> Kallmes performs vertebroplasty, a surgery he has helped to develop and standardize, that involves injecting medical cement into the fractured bone to stabilize the fractured area and relieve pain. He says he gets great results from his patients, and teaches the method to other doctors at conferences.
> But here’s the thing: he has no idea why vertebroplasty works. So a few years ago, he decided to test it against a placebo. Kallmes found that pretending to perform vertebroplasty – making it seem like he was injecting a needle into the spine but without the cement – had similar effects. About 40 percent of both groups experienced immediate relief from pain after the surgery. He published his results in the New England Journal of Medicine.
> I remember my father, as an orthopedic surgeon, when he was a resident, he was working in one of those crazy, New York City hospitals where people would come in with like overdoses and shooting wounds and stuff like that. And he was telling me that the most often kind of prescribed [medicine], especially on the psychiatric stuff that came in, was 100cc of Obecalp, which is, of course, "placebo" spelled backwards. And how as soon as someone would be like, "Obecalp, stat, 100cc," that would, suddenly, switch something in a lot of these patients’ minds, in terms of where they felt they were in their hope. And that always stuck with me.
I mean, their oath is to help people, not to tell the truth, the whole truth, and nothing but the truth.
To my mind, there isn’t an obvious answer, but the conflict between these two is why there is debate about “using” the placebo effect as a treatment.
This is because studies have since found that amputations can cause a great deal of psychological harm and it can be better for the patient if they arrive at the conclusion to amputate of their own volition - even if that takes months of excrutiating agony spent realizing not having the limb is better than the pain.
It was an interesting additional dimension to consider - even if the doctor knows much better than the patient, sometimes the patient feeling a sense of autonomy could be important for their wellbeing, and that short term pain could be beneficial.
Atul Gawande talks about how much we have discovered in medicine in the last century, but that the next century is going to be about how to effectively implement that knowledge to help people. This applies to both the first world and to the developing world, though the challenges in both are different.
(also we probably wont stop discovering new treatments that we will them have to deploy...)
Yeah, but a lot of patients would consent to an offered treatment plan where they're locked up (and unable to sign themselves out!) and fed only 1300 calories of veggies.
The weird thing is, there are private businesses willing to provide exactly that kind of service (see: de-tox centers.) But doctors and hospitals generally don't see this as a valid form of in-patient medical treatment. Why is that? Do doctors think that patients have an inalienable right to bodily autonomy? (If so, how would surgery ever work?)
(The annoying point about this difference, to me, is that if a doctor were to diagnose you with X thing that keeps you at the hospital for a month, unable to leave—then your insurance would likely pay for that, and your employer would likely consider you on sick leave. But if a private business like a detox center keeps you for a month, then you have to pay for that out-of-pocket and you're likely to be fired from your job if you don't have the requisite vacation days saved up. From what I can see, it is in the patient's long-term interest if doctors get into this business!)
I am in two minds about it. On the one hand it would appear pretty ridiculous and there is no way that it should be paid for. On the other hand if it works via the placebo effect in a cost effective manner, is that a bad thing?
And what is the cure worth? How do you measure that?
In other words the lie is integral to the working of the placebo. This is the whole source of the issue.
"We did procedure X, but your insurance covered all of it."
Last year I fell while mountain skiing and was in great pain at first (could barely move, standing up from lying down was excruciating, etc.)
The first day I didn't take any pain killer; the second day I did but it didn't really help. The third day I stopped taking the pills and just kind of "decided" I wouldn't suffer that much.
The pain didn't disappear completely, and it still hurt too much to get back on skis, but it stopped being so intense. When I got back home I did an x-ray exam and MRI and found I had broken a vertebra in two, that had lost 25% of its height. The doctor was super surprised I could walk normally and said: "do you not feel pain". I said I did but it was very manageable. She didn't investigate and just said "ok then, good for you!"
Also, I used to get hiccups that lasted a long time (30 minutes); and then I discovered you can make them stop very fast by being super calm and concentrating. Not only that, but since I found this out, I barely get hiccups at all anymore.
I think we can consciously control much more of our own body than we think, and we're only scratching the surface.
