"NICE should recognise 'placebo effect' of complementary therapies."

[Mojo]

A King's Fund report, as reported by Pulse: http://www.pulsetoday.co.uk/story.asp?sectioncode=23&storycode=4123423&c=2

The report itself can be found here: New research methods needed to build evidence base on effectiveness of popular complementary therapies

"New research methods needed"? Perhaps the old ones don't give the right results...

Among the questions they discuss is "How should complementary practice research think about the placebo effect?" Perhaps a more relevant question would be "why should 'complementary practice research' think any differently about the placebo effect than research into other types of medicine?" After all, the placebo effect works just as well (or, according to Rustum Roy, better) with conventional medicine.

 

[Rolfe]

I thought the whole dilemma was that doctors are not allowed to give inert substances and make therapeutic claims for them. So yes, as we all know, they would sometimes let a patient go to a homoeopath so that they could give them the inert pills and make the spurious therapeutic claims. Many doctors consider that this is the use of homoeopathy within the NHS - legalised placebo.

If they're now going to come straight out and admit that these interventions are essentially inert, and being indulged in for their placebo effect, why not just cut out the middle-man?

Rolfe.

 

[Asolepius]

You were very quick off the mark here Mojo. I just posted a comment at Pulse Today, which hasn't appeared yet:

I wonder whether the esteemed professors Black and Holgate have heard of informed consent? Are they going to lie to their patients in order to get the placebo effect to work?

I am avidly interested in the ground-breaking study designs that these experts will develop, which will somehow "control for the possibility of the patient getting better over time". Come on, do tell.

Look at the "heavy weight" panel that came up with this travesty. The usual suspects one might say. Are there any GPs among our readers here? If so please comment as it might appear in the print edition. An earlier comment of mine was so selected but they have a policy of only allowing GPs to write in the print edition.

 

[Ocelot]

Of course it may still be possible that a placebo can be given with informed consent and be expected to work.

http://www.leecrandallparkmd.net/researchpages/placebo1.html

Mr Doe … we have a week between now and your next appointment, and we would like to do something to give you some relief from your symptoms. Many different kinds of tranquillisers and similar pills have been used for conditions such as yours, and many of them have helped. Many people with your kind of condition have also been helped by what are sometimes called ’sugar pills’, and we feel that a so-called sugar pill may help you, too. Do you know what a sugar pill is? A sugar pill is a pill with no medicine in it at all. I think this pill will help you as it has helped so many others. Are you willing to try this pill?”

 

[Asolepius]

Of course it may still be possible that a placebo can be given with informed consent and be expected to work.

http://www.leecrandallparkmd.net/researchpages/placebo1.html

They are confusing the contextual effect with the placebo effect. The latter is a product of expectation, whereas the former is a product of the consultation. But if you give a real medicine, you get all three - real effect, contextual effect, and expectation effect. Why settle for only one of the three?

 

[shuttlt]

Surely the following paragraph from the Pulse link is important:

‘As long as findings from research can provide confidence in the positive effect of the physical intervention at the heart of the treatment, then any added benefit brought by the therapeutic relationship and the context for treatment should count as part of the treatment effect,' the report says.

I guess what you think about this depends on whether you feel this weakens the evidence required.

 

[zooterkin]

They are confusing the contextual effect with the placebo effect. The latter is a product of expectation, whereas the former is a product of the consultation. But if you give a real medicine, you get all three - real effect, contextual effect, and expectation effect. Why settle for only one of the three?

Because 'real medicine' may have a side effect that is worse than the ailment? Assuming your breakdown of the placebo effect into two parts is valid, the problem is surely how to get 2 out of three; the contextual effect plus the expectation effect, in an ethical manner.

 

[Asolepius]

Surely the following paragraph from the Pulse link is important:

‘As long as findings from research can provide confidence in the positive effect of the physical intervention at the heart of the treatment, then any added benefit brought by the therapeutic relationship and the context for treatment should count as part of the treatment effect,' the report says.

I guess what you think about this depends on whether you feel this weakens the evidence required.

Of course the treatment benefit has more than one component, and they are all important. This is exactly why we do randomised controlled trials (RCTs). We are asking the question: Does this treatment do anything? The context within which it is given, and the expectation of the patient, are distinct components that can and have been measured. But what is deeply worrying about this report is that it is now well known that virtually all CAM actually does not have any intrinsic effects, as we have seen from RCTs. Indeed, as RCT methodology improves the effects get smaller. Good example is acupuncture. I was pretty connvinced that it worked for pain, nausea and vomiting, but when tested against better placebos the effect disappears. Now what these people seem to be saying is that they have given up on RCTs, because they didn't show what they wanted, so they now want to use unscientific methods to show it.

But in an odd way I am encouraged that it's now recognised that CAMs are placebos, although I still can't see a credible role for placebos in clinical practice.

 

[Asolepius]

Because 'real medicine' may have a side effect that is worse than the ailment? Assuming your breakdown of the placebo effect into two parts is valid, the problem is surely how to get 2 out of three; the contextual effect plus the expectation effect, in an ethical manner.

No, it's nothing to do with side effects. It's only about benefits. You can get the contextual effect ethically - eg by wearing a white coat - but can you get the expectation effect without lying to the patient?

 

[shuttlt]

CAM aside, surely it is right that placebo be included in any cost/benefit analysis, or is conventional medicine so good that this wouldn't make a spit of difference?

 

[Asolepius]

CAM aside, surely it is right that placebo be included in any cost/benefit analysis, or is conventional medicine so good that this wouldn't make a spit of difference?

It already is. Quality of life measurements include the overall impact of the treatment, as opposed to RCTs which measure specific effects. NICE uses RCTs to decide whether a treatment is effective, and QoL as an input to cost-effectiveness. What this report is demanding is that the RCT step is missed out.