{"id":1059,"date":"2013-05-11T09:22:27","date_gmt":"2013-05-11T09:22:27","guid":{"rendered":"http:\/\/solveeczema.org\/eczemablog\/?p=1059"},"modified":"2022-08-09T04:43:08","modified_gmt":"2022-08-09T04:43:08","slug":"off-topic-sort-of-is-the-placebo-effect-real","status":"publish","type":"post","link":"https:\/\/solveeczema.org\/eczemablog\/?p=1059","title":{"rendered":"Off Topic (sort of): Is the Placebo Effect Real?"},"content":{"rendered":"

In order to help people with my site and blog<\/a>, I try to stay away from saying anything controversial \u2014 aside from my belief that eczema is eminently solvable and understandable, and that there is nothing really wrong with these kids absent these relatively new environmental influences. \u00a0I only wish what I have to say in this post weren’t controversial \u2014 I don’t know why it is, but it is. \u00a0Forgive the lack of photos, I’ll try to remedy that soon. \u00a0This post is excerpted from a letter I wrote many years ago, and it highlights the philosophy that led to the way I went about problem solving eczema for my son. \u00a0I have posted this opinion anonymously online since, but I may as well come out and say it. \u00a0There are critical (unnecessary) barriers to solving intractible health problems, and real people suffer while we all wait for those in ivory towers to break them down. \u00a0In the era of distributed knowledge and the Internet, that must change.<\/em><\/p>\n

When people use the site to problem solve their own children’s eczema, the breakthrough is usually when they can see the eczema outbreaks are not random. \u00a0In my experience, when people accept they can solve the problem, they are more than halfway there. \u00a0When they see they are in control, they’re there \u2014 they may not yet have all the influences or rashes eliminated, but they know they can do it. \u00a0I believe the perspective discussed below could help solve other currently-deemed intractable diseases. \u00a0I hope the following is helpful to others:<\/em><\/p>\n

\u2014AJ Lumsdaine, SolveEczema.org<\/p>\n

More than ten years ago, Danish researchers Hrobjartsson and G\u00f8tzsche published the watershed study, \u201cIs the placebo powerless?\u00a0 An analysis of clinical trials comparing placebo with no treatment,\u201d in the New England Journal of Medicine<\/em>.\u00a0 The two researchers looked through the history of placebo-controlled clinical trials and found over 100 studies that included three patient groups rather than two:\u00a0 1) a group given treatment, 2) a group given a placebo intended to mimic treatment, and 3) a group given nothing at all.\u00a0 The authors decided to compare the groups given nothing to the placebo groups, and found that there is no significant clinical effect associated with placebos<\/strong>.\u00a0 In other words, the placebo effect \u2013 interpreted as improvement resulting from patients\u2019 belief in a treatment \u2013 is more myth than reality.<\/p>\n

As you might imagine, the study generated quite a firestorm in the medical community.\u00a0 I remember reading a letter by the head of Harvard Med School, in which he scratched his head at the earth shattering results, but also said he wouldn\u2019t want anyone to give him a placebo.<\/p>\n

And after such earth-shattering results, then what happened?<\/p>\n

Hrobjartsson and G\u00f8tzsche followed up with another study in 2004:\u00a0 \u201cIs the placebo powerless?\u00a0 Update of a systematic review with 52 new randomized trials comparing placebo with no treatment.<\/em>\u201d\u00a0 Again they \u201cfound no evidence of a generally large effect of placebo interventions.\u00a0 A possible small effect on patient-reported continuous outcomes, especially pain, could not be clearly distinguished from bias.\u201d<\/p>\n

Although these researchers were arguably the first to make a dent in ironclad beliefs about placebos, especially in the media, they are not the first to analyze and refute the concept.<\/p>\n

In 1997, researchers Kienle and Kiene wrote, \u201cIn 1955, Henry K. Beecher published the classic work entitled \u201cThe Powerful Placebo.\u201d\u00a0 Since that time, 40 years ago, the placebo effect has been considered a scientific fact.\u00a0 Beecher \u2026 claimed that in 15 trials with different diseases, 35% of 1082 patients were satisfactorily relieved by a placebo alone.\u00a0 This publication is still the most frequently cited placebo reference.\u00a0 Recently Beecher\u2019s article was reanalyzed with surprising results:\u00a0 In contrast to his claim, no evidence was found of any placebo effect in any of the studies cited by him.\u00a0 There were many other factors that could account for the reported improvements in patients in these trials, but most likely there was no placebo effect whatsoever.\u00a0 False impressions of placebo effects can be produced in various ways. \u2026 These factors are still prevalent in modern placebo literature.\u00a0 The placebo topic seems to invite sloppy methodological thinking.\u00a0 Therefore awareness of Beecher\u2019s mistakes and misinterpretation is essential for an appropriate interpretation of current placebo literature.\u201d<\/p>\n

No one is claiming that placebo-controlled trials are unnecessary.\u00a0 On the contrary, these studies further emphasize the importance of placebos in clinical trials to eliminate the junk drawer of biases and other effects that needs to be separated from the clinical effect of the drug or treatment under scrutiny.\u00a0 But the studies also point out how sloppy definitions of the placebo effect have perpetuated false beliefs.<\/p>\n

The popular lay understanding of the placebo effect \u2014 the myth \u2014 is of powerful physical changes that result from an expectation or hope, a belief that good will happen if one is taking a medication (or that bad will happen if one is expecting bad side effects).<\/p>\n

On the other side of the spectrum, is the definition of placebo effects as what is attributable to everything else that is not a medication effect \u2013 including the natural course of the illness, other effects caused by a placebo, even reporting biases among researchers and patients.\u00a0 When the definitions are confused, the placebo effect is falsely supported as resulting from belief in treatment.<\/p>\n