We see that all of the time... I recall working in a bakery in the mall in high school and chatting with a Vietnam veteran with chronic pain from a lung issue and a missing leg who would walk 8-10 miles on crutches every day at 5AM and sometimes do push-ups in our cafe area. He was the most positive person that I have ever met, which was striking when you'd see other folks with very minor issues grouse and complain and be visibly ill.
My mom was taught "therapeutic touch" in the 1960s in nursing school, which I believe isn't considered pseudoscience today. For certain types of patients, it was helpful, but the technique was mostly placebo.
Fundamentally, changing how people think is ethically problematic if it becomes manipulative, but it's a key factor for our well being as well.
This might simply be that the Vietnam veteran happens to have much better and more stable chemistry than people with, say, depression.
It seems one danger with this placebo discussion is that we may end up at square one, blaming depressed/anxious/ADHD/BPD people for their problems...
Now, they can say, "I may do A, and I may do B, and there is evidence that both are effective"
The idea itself isn't that controversial - age of majority laws for contracts, voting, and even medical treatment clearly acknowledge the idea that some people are too young to know what they are agreeing to, so the decision should be made by someone else who takes responsibility for them (most things), or there should be no decision because there doesn't need to be one (voting).
We just need to refine our understanding to reflect the reality that as old as you may get, you will never understand some things.
Without autonomy, the concepts of voluntary/involuntary lose meaning, which can enable some very nasty scenarios. Exceptions to autonomy are rare and come with stringent legal duties and obligations on the responsible party. Doctors are not responsible for their patients in that way; they are service providers.
Lack of understanding should not be sufficient to undercut an ethical principle like autonomy. Imagine if I had the power to decide that you don't sufficiently understand the concept of autonomy, and must be shipped off to a re-education center.
Talking about it outside of the specific conflict, is disingenuous. Everyone understands how important Autonomy is. That's part of the issue, not a supporting argument to value it over the health of a patient. If there's no patient, there's no Autonomy either.
So, I do not agree with you that "everyone understands how important autonomy is."
You don't see the irony in that, when talking about the Placebo effect? This discussion is about an implicit assumption.
Health care costs have ruined many, and that's frankly unethical. I don't see a point treating the unethical American health care system as a premise in these ethical debates.
If the doctor lies to the patient, the patient cannot make a proper decision for himself.
So yes, it truly is an ethical dilemma.
Well, if it actually helps, is it a lie? A placebo is something intended to have no therapeutic value, generally for the purpose of testing another treatment. Arguably if you intend something to be the treatment then it isn't a placebo. :)
Let's sharpen the question: What if the lie is the treatment?
It sounds to me like the 40% who the placebo helps for have a different, mainly mental, problem than the 60% for whom it doesn't.
It's likelier that the 60% not helped are those who have a different, mainly mental, problem that the 40% for whom it does work.
If the cure comes from strength of mind, then it probably isn't correct to say that those with weaker minds and wills are healthier mentally.
That seems overly radical. Then again, I suppose all pain is in the mind at some level.
What evidence do you have that the placebo effect is 'mental'?
Given that it can still be effective even when you tell your patients you are giving them a placebo, I don't think this needs to be an issue (it's a worthwhile thought-experiment nonetheless, of course).
Patients dont know they are getting a placebo in clinical trials. It's double-blind by design (doctors dont know either which one is placebo or active ingredient).
Since we assume placebo effect is partly psychological, if you tell a patient you are giving them placebo this could possibly lead to worse outcomes.
> You don’t even have to deceive the patients. You can hand a patient with irritable bowel syndrome a sugar pill, identify it as such and tell her that sugar pills are known to be effective when used as placebos, and she will get better, especially if you take the time to deliver that message with warmth and close attention.
The tl;dr is that if you lie to people about their treatment, they get better than those who get told they may or may not receive placebo.
Additionally, if you administer naloxone to people in pain trials, it appears to reduce the placebo effect, which suggests that the effect is mediated by endogenous opioids. (Except in IBS for some reason).
Finally, if you tell dentists that they may be administering placebo analgesics to their participants, the participants report significantly higher pain during dental treatment (even though all participants got an active drug).
