A question about placebos ...

[Benguin]

Back when my grandfather ran a pharmacy shop (from the 50s) he and other relatives recall dispensing prescriptions explicitly marked 'placebo'. Obviously they'd just measure out some sugar pills.

They always maintained this was GPs catering to (older) patients who seemed to only be happy if they had a pill to take for their stomach/headaches/dodgy knee. Whether these were real symptoms of conditions for which effective medication did not exist, or just hypochondriacs I can't say.

My question is, do doctors still prescribe placebo remedies?

 

[Deetee]

No, they cannot prescribe anything that has no direct therapeutic value, and certainly nothing which has no active ingredient.

However, this is very different from prescribing or recommending that a patient have a drug which the doctor knows will have no clinical effect but might actually act as a placebo.

 

[Prester John]

I'd guess people are a lot more questioning and possibly even knowledgable these days. The argument seems to be whether decieving the patient can be justified for a potential benefit.

http://www.medicalcrossfire.com/debate_archive/2000/March_00/Placebo.htm

http://www.fda.gov/fdac/features/2000/100_heal.html

from the first link:

Given the power of suggestion that placebos and the placebo effect reveal, it is ironic to think that we should conclude that the deception is justified, when its success reveals so much more about the role of communication in the physician–patient relationship. Physicians should avoid the morally questionable practice of deceptive placebo use in favor of a respectful and beneficial relationship aimed at maximizing the patient’s own ability to heal within the morally appropriate framework of honest and caring communication.

 

[Badly Shaved Monkey]

I'd guess people are a lot more questioning and possibly even knowledgable these days. The argument seems to be whether decieving the patient can be justified for a potential benefit.

http://www.medicalcrossfire.com/debate_archive/2000/March_00/Placebo.htm

http://www.fda.gov/fdac/features/2000/100_heal.html

from the first link:

The really interesting question is whether the power of a placebo medication can ever be fully replicated by the right combination of bedside manner and patient education. What you'd need would be studies that compare no intervention at all vs psychological support with or without co-administration of a placebo. Thhis would be easiest for conditions with no useful treatment already in existence: you'd have difficulty justifying a study in which no one gets any 'real' drug or you end up with so many treatment groups that it becomes unwieldy.

 

[Nucular]

As far as I know in this country (UK) placebo treatment doesn't have any kind of 'official' use.

However, I have known a kind of semi-official use of placebo, though I'm not sure whether this use was contrary to any of the service policies applying to the ward or NHS trust where it was used. For that reason I don't want to give away too much information about where it happened, but it was in a mental health ward where I used to work as a nursing assistant.

A patient who had severe psychiatric problems which led often to extreme discomfort and sometimes violence was prescribed PRN (as-and-when) medication for when she was very upset. Whenever she was upset, she would demand the medication, and would often become worked up if she couldn't get it immediately (especially when she had already reached the dose limit for that day).

However, when given the medication, she would calm down instantly, and her mood would alter for the better, in a far quicker time than the medication would have taken to have an effect. It seemed really unpleasant to be giving a lot of potentially harmful medication when its main effect was clearly psychological, but there didn't seem to be a viable alternative, as the patient's behaviour was extraordinarily difficult to manage, ward resources were vastly overstretched anyway, and staff and patients were endangered by this girl's behaviour (I still have a scar from one outburst!).

So, among the nurses, manager, psychiatrists and the patient's family, it was agreed to try a placebo in place of the medication - a smartie I believe, washed down with orange juice in a medicine cup. It actually worked quite well as far as that particular behaviour went. Though there were perhaps better possible approaches to the problem (a structured behavioural approach, perhaps), practically speaking the placebo approach was a bit more realistic given the circumstances, and nobody involved had any objections, since this solution had everyone's best interests at heart.

I've worked in various mental health wards and clinics since, and have never come across this practice again. But, though it was recorded properly in the patient's notes, etc., I'm not sure anybody investigating the use of placebo medication in clinical practice would have been able to discover this instance, which makes me wonder if it might be a bit more widespread than we might think from official policies and empirical enquiries.

