Respectful Insolence

The “myth” of placebo effects

Heidi Stevenson amuses me.

The reasons are legion. Be it the time when Heidi lectured scientists on anecdotal evidence (which she values far more highly than scientists, of course, declaring it the “basis of all knowledge”); launched a vile and nonsensical attack on Stephen Barrett; argued against prior plausibility with using a straw man argument so massive that if it were set on fire (which she did) it could be seen from space; or made an even more idiotic argument to try to “prove” that wi-fi signals and EMF cause autism, Heidi never fails to deliver the stupid in mass quantities of black hole density. Of course, what does one expect? Stevenson is a homeopath, after all. Anyone who can believe the pseudoscience and wishful thinking that underlies homeopathy is already almost by definition lacking more than a little something in the logic department. Certainly she’s missing a lot in the science department as well. All of this is why she amuses me so much and why on occasion when she catches my attention I feel like laying down just a touch of that not-so-Respectful Insolence that you all know, love, and crave. True, sometimes I feel as though I’m slumming, but in actuality Stevenson’s very useful in that she is very good at demonstrating logical fallacies and misunderstandings of science that provide a number of what we in the science and skeptical blogging biz like to refer to as “teachable moments.”

Yesterday, Stevenson provided yet another in her long line of teachable moments in the form of a post entitled, Busting the Placebo Myth: Placebos Don’t Cure. In it, she rails against us nasty, pointy-headed skeptics who point out that placebos only make people think they feel beter and don’t actually make people better. The hilarious thing is that she uses studies that I’ve blogged before in order to come to exactly the wrong conclusion. Stevenson’s great that way. Even better, since I’ve blogged these studies before, I can try to get a handle on my logorrhea in this post. Well, no I can’t. As Hans Solo said, “Hey, it’s me.” I can keep it short for a while, but sooner or later the logorrhea always returns. Whether it will return during this post or not, you’ll just have to keep reading to find out. We’ll have to see if it works out. Either way, it’ll be entertaining and educational. I promise.

Clearly, Stevenson is really, really peeved at the criticism of her quackery that labels it as “placebo medicine.” Of course, as I’ve discussed time and time again the vast majority of so-called “complementary and alternative medicine” (CAM) or, as it’s called now, “integrative medicine,” is based on placebo medicine and the idea that wishing makes it so. I realize that Stevenson doesn’t like that, but that’s just tough. Reality is reality, quacks are quacks, and science is science, and never the three shall meet at the same time. In any case, Stevenson starts out:

One of the most frequent epithets tossed at people who make claims of alternative medicine is that it’s just the placebo effect. But that is based on the myth that placebos can cure. The reality, as clearly documented by science, is that they don’t. So the skeptics base their favorite claim on a myth, not reality, and most assuredly not on science.

Stevenson then goes on a brief rant about what she refers to as the “myth” of placebos, including that placebos don’t heal, that placebos are a “complete flop,” that no one is ever “cured” by a placebo. Of course, these are not myths. They are more or less true, except for the second one. Even skeptics don’t say that placebos area a “complete flop.” we’re all for studying placebo effects and determining ways to maximize it during treatment with actual…oh, you know…effective medicine. What we don’t approve of is relying on placebo effects alone, which is what the vast majority of CAM is. Not only is it unethical to lie to patients that way, but it doesn’t help the pathophysiology of the condition being treated. To most ethical, science-based physicians, that’s a double whammy against using placebos that can’t be overcome. The first funny thing is that, in order to make her point, Stevenson in essence buys into this point. Rather than trying to argue for the “pwoerful placebo,” some like to put it, or The Secret, as I like to put it, she actually does her best to rubbish placebo effects as insignificant as an introduction to arguing that any condistions “cured” by alternative medicine couldn’t possibly have been cured by placebo effects. This is a straw man even bigger than the aforementioned straw man whose demolition with napalm-grade flaming stupid could be seen from space. That straw man is that skeptics dismiss “healing” by alternative practitioenrs as being due to placebo effects.

The second funny thing about this article is that Stevenson relies largely on Ted Kaptchuk, the Harvard high priest of acupuncture studies in quackademic medicine in the United States. Just type his name into the search box of this blog, and you’ll see that I’ve discussed him many times before in the context of how the results of his studies do not show what he concludes that they show or what they are claimed to show by advocates and the press. It thus amuses me greatly that both of the studies that Stevenson chooses to use to demonstrate her point are ones that I wrote. One I wrote about a couple of years ago—along with practically every skeptical blogging doc out there. Amazingly, Stevenson more or less correctly interprets the study:

The study used FEV1, Forced Expiratory Volume in 1 Second, to measure effectiveness. The graph on the left clearly shows that the drug placebo and sham acupuncture (another kind of placebo) had no curative effect, as they didn’t cause any change in FEV1. However, in the graph on the right, you can see that the subjects felt that both the drug placebo and sham acupuncture were nearly as effective as the actual drug, albuterol.

Two things are clearly demonstrated. One is that a patient’s sense of well-being can readily be skewed by belief. The other, though, is that placebos have absolutely no healing benefit.