So, to sum up, its pretty complicated, but the practical takeaway is that you should try to have faith in medical treatments if you want to get better.
Interesting, I had never considered that as a thing to research! But I can imagine it working like a placebo-equivalent of reverse-psychology.
> if you tell dentists that they may be administering placebo analgesics to their participants, the participants report significantly higher pain during dental treatment (even though all participants got an active drug)
whereas the study seems to claim
> if you tell dentists that they may be administering an antagonist to their participants, the participants report significantly higher pain during dental treatment (even though all participants got a placebo)
The latter seems much more believable to me.
Placebo does not work on everyone. And it's not the best treatment even if you consider it "works somehow". So doctors will provide what work more often than not, hence an actual drug with proven efficacy vs a placebo.
At least that's how it worked until someone looked at the term "placebo effect" and got confused into thinking that's anything other than regression to the mean.
How did he manage not to be sued into oblivion?
As is, they were told that they'd either receive an injection with the cement or a placebo injection, and they agreed to participate under those terms.
This is false as a blanket statement. For specific categories like Cancer treatments, nobody is given placebo in Phase III for example, because their life/survival is at stake. For such clinical trials you prove the efficacy by comparing with the typical survival in other studies/other treatments (overall survival chart) like this: https://media.revlimid.com/wp-content/uploads/mm-hcp-overall...
Yes, but in trial where patients may receive placebo, the patients always consent to be randomized to the possibility of being treated with placebo.
you would have to consent.
People do this all the time, it's called homeopathy
These researchers (specifically molecular biologist Kathryn Hall) seem to have found a link between an enzyme called COMT and response to placebo treatments. That is, people with a genetic pre-disposition for lower COMT-production will respond less to placebo effects and MORE to actual drugs whereas for people with higher COMT-levels the opposite holds true.
I think this is a fascinating finding and does a lot to do away with hand-waving explanations of the placebo-effect as 'it's all psychology' (just look in the comments here).
Unfortunately the article ends with a kind of esoteric tone of one of the researchers, in that he believes it would be unfortunate if we did away with the rituals and warmth and caring involved in more esoteric practices completely. I don't really get that: If we figured out why the placebo effect works and we can very effectively treat patients depending on their genetic pre-disposition that's awesome!
It would be interesting to see what else COMT levels are correlated with especial religious and social beliefs.
Very interesting indeed! Maybe it's my 'I'm such a rational thinker'-pride, but I guess I'm in the group that doesn't respond strongly to placebo effects. I'd be more than happy to pop a social-wellbeing pill in combination with whatever pill I need to treat my condition. As opposed to Mr. Kaptchuk’s view that it would be a shame if we lost this dependency on other humans and their empathy for healing.
It’s well established that the mind controls the brain which controls the body. (And the other way around, too). A physiological problem in the mind can cause a chemical problem in the brain which can cause a ‘physical’ problem in the body. Or heal a problem in the body.
Quotes around physical because mind and body are both physical. If doctors are surprised by this it must be because they are still clinging to some form Cartesian dualism.
There is some limited evidence that placebos have some actual effect on reducing pain, but it's hard to separate the effects for many conditions.
Edit: Although even here, you often need to trust the answer of a patient about their well-being and can’t necessarily pinpoint the duration of the flu to measurable symptoms only.
This article supports a plausible theory that the mind is a complex system and does not define easily as being purely local to the body:
I think when it comes to mind/consciousness the humble position is to say "we don't know enough yet". Humans are certainly not so enlightened that we can define ourselves with precision and we should operate in the world with appropriate humility.
If you decide to think of biting a lemon and your saliva glands react, is that any weirder than throwing a ball? If you just think about throwing a ball without doing it your muscles will still contract in "micro-movements" to act out the act of throwing.
And yes, I do think most doctors in Western medicine cling to a form of Cartesian dualism. It's somewhat tempered, but the mind body connection is vastly underexplored.
