Placebos in chronic pain

[mart_bradley]

Hi,

I don't know whether the BMJ is one of the journals on your "watch" list, but I read this recently and thought fascinating.
https://www.bmj.com/content/370/bmj.m1668

I think fits in well to your pain science information?

But I found really interesting was that there is evidence that there is data suggesting that concealment and deception are not needed for the placebo effect (open label placebo). I don't think it's unethical to use such a strategy in medicine? So perhaps could be perused? Taking away the taking of an actual pill, but keeping the "medical ritual" part, perhaps not wrong to encourage even a theatrically meaningless "rehab ritual" if it seems to work for someone despite no adequate theory to explain it?

[Michael Ray]

Hey mart_bradley - yes, the BMJ is a well respected journal with a high impact factor. In other words NOT on a watch list for say predatory publishing.

OLP - yes, the lead author, Kaptchuk, has been examining open label placebos for quite some time. He's also a co-author on a popular predictive processing paper here -
Symptom perception, placebo effects, and the Bayesian brain

There's a lot to unpack regarding ethical usage of OLPs that I'll refrain from getting into here. However, the overarching theme would be centered around necessity. Personally, I'd rather aid with folks realizng their own abilities for self-management. There are many factors influencing outcomes (as the paper discusses), so I'm not sold on the need to introduce a placebo (pill).

With that said, I appreciated their entering into the literature official definitions for future usage, as that in of itself has been an area of debate for a bit:

From Box 1:
Placebos are pills composed of inert substances (eg, microcrystalline cellulose) or sham procedures without any direct effect on pathophysiology

Placebo controls are simulated treatments (pills or procedures) designed to appear indistinguishable from the intervention under investigation while lacking the properties thought to be therapeutic

Placebo effects are the salubrious clinical outcomes patients derive from participation in the rituals, symbols, and behaviors of medical treatment. This descriptive definition avoids any premature inference about putative mechanism(s). The definition also avoids the oxymoronic idea of an “inert” substance causing symptom relief

Placebo responses are outcomes detected with placebo controls in randomized controlled trials that include both genuine placebo effects and such non-specific effects as regression to the mean, spontaneous improvement, and normal fluctuations in illness. Placebo responses also accompany most clinical interventions for subjective complaints

Placebo treatment is an inclusive term for different conditions under which placebos can be administered: double blind, deceptively, or honest open label

I also appreciated their 3 rationalizations for explaining placebo effects, albeit transposing these ideas to clinical practice pragmatically is a bit murky.

At any rate, Kaptchuk has an interesting history (I don't mean this negatively) most aren't likely familiar with but is cool to see how he has integrated into Harvard and carved out a niche for himself: https://www.tedkaptchuk.com/

[mart_bradley]

Hi,

Thanks for this extra information, I'm definitely interested in reading more on this. I definitely understand that it's murky incorporating any of this into clinical practice, but it just seems it would be a shame not to think of ways whereby placebo effects could be used ethically. A lot of thought would need to go into that though. As part of my work, I had to write an evidence summary for esketamine nasal spray, a new treatment for resistant depression, I found the placebo response in the studies startling, accounting for up to 80% of the response. The difference between esketamine and placebo was just about statistically and clinically significant, but for something with so many potential adverse effects, some of which can be significant. If I thought about it as a clinician, I might be far happier being able to offer patients the placebo response were it possible! https://clinicaltrials.gov/ct2/show/results/NCT02418585

Thanks for the link!

[Michael Ray]

Hi,

Thanks for this extra information, I'm definitely interested in reading more on this. I definitely understand that it's murky incorporating any of this into clinical practice, but it just seems it would be a shame not to think of ways whereby placebo effects could be used ethically. A lot of thought would need to go into that though. As part of my work, I had to write an evidence summary for esketamine nasal spray, a new treatment for resistant depression, I found the placebo response in the studies startling, accounting for up to 80% of the response. The difference between esketamine and placebo was just about statistically and clinically significant, but for something with so many potential adverse effects, some of which can be significant. If I thought about it as a clinician, I might be far happier being able to offer patients the placebo response were it possible! https://clinicaltrials.gov/ct2/show/results/NCT02418585

Thanks for the link!

There may be some miscommunication here. I'm stating to fail to see the need for using a placebo (pill), however, that doesn't mean we fail to capitalize on placebo effects in clinical practice.

See:

Testa 2016

Peerdeman 2016

Peerdeman 2017

Davis 2020 (sport performance / social placebo)

Fabrizio Benedetti is a leading expert in this realm.

We play off of placebo effects quite often in clinical practice, hence my desire for us to print a BBM shirt that says "I'm a placebo".

[mart_bradley]

Thanks for this. I work in pharmacy - my misunderstanding probably lies in the fact that my work makes the assumption that everything needs to be solved via using a pill! Definitely need to break out of that mindset...

Thanks for the links - I'll make sure to read. From the title the Davis link looks particularly interesting from my perspective/learning.

If you do print that T Shirt pls let me know and I'll buy one!

[Nick.Suhanic]

my desire for us to print a BBM shirt that says "I'm a placebo".

my dude, please get that going. I'd love one of those!