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Screened and Examined: Placebo on the Brain

Ballard, Dustin MD

doi: 10.1097/01.EEM.0000407239.98583.be
Screened and Examined
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I had placebo on the brain the other day. This occurred shortly after I took my mor-ning glucosamine supplement (to ward off arthritis, of course) and right before I ordered two mg of morphine for a drug-seeking patient with chronic pain.

The principle of placebo is at work all the time in our daily and professional lives, and its power is undeniable. The medical literature has demonstrated it in dozens of studies, and the media have followed that lead. Last year, for instance, a Newsweek cover story examined the remarkable performance of the placebo arms in clinical trials evaluating new anti-depressants. (http://bit.ly/p5vsP6.) Their performance was so robust that it's making it difficult for drug makers to demonstrate the superiority of their new medications over placebo.

Similarly, a recent Harvard study of asthmatics found 45 percent improvement in symptoms with a fake inhaler and 46 percent improvement with impostor acupuncture compared with 50 percent with an actual treatment (albuterol). Beyond just tricking the brain to feel better, placebo treatments seem capable of causing actual neurological and physiological changes. But the trickery has been somewhat of a sticking point for placebo. Many physicians consider using an impure placebo (a treatment with dubious physiological effect) for its psychological benefits, but would not go as far as prescribing fake pills. In fact, a survey-based study found that approximately 50 percent of U.S. doctors report using such impure treatments. I count myself among them. It was with great interest, then, that I read a recent study of patients with irritable bowel syndrome (IBS) that utilized an “open-label” placebo, a placebo treatment without deception.

In this investigation, which was led by Ted J. Kaptchuk and colleagues and published in December 2010 in PLos ONE, 80 IBS patients were given either no additional therapy or open-label placebo. This placebo treatment was described to patients as “placebo pills made of an inert substance, like sugar pills, that have been shown in clinical studies to produce significant improvement in IBS symptoms through mind-body self-healing processes.”

Both arms of the study received a counseling session from a physician and nurse that emphasized the importance of maintaining a positive mindset toward the therapy (suspending disbelief). Self-reported symptom scores were assessed at 0, 11, and 21 days. The results demonstrated significant improvements in symptom severity and relief in the placebo group at 11 and 21 days. These included an improvement in the global improvement scores of the placebo group of 5 points (vs. 3.9 for the control group, p=.002).

This study was a small one, with possible confounders such as unreliability in patient symptom reporting, but it certainly is provocative and promising. For years, physicians have struggled with placebo treatments because we've assumed that trickery was necessary for them to work. Trickery puts us in an uncomfortable position, having to choose between two ethical principles: beneficence and autonomy. But if the results of the IBS study are borne out in subsequent studies, the ramifications are tremendous. The placebo effect may not require deception at all. Perhaps it's been mischaracterized for decades. To prescribe placebo freely without the troublesome concealment component opens up a pathway for placebo treatments for many conditions: depression, asthma, chronic pain, IBS, addiction, hypertension, and more. And in the ED? Well, I see some obvious possibilities:

The Patient: Bonked Brenda who bumped her head on a kitchen cabinet last week, and today was reminded of the Natasha Richardson tragedy by a friend.

The Treatment: Trick O'Tomography. This happy-thought scanner is radiation- and risk-free! Who cares that it doesn't generate any pictures? They weren't needed to begin with.

The Patient: Snotty Scott with a touch of congestion, convinced that he has the sinusitis.

The Treatment: Placebiotics. Sweet-tasting and side effect-free, these pills help provide exactly what's needed: some harmless reassurance.

The Patient: Worried Wilma who is not happy with the past 48 hours of her life, and wants to let someone know it.

The Treatment: DeceptoTherapy. This is where your registration clerk can come in super-therapeutic. Rather than call in the psychiatrist in the middle of the night, send in someone qualified to provide the necessary treatment: a set of ears.

The Patient: Anxious Alejandro. A high-stress meeting at work has him breathing like a bunny and complaining of tingling in the hands and feet. He tells you he just can't catch his breath.

The Treatment: A dose of Ativan plus two puffs from the Placebo Pump. With this benzo/placebo cocktail, Alejandro will be ready to bolt back to the office before you can even begin to consider an alternative diagnosis.

These are, of course, tongue-in-cheek examples but perhaps not that farfetched. Could we use placebo to help with the expectant management of conditions like rule-out strep, bronchitis, and, yes, sinusitis? And could we use a simple strategy to improve mood and alleviate discomfort in certain segments of our patient population? Of course. We already do this in myriad ways.

Clearly, the physiologic possibilities for placebo have limits. We can't expect mind-over-matter to work with a bleeding limb, widely metastatic cancer, or a hardcore tweaker. In fact, a 2010 Cochrane review suggests that placebo may be ineffective beyond conditions with subjective symptoms (like pain and nausea). But in the ED, the sickest patients are not always the trickiest ones. Instead they are often the ones with subjective complaints and requests for treatment they don't need. For them, open-label placebo holds tremendous promise.

Comments about this article? Write to EMN atemn@lww.com.

Dr. Ballardis an associate emergency physician at Kaiser-Permanente in San Rafael, CA, and the chair of the CREST ED Research Network. His writing credits include co-authorship with Angela Ballard of the award-winning travel narrative A Blistered Kind of Love: One Couple's Trial by Trail (Mountaineers Books, 2003) and authorship of The Bullet's Yaw (IUniverse, 2007). Dr. Ballard writes a biweekly-medical column for the Marin Independent Journal, which he posts on his blog:http://incisionanddrainage.blogspot.com.

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