>You don’t even have to deceive the patients. You can hand a patient with irritable bowel syndrome a sugar pill, identify it as such and tell her that sugar pills are known to be effective when used as placebos, and she will get better
Which comes to mind because I know a few people who are quite knowledgeable about medicine, committed to evidence and rigor, and also go to treatments like acupuncture regularly. They all do it with that same sort of winking sense that sure, this probably doesn't work double-blind, but as long as I don't focus too hard on that it'll work for me. One or two have even said that they consciously avoided investigating past "it's not harmful" to preserve ambiguity.
I'd always wondered how well that kind of doublethink could do for placebo, and while this isn't exactly the same I'm excited to find a discussion along those lines.
”Two strangers sat down opposite each other in a railway carriage. One of the men had on his lap a cardboard box with holes in the top. After some time wondering what might be inside it, the second man said, “Excuse me, but I couldn’t help noticing your box. Does it contain an animal?”
The first man smiled politely. “Yes, a mongoose.”
“A mongoose? Where are you going with that?"
“Ah,” the first man replied, “My sister has terrible dreams. She sees snakes everywhere. I'm taking her the mongoose so it can scare them off."
“But how can that work,” the second man said, “Those are imaginary snakes?”
“Indeed,” his fellow traveller replied. “Which is why this,” and here he lifted the top and tilted it to show an empty box, "is an imaginary mongoose.”
I think it was also Crowley who commented that of course magic can produce light and fire and all kinds of verifiable signs, but that's all beside the point and so the best magicians are indistinguishable from fakers.
I'm sometimes surprised how many people have hit on some variant of this. It's everywhere from the Black Bible saying that its spells work but have no mechanism of action, to the hacker koan about Tom Knight, to the various "haha only serious" faiths like Discordianism and SubGenius. And it seems like quite a lot of very similarly-minded people arrive at it from different direction - I get the sense that there's a certain mindset that's particularly good for maintaining faith and disbelief simultaneously.
Unless my particular pathways are different and I respond to placebos differently than another population.
You're not wrong that it's well established that there's some effect, but beyond that, it's barely science until we can map these pathways.
So it's still a 'trick'.
In any case after studying some pharmacology, my takeaway really was that "understand" is a pretty relative term - biochemistry is insanely complex and medical chemistry is a pretty fuzzy thing when it boils down to it...
Is it a common misconception that the placebo effect is a 'trick'?
My experience says yes, it's a trick. As in, mind may be over matter but if it's a placebo it's worse than the real thing, or at least that's the connotation I had for the word.
(This post sponsored by MacOS' built-in dictionary)
People pretending to be journalists who need to clickbait to make money.
I wish the nytimes would stop making their headlines a question already.
It's universally established and accepted that placebo is a legitimate medical effect. That's one of the major purposes of control groups and double blind studies: many medicines don't make it to market because they have a positive effect LESS than placebo.
Clickbait more and more out of NYT. What a world.
More importantly, "trick" may also not mean what you think it does.
It's a rather interesting word, actually. Your interpretation seems to focus on the bad aspects, i. e. deception. But a trick can also be a clever shortcut. It might still involve some make-believe, but puts it in service of a good cause.
That's somewhat closer to the intended meaning here. And it's a perfectly valid way to describe the undeniable peculiarity of placebos.
> “Medical care is a moral act,” he says, in which a suffering person puts his or her fate in the hands of a trusted healer.
I have a friend who is a naturopath, and this is basically what she believes her job to be. Almost more of a therapist at times, a friendly ear to confide in.
The average experience with doctors isn't always that pleasant. It feels clinical and rushed, and very non personal. They are concerned with symptoms, not the actual person in front of them. They don't really listen, as a therapist would. And it's not their job too.
Contrast that with an alternative healer. They will sit and talk and listen and empathize with you for an hour. For a person in pain, it might be the first time they have ever felt like someone actually understands and cares. It's not surprising that they feel better afterwards. I think that goes a long way to explain the popularity of fake medicine.
Got a cold? A muscle tear, connective tissue damage? weird back pain?
There are no definite solutions to those. And ever smart HN person who think they know the solution to that, only knows a thing that they believed worked for THEM and won't necessarily work for ME and may not even have worked for them, it just got better with time and they think it was their special cross fit routine because of chronological fallacy.
