Tuesday, August 2, 2016

Understanding Placebos 101

There are two fundamental types of placebos, although this is seldom recognized in any literature. Even though there are thousands of articles about placebos, and possibly hundreds of books, most of them are based on the confusing foundation, attempting to explain two types of placebo with one logic, resulting in nonsense.

Placebos (real placebos)
are medications or treatments prescribed by a physician with the intent to help the patient, when the physician does not know how to help the patient. The physician might believe that the prescription has no 'physical benefit' to the illness - but prescribes because they do believe it will benefit the patient in some way. The physician's beliefs might prove right, or wrong.  If the physician is wrong, there is little consequence. Physicians often make incorrect prescriptions - and items chosen as placebo prescriptions are generally very low risk. If the physician is right, or if any other factor causes an improvement in the patient, both the patient and the physician benefit. The physician benefits because the patient believes the doctor's action provided the benefit. Of couurse, correlation does not prove causation.

Note: The benefits resulting AFTER (not necessarily because of) the placebo prescription have real causes. In many, perhaps all cases, assigning them to the placebo causes much confusion and avoids actual investigation  Calling them "placebo effect" is navel gazing, when the challenge is to understand what is going on outside of the medical system, outside of the treatment prescribed.

Clinical Placebos (fake placebos)
are false medicines or treatments.  They are not prescribed by a physician and there is no intention to provide any benefit to the patient, nor is there any intent to deceive the patient about the administration of the placebo.  There is an active attempt to deceive the patient, and the administering physician, in the design and delivery of the placebo, eg. who gets a placebo and who gets the medicine being studied. Clinical placebos are used in scientific experiments to provide a statistical measure of the so called 'placebo effect'. So called, because clinical placebo 'effects' are not 'real placebo effects'.

Note: The benefits resulting AFTER (not necessarily because of) a clinical placebo is administered also have real causes. Ignoring these causes, naming them "placebo effects" assigning them to 'the mind of the patient' is simplistic nonsense, avoiding true investigation of the facts. Correlation between administering the fake placebo and changes in the mind (or the body) of the patient does not prove causation.

There are many fundamental difference between a real placebo and a clinical placebo. Unfortunately most references do not notice, much less attend to this distinction. The result is total nonsense and confusion in much that is written about placebos and placebo effects, more so when results from one, a clinical placebo for example, are used to support analysis about the other, a real placebo.  It's as if we used the same name for bears and teddy bears, and then did scientific experiments on teddy bears, to draw 'scientific' conclusions about real bears. Here's a comparative list of some differences:

Placebo (real placebo)
Clinical Placebo (fake placebo)
prescribed by a doctor
Patient decides to take, or not.
administered by a scientist physician.
Patient agrees to take. 
doctor doesn't know what is best
researcher believes that the placebo is useless
doctor intends to improve the health of the patient
researcher has no intention to improve the health of patients who receive a placebo
prescribed to sooth the patient, and perhaps the physician, who feels frustrated.
administered to measure statistically, the effects of medicine, by subtraction of 'clinical placebo effect'. 
can be active or passive. Active are more effective. Deliberately chosen to help the patient.
often specifically designed to simulate the activity of the drug or treatment being tested. Chosen to deceive the patient and the study physicians.
when a real placebo works, patient and doctor are happy. The data is ignored.
when the clinical placebo works, the research has failed. The data is ignored.
patient believes they are getting a medicine
patient hopes they are NOT getting the placebo

When we assume that clinical placebos are the same as real placebos, we create nonsense because the assumption is nonsensical.

Because of this fundamental difference between real placebos and clinical placebos, it is very difficult to measure the effects of real placebos in a clinical study. As far as I am aware this has never been accomplished - and I have looked for research studies. To create the real life placebo, it would require the doctor to be allowed to decide when to prescribe a placebo, and to choose the placebo being prescribed. To maintain a double blind externally controlled trial, another entity would be required to determine if the patient gets the placebo prescribed, or ... ?what?

Not only are real placebos fundamentally different from clinical placebos, 'real placebo effects' are quite different from 'clinical placebo effects', but that's another blog post, maybe someday....

Until this distinction between a real placebo and clinical placebo is recognized, we will continue to publish nonsense about placebos, because we simply don't understand the fundamentals.

to your health, tracy
Founder: Healthicine.org 
ps. Cures Rule!
It is important to be aware the clinical placebos, the medicines they are being tested against, and real placebos do not, in general 'cure' any illness. They provide relief from symptoms. Most medicines, and most placebos are symptomicines. When a real placebo is claimed to 'cure', a thorough investigation is likely to produce the real reason for the cure. When a clinical placebo or a medicine being tested produces a cure - the cure is ignored, because clinical studies in general do not define and do not test for cured.