For a classic example of confusing changes from belief in treatment with other effects caused by a placebo, look no further than a watershed arthroscopic surgery trial from a few years ago, meant to test whether placebo-controlled surgeries are necessary and oft-cited as demonstrating that placebos are powerful.\u00a0 Unfortunately, the many who wrote about this study as proving the power of placebos, meant placebos-as-causing-physical-effects-from-expectation.\u00a0 But that\u2019s not how the researchers of the study were using the term.\u00a0 (This is one reason, especially in this day and age, full medical articles really must be made available to everyone online, not just abstracts.)<\/p>\n

Patients were divided into three groups \u2014 patients to receive one of two popular arthroscopic surgeries, and a patient group to receive a sham surgery in which they were operated on and closed up without any actual surgical intervention.<\/p>\n

Patients in all three groups improved, and this was taken as proof the placebo effect is powerful, and equated to mean the belief in treatment produces powerful effects.<\/p>\n

But in fact, if people read the full article, they could see the placebo in this study wasn\u2019t just the surgery.\u00a0 Patients in all three groups \u2013 those given one of two different kinds of common knee surgeries and those in the placebo surgery group \u2013 all patients followed a comprehensive regimen of rest, walking aids, gradual exercise, and analgesics, in addition to their surgeries.\u00a0 So, the placebo in this study was not just a sham surgery, the placebo was a sham surgery AND a comprehensive regimen of rest, walking aids, gradual exercise, and analgesics.\u00a0 Unfortunately, there was neither a group that got the same regimen of rest and rehabilitation but did not get surgery at all, nor was there a control group that got nothing, to determine whether the observed improvements were from an independent effect of the placebo (i.e., improvements from just the rest and rehabilitation) or the natural course of the disease.<\/p>\n

The study authors merely examined whether two common knee surgeries produced better outcomes than a placebo surgery (they did not), the study design in no way supported the existence of real clinical changes stemming from patients\u2019 belief in treatment.\u00a0 In fact, the study authors made oblique reference to the Hrobjartsson results and suggested themselves that the effects they observed could be the result of the natural course of the disease or related to an independent influence (but not the result of a belief in the treatment).<\/p>\n

Despite such serious research supporting the need for a revolution in how we think about the placebo effect, nothing has really changed in over a decade.<\/p>\n

Too few studies bother to delve into how the natural course of a disease plays into the picture.\u00a0\u00a0 If we know now from definitive research that improvements aren\u2019t from belief in the treatment, but the result of something else, shouldn’t we be acting on this?<\/p>\n

I\u2019m sorry to burst one of the happiest bubbles in popular medical mythology, but there is just no good evidence that belief in a treatment <\/strong>alone <\/strong>produces a significant clinical change down the road, only wishful interpretations that it does.<\/p>\n

Now, I\u2019m not suggesting there is no mind-body connection, far from it.\u00a0 I\u2019m only saying that just because we see some obvious mind-body connections, does not mean that the conscious brain has unfettered control of all physiological processes.\u00a0 Just because you can jump over a box, does not mean you can leap tall buildings in a single bound.<\/p>\n

I\u2019m also not saying, believe it or not, that there will never be a role for harnessing hope in medical treatment.\u00a0 I\u2019m just skeptical that sham treatments are the right vehicle.\u00a0 If a passenger tries to catch a moving train, for example, a sudden surge of hope might make all the difference in whether she catches it and reaches her destination.\u00a0 The surge in hope won\u2019t allow her to keep outrunning a train forever, though.\u00a0 In other words, a short-term belief could affect the long-term outcome in a significant way \u2013 but only if the train is real, not a mirage (or a sugar pill).<\/p>\n

There is a much more serious issue at stake here than whether we can harness the power (however minor it has proven to be) of belief in treatment.\u00a0 The popular concept of the placebo effect\u2014as resulting from belief\u2014undermined the crucial role of empiricism in medical practice, which has in turn seriously degraded the scientific authority of clinicians (even within the medical profession, very rigorous and scientific observations by good clinicians of individual patients are typically deemed “anecdotal” by definition).\u00a0 This has in turn led to an over-reliance on statistical studies in medicine to problem solve for individuals (leading naturally to “one-size-fits-all treatments”), rather than to PROVE solutions found through empirical means<\/strong>.<\/p>\n

In the decades since the concept of the placebo effect was first embraced, how many millions of times have doctors come across clinically significant improvements in their patients, even cures, but dismissed what they saw as the probable result of their patients\u2019 beliefs in treatment, the irreproducible products of their patients’ minds?\u00a0 How many times have clues to cures been left uninvestigated because of how beliefs about placebos lead to handwaving about the “vagaries of the human body”?\u00a0 <\/strong><\/p>\n

We know now, we have solid proof now, that significant clinical changes are not the result of beliefs but of something else.\u00a0 Something else \u2014 like the rigorous plan of rest and rehabilitation in the arthroscopic surgery study \u2014 that could, through empirical problem solving, be discerned and tested and turned into a solution<\/strong> or many solutions<\/strong>.<\/p>\n

Every day, the belief that clinically significant improvements in individuals may merely be the result of the placebo effect costs our world opportunities to solve or cure tough diseases.<\/strong><\/p>\n

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In order to help people with my site and blog, I try to stay away from saying anything controversial \u2014 aside from my belief that eczema is eminently solvable and understandable, and that there is nothing really wrong with these kids absent these relatively new environmental influences. \u00a0I only wish what I have to say 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