Placebo just refers to the bundled biases and other uncontrolled-for influences. It is not a real thing that can be used to make anyone actually better. Whenever there is a physical measurement that can be made about some affected body function, the placebo effect mysteriously disappears.
The breaking of blinding and contrary measurements is enough to undermine most claims for placebo.
"Ah, people with pain. One group will get nothing and the other a placebo."
Reminds me of the old joke, where a respected scientist is announcing he has some great cure for the disease of the day and is presenting the impressive results to an audience, when someone pipes up and asks:
'How did this compare to the control group?'
The presenter is indignant and says, "Excuse me? You're asking if I randomly selected half of these poor souls to be deprived of the medicine, just to see what would happen to them?"
"Of course not! That would have condemned half of them to an avoidable death!"
'...but which half?'
not that I was proposing such a study - I was asking if we have already done them and what the data says if we have.
(Not a real site, just riffing off whydoesntgodhealamputees.com.)
Following is the assumption that, while we have learned a lot recently, the total map of mind/body connections is enormously larger than our current understanding of it.
So, it seems possible to me that the placebo effect can have real, physical and measurable effects on a human body, given the above assumptions.
One way or another, decades of research of, to varying degrees, confirmed this connection, though we haven't made much progress in understanding the underlying mechanisms of action.
- A placebo pills and a nice, empathic, optimistic doctor
- No pills and a nice and empathic doctor
- A placebo pills and a cold and pessimistic doctor
- No pills and a cold and pessimistic doctor
The pills have practically no effect at all, doctor behavior can have a measurable impact.
Besides I don't think there is a proven effect of placebo for other than psychosomatic symptoms (in particular pain and depression symptoms).
What matters is not that subjective feelings do improve?
Like, I really don't see any way of avoiding this in psychology and neuroscience (and indeed even if possible, it might not be a good idea).
These sorts of experiments are helping with making prognoses of whether a patient recovering from a coma will remain in a vegetative state, or if they'll regain consciousness in time.
A prominent placebo researcher, Dr. Fabrizio Benedetti, was able to show just how peculiar the placebo effect really is. After inducing pain in participants for seven days whilst treating them with morphine, Benedetti secretly switched the pain medication to salt water. Luckily for him, the participants’ reports of pain went unchanged. Then things got weirder. Benedetti didn’t want to stop there, so he [secretively] gave the participants a morphine blocker and, bizarrely, the participants found that their pain returned, suggesting a form of biochemical reaction to the salt water placebo.
So you give people morphine and it works (to block pain). Switch it secretly with salt water and it still works. Secretly add a real morphine blocker and it no longer works. Bizarre.
I know this was a quote from the article, but... Does it really suggest that? Isn't it possible something else is going on?
By the same token, it's only a trick as long as the underlying mechanism is unknown.
The body is fucking weird.
There's a general tendancy to discount the matters of the mind when treating the body, but both are very much connected and usually for a good reason—at least from an evolutionary perspective. In the US, there's often a stigma associated with just admitting weakness. Support exists but it's not always easy to come by.
It helps a lot if you can find a Primary Care Physician who has at least some notions of psychology and can help bridge that gap—and if needed, recommend the help of specialists regarding our thought processes. (In your case, it sounds like you were on your own to figure this out: glad it worked out, though!)
For stories like this, people always predictably discuss how ethical it is for doctors to knowingly prescribe placebos for stories and how different interventions have different impacts.
If placebo alone can't cure anything and only gives mild pain relief, I'm surprised nobody mentions it's overhyped.
> Placebo effects are strongest for patient self-reported subjective symptoms (classically, pain) and weakest for objective clinical signs measured by experienced observers.
My point is people seem to discuss placebo with an implied assumption that the effect is so big it's worth e.g. discussing the ethics of prescribing it. If it's only giving mild pain relief I don't see why it's that interesting.
And you're misrepresenting Homeopathy--that's not the principle on which it operates.
Isn't this just showing the supposed real surgery doesn't work? I don't see how this is showing placebo has an impressive effect.