 

[Dr.Stefano]

I've worked in various mental health wards and clinics since, and have never come across this practice again. But, though it was recorded properly in the patient's notes, etc., I'm not sure anybody investigating the use of placebo medication in clinical practice would have been able to discover this instance, which makes me wonder if it might be a bit more widespread than we might think from official policies and empirical enquiries.

Nucular, this practice is usual in some situations, like patients with signs of addiction to pain drugs. Some patients with excrutiating pain gets better imediately after an IV medication that should work only about half an hour. In this cases, I usually try to use saline instead of the real drug. It´s amazing how often the pain goes away in these patients...

 

[Badly Shaved Monkey]

Nucular, this practice is usual in some situations, like patients with signs of addiction to pain drugs. Some patients with excrutiating pain gets better imediately after an IV medication that should work only about half an hour. In this cases, I usually try to use saline instead of the real drug. It´s amazing how often the pain goes away in these patients...

Pain is an interesting topic in this regard because, ultimately, all pain is only 'in the mind'. If the brain refuses to register pain it doesn't exist in any meaningful way whereas a broken leg exists objectively whether or not its owner wishes to acknowledge it.

Conversely it must be the case that pain can be imagined in the absence of a real physical basis for it, yet it is just as 'real' for the mind suffering it.

 

[Nucular]

Nucular, this practice is usual in some situations, like patients with signs of addiction to pain drugs. Some patients with excrutiating pain gets better imediately after an IV medication that should work only about half an hour. In this cases, I usually try to use saline instead of the real drug. It´s amazing how often the pain goes away in these patients...

That's interesting - presumably that's in Brazil? As i said, I haven't seen it used since in the UK (that's not to say I haven't just missed it). In the UK NHS practices like this are usually caught up in an ethical minefield and various policy documents (of which there are a frightening amount). Do you have these restrictions to work around in Brazil, or have you got more freedom to decide whether it's appropriate yourself?

 

[Sarah-I]

This is perfectly possible and is known as somatisation. There is genuine physical pain that is felt, but without a physical cause. Mostly, this can be due to emotional problems where the psyche produces the pain. It is 'all in the mind', but is no less real to the person who is suffering at the time.

 

[Dr.Stefano]

That's interesting - presumably that's in Brazil? As i said, I haven't seen it used since in the UK (that's not to say I haven't just missed it). In the UK NHS practices like this are usually caught up in an ethical minefield and various policy documents (of which there are a frightening amount). Do you have these restrictions to work around in Brazil, or have you got more freedom to decide whether it's appropriate yourself?

We can not prescribe placebos here either. What I described is not the use of placebo as a treatment, but a diagnostic ( and very useful ) tool in controled situations. After we know that there is no real cause of pain, we usually call for help from the psychiatrist and prescribe lighter analgesics.

 

[Dr.Stefano]

This is perfectly possible and is known as somatisation. There is genuine physical pain that is felt, but without a physical cause. Mostly, this can be due to emotional problems where the psyche produces the pain. It is 'all in the mind', but is no less real to the person who is suffering at the time.

Sarah, I agree with you. The pain is real, but the cause is very different. In this case, the treatment approach should be quite different and analgesic drugs have little effect.

 

[JamesM]

Interesting thread.

I was involved in a 'discussion' about this the other week. I was told it was common practice to prescribe placebos to people with high blood pressure, if the condition was exacerbated by their hypochondria (this is in the UK). I was then roundly ridiculed when I suggested that there was perhaps just the teensiest possibility of an ethical dilemma involved in this practice.

Based on this thread, do I have enough evidence to go and carry out a war dance of correctitude near those who opposed me and then raise the flag of righteousness up the flagpole of victory and have a good old salute?

Yes, the sort of discussions I have are very mature.

 

[Dr.Stefano]

I was involved in a 'discussion' about this the other week. I was told it was common practice to prescribe placebos to people with high blood pressure, if the condition was exacerbated by their hypochondria (this is in the UK).

I never saw this kind of practice.