since the Danish study, but Dr. Maher argues that the problem of poorly designed studies in placebo research is still widespread.

Professor Kaptchuk said he agreed with Dr. Maher 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 in providing some symptom relief in conditions that sometimes have no clear physiological cause, like chronic pain, chronic fatigue and irritable bowel syndrome.

Often, those suffering from these ailments run through an assortment of pharmaceuticals before joining Professor Kaptchuk’s trials. “The people we see have been failed by regular treatment and are desperate,” he said. “What placebos appear to do is turn down the volume of some of their symptoms.”

...

Dr. Maher, however, believes that conceiving of 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’re acting as if the placebo is this magic potion,” he said. “It is a return to medicine’s dark age.”

 

I don't see any compassion from a doctor in giving someone in pain a fake pill or even a clearly avowed "magic potion". For me, this is nonsense, dishonesty or an insult to the dignity that every person deserves. Under the guise of some supposed good, it's twisted.

 

When the "placebo" effect disappears:



Quite amazing that this guy can "observe" that it works best on commonly misdiagnosed conditions that heavily feature fluctuating symptoms and a relapsing-remitting pattern, and still completely miss the obvious. There are no more convincing lies than the ones we tell ourselves.

Bias biases results, made even worse when the outcome can't be measured. This isn't even hard, in the end it's basically just this delusion acting out in methodological flaws:

Ugh, come on. There is no need to infuse any profession with mysticism. Get off your damned dead horse.

 

Some doctors seem content with providing momentary emotional comfort to hopeful patients but I'm glad others think their job is primarily treating illness.

 

how much does a placebo pill cost . that is of course all that matters when big business runs medicine for the sake of profit . everything else is marketing .

 

on point

 

I have a question about the use of placebos in medicine.

If I want to buy a supplement in the UK - say - vitamin C, by law it will have a list of all the ingredients on the bottle - active ingredients, fillers, excipients, inactive ingredients etc. I can look them up and research what I'm planning to buy.

If I am prescribed a placebo by any doctor in the UK what will the ingredients list say? Will I be able to identify I've been given a placebo? Will I have any right to complain and insist on being prescribed something with active ingredients?

 

Folks, it exists already: https://zeeboeffect.com/

just wait until it gets FDA approval!

 

https://onlinelibrary.wiley.com/doi/10.5694/mja2.51230

Coincidentally I was listening to a podcast discussing the placebo effect today, among other topics. Gave a good run-down of all the issues with the various placebo effect claims. It was episode 312 of a podcast called Skeptics with a K. The description for the following episode 313 looks like it may be about the paper discussed in this thread, doesn't name it but says it's a recent Australian one.

 

Very Fallout meme: [The alternative medicine industry looooooooooove$ this].

Or: how to fuel the antivaccine/antimedicine movement in one easy step. How do these people think this plays out for people who have serious health problems only to be dismissed openly with a sugar pill and a BS explanation that may as well be shamanic? How do they think it gets discussed in communities already primed to find anything to support their opinions? Thought bubbles are very insulating, but what happens outside is far larger.

That one is a bit funny when you think of it:

It's not as if people everywhere used the same methods, tools, instruments and processes, or had the same expectations, training and culture. The placebo being an artifact of non-measurement makes is the most logical explanation for this. Horses, not zebras, unless howling monkeys are preferred anyway. Or maybe "unicorns" who feature a tiny baboon on their nose, instead of a horn?

But the next sentence is odd, since I've seen reported many times that placebos have been less and less effective with time, again a logical explanation of artifacts of poor methodology as they are tested slightly more rigorously with time, but never quite enough to really dispel the myths. Probably the BPS literature.

Reminder that Simon Wessely, when asked about the placebo effect in PACE replied something like: the placebo is one of the most powerful interventions we have. He also thought the thing about cancer outcomes being affected by positive thinking was one of the most potentially revolutionary findings in the history of medicine, so his judgment is not exactly solid.

 

The NYT article is good. It revolves around Chris Maher, a professor at the University of Sydney’s School of Public Health, who makes similar arguments as you.

Maher recently published an article about this:
Placebos in clinical care: a suggestion beyond the evidence | The Medical Journal of Australia (mja.com.au)

 

Can confirm it was this Maher paper they discuss in the podcast. In summary, like Maher, they don't have a lot of faith, or any faith really, in the evidence base for the placebo effect. Entertainingly presented, too.

I've only listened to the two episodes but the impression is that they're pretty sharp at spotting dubious research methodology and unjustifiable conclusions. Their site isn't easily searchable so I don't know what topics they've covered in the past but I seem to remember some people here saying that the skeptic community in general hasn't shown much interest in investigating the nonsense and pseudoscience we get in ME. I wonder why they're not interested. So much potential. They could have a real field day.

As a bonus, the podcast discussed the zeeboeffect thing, too. Their rating of it was more zeeroeffect.

 

Didn't know where to put this but

https://twitter.com/user/status/1473413008911130631

 

Very odd article that does not have much to do with the title, blatant clickbait.

This is funny, just not haha funny:

But placebos are not all about releasing brainpower. You also need the ritual of treatment. "When you look at these studies that compare drugs with placebos, there is the entire environmental and ritual factor at work," says Kaptchuk. "You have to go to a clinic at certain times and be examined by medical professionals in white coats. You receive all kinds of exotic pills and undergo strange procedures. All this can have a profound impact on how the body perceives symptoms because you feel you are getting attention and care."​

I'm not sure that person is aware that most humans are no longer illiterate savages and most of what happens in medical care is pretty straightforward. This isn't like showing a satellite phone to a tribe of hunter-gatherers. However here the same dude straight up contradicts himself:

How can you give yourself a placebo besides taking a fake pill? Practicing self-help methods is one way. "Engaging in the ritual of healthy living — eating right, exercising, yoga, quality social time, meditating — probably provides some of the key ingredients of a placebo effect," says Kaptchuk.​

So it's both the confusing but pleasing ritual of a stronk doctor with stronk doctor hands doing doctory things while wearing doctory garbs in a doctory environment. But also it's just, you know, eat right and exercise and stuff. Same magic.

Anyway this is basically what the article is about:

A study published online by PLOS Biology may have identified what goes on in the brain during a placebo effect. Researchers used functional magnetic resonance imaging to scan the brains of people with chronic pain from knee osteoarthritis. Then everyone was given a placebo and had another brain scan. The researchers noticed that those who felt pain relief had greater activity in the middle frontal gyrus brain region, which makes up about one-third of the frontal lobe.​

Which of course says absolutely nothing about placebos, and probably more about the sensation of pain, or whatever a full third of the frontal lobe happens to be doing at the time. Though one thing is confirmed: Harvard Health is a clickbait commercial piece of Goop.