To be honest, we are actively hacking our body when using hormone replacement therapy. Strange things are bound to happen. Skipping a dose of estrogen can trick the body into triggering PMS like symptoms, etc.
As far as I can tell, there are two distinct effects, and both are meaningless. The first "placebo effect" is observed everywhere, and is simply reversion to the mean. Nobody studies a treatment on healthy people, because treating people for a condition they don't have makes for a very expensive study. But some of those people get better spontaneously, and some weren't even sick, but had the right symptoms. Their improvement without actually being treated was originally called the placebo effect.
The other "placebo effect" is the one where treatment with a placebo (preferable an expensive placebo labelled "forte" and administered by the chief of medicine) is more effective than no treatment. But that effect only happens where the only way to measure the outcome is by asking the patient. A human is a very unreliable instrument. A human may report that the irritable bowel is gone because he doesn't take the symptoms as seriously anymore after the treatment, or maybe because he just wanted attention and there had never been an irritable bowel.
So, does anyone know of a study that finds a placebo effect that isn't explained by "bad instrument" aka. self reporting?
Retrospectively analyzes patients who got placebo, vs natural course patients. Placebo group fared better in physical exercise compared to the natural course group.
> A nocebo effect is said to occur when negative expectations of the patient regarding a treatment cause the treatment to have a more negative effect than it otherwise would have.
People with [psycho]somatic symptom disorders, with medically unexplained symptoms, are more likely to report negative side effects in response to placebo, for example.
When I've read about it, the research is often focused on perceived negative symptoms rather than lack of therapeutic effect, but that's just my impression and I suspect both happen.
"Results from small clinical trials suggesting that placebos can be ethically and effectively used in
clinical practice warrant further study, argue Ted Kaptchuk and Franklin Miller"
BMJ 2018;363:k3889 doi: 10.1136/bmj.k3889 (Published 1 October 2018)
- Placebo pills in randomised trials can significantly benefit patients’ subjective symptoms
- Using placebo pills clinically is an ethical challenge as prevailing wisdom asserts that deception or concealment is required
- Recent small randomised trials suggest that openly prescribing placebo can evoke meaningful therapeutic benefits
- More research is required to determine the role for open label placebo and the conditions in which it is effective.
There's been studies done on the effect of different placebos: bigger pills, with bigger markings, administered by professionals in professional settings etc work better.
My pet theory is that, since almost all medicine merely assists the body's own healing (e.g. a plaster cast doesn't heal the bone), the belief of safety and being looked after is enough for your body to switch resources away from dealing with a threat towards healing. (You can't afford to heal while your attacker is still around.)
A placebo signals safety.
Seems to me that attitude is 90% of success in this world...
Many Trippy effects are possible.
This should tell you if you have the COMT gene and what variant
Sample report: https://gene.meports.com/report/8d489a74-0a02-410e-a278-8238...
(A;A): (worrier) advantage in memory and attention tasks
(A;G): Intermediate dopamine levels, other effects
(G;G): (warrior) multiple associations, see details
They tested positive for this condition. It wasn't all in their head. But then again it was in some sense. They spent time away from their family and their condition would stabilize to the point that they'd no longer test positive. I asked about things like diet and sleep and the guy telling me the story said that this was of course the first thing they checked and the person's diet and sleep habits hadn't changed.
The psychologist who told me this story wasn't particularly "woo-woo" and was personally blown away by it. He said you can find other cases like this in the literature.
Anecdotes like that aren't proof, but they're interesting in that they agree with some of this placebo effect research. It looks as if the brain has more influence over the body than we realize or understand.
I find this just completely fascinating. That prozac shows a negligible effect over placebo in blind studies is even more interesting to me because of the side effects. It has some really serious side effects - you'd know if you were getting the 'real' stuff, at least if you were allowed to communicate with the others who were. And the prozac brand alone was, at its peak, reaching profits of $2.6 billion a year. This creates a nasty incentive for pharmaceutical companies to target 'drugs' at conditions that can be treated by placebo. Because in these cases, you can always prove the drug works, without actually having to go through all that nasty work involved in creating a drug that actually works.
 - https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4172306/