It kind of creeps me out that that’s more or less what I concluded in my analysis of this particular study. She also discussed the infamous “placebos without deception” study by Kaptchuk that was sold as evidence that you don’t have to lie to patients in order to invoke placebo effects but, when examined more closely, shoed nothing of the sort. For a moment, I was wondering if I was losing my sanity. What kept me from getting too worried was the tone of the article, very confrontational to science-based medicine and skeptics. Also, the sarcasm. Given how good I’ve become at not-so-Respectful Insolence, I’m very much in tune with other people’s sarcasm, and Stevenson was being quite sarcastic. I knew there had to be a reason and that there would be a payoff, and I wasn’t wrong:

The claims by skeptics that the placebo effect can explain away any and all results of alternative medicine are pure bunk. They’re based on a false belief, the idea that the placebo effect is so powerful that it can cure. That is nothing but a myth. They can palliate—make people feel better—but never cure.

The placebo effect can be powerful in terms of people’s sense of health and welfare. However, no one is ever healed by a placebo. Therefore, when someone is actually cured by an alternative treatment, the false bravado of the skeptics, who invariably come streaming along shouting about the placebo effect, usually full of condescension and insults, is nothing more than that—hot air based on a belief that is founded only in myth.

The simple fact is that placebos cannot cure. So those claims of successful treatment for diseases that are not subjective—such as cancer, autism, mastitis in cattle, skin conditions, or any other—cannot be denied with that off-hand line, “But, my dear, it can easily be explained by the placebo effect.” No, it cannot.

And there’s the flaming straw man.

In fact, I challenge Heidi Stevenson to produce an example of a skeptic dismissing an “alternative” therapy story in which cancer, autism, mastitis in cattle (where did that one come from?), or skin conditions were “cured” by alternative medicine as being just due to placebo effects? Cancer is a very good example. Many are the times that I’ve spoken about alternative medicine “cancer cure” testimonials, going all the way back to the very beginning of this blog and continuing forward. What you’ll find are explanations of the potential for spontaneous remission, what the difference between adjuvant therapy and curative therapy is and how alternative cancer cure testimonials confuse them, and a variety of other explanations. One thing you will not find is me trying to dismiss these cancer cure testimonials as being due to placebo effects. Indeed, if I ever saw a skeptic trying to do that, that skeptic might well himself become the target of a little bit of not-so-Respectful Insolence. And he’d deserve it, too.

In a way, maybe Stevenson can be forgiven for thinking that the only arguments skeptics have against alternative medicine is to label it all as “placebo.” She is, as has been noted before, a homeopath, and if there is a form of “medicine” that is nothing more than pure placebo, it’s homeopathy. However, that doesn’t mean that pointing to placebo effects is the only weapon in the skeptical arsenal against the unscientific and pseudoscientific claims of alternative medicine. it is but one of many, and it’s generally only invoked—and correctly so—when claims about the ability of this quackery or that to relieve pain, anxiety, or other subjective symptoms. No one—and I mean no one—tries to dismiss alternative cancer cure testimonials, for example, as mere placebo effect. Ditto the issue of autism, the “cure” of which is generally discussed in terms of development (autism is a condition of developmental delay, not stasis) and not placebo effects. Improvements in skin conditions are usually explained by how such conditions often wax and wane.

In the end, I can’t help but wonder how Stevenson’s fellow quacks will react to her dismissing the ability of placebo effects to cure as a “myth.” Somehow I suspect they won’t be so happy. At least, Mike Adams won’t.

Comments

  1. #1 Heliantus
    March 21, 2013

    Busting the Placebo Myth: Placebos Don’t Cure

    Can we quote her next time someone proposes to harness the placebo effect?

  2. #2 palindrom
    March 21, 2013

    Crowd: We need a cure! We need a cure!

    Dr. Hibbert: Ho ho ho. Why, the only cure is bedrest. Anything I give you would be a placebo.

    Woman: [frantic] Where can we get these placebos?

    Man: (points at truck) Maybe, there’s some in this truck!

    (Crowd knock over truck and a box of killer bees from it break out and attack the crowd. A man, thinking the bee is a vaccine, takes it and swallows it)

    Man: I’m cured! I mean, ouch!

    — The Simpsons, “Marge in Chains”

  3. #3 palindrom
    March 21, 2013

    On that Simpsons quote — the crowd was upset because the dread Osaka Flu was going around.

    Ironically, the Osaka Flu arrived in Springfield from Japan in boxes of “Juice Looseners”, which had been pushed on TV in an infomercial by quack Doctor Nick Riviera and washed-up movie star Troy McClure.

    Homer and others had ordered them: (Homer: “Gotta get a juicer! Won’t get chest pains from answering the phone any more!”); the juicers were packed by hyperconscientious Japanese workers working sick, and the rest followed.

    And that wasn’t even the main storyline.

  4. #4 Dangerous Bacon
    March 21, 2013

    Orac can sneer at homeopaths, but I bet he’s never cured a case of bovine mastitis.

  5. #5 Mephistopheles O'Brien
    March 21, 2013

    Actually, Stevenson’s argument is pretty good:
    1. Placebos don’t cure anything, they just make people feel better sometimes.
    2. Alternative medicines cure things.
    ergo, Alternative medicines are not just placebos.

    Now, if she could only prove statement 2 were true, she’d have a case.

  6. #6 Leigh Jackson
    March 21, 2013

    So Stevenson get’s placebos but doesn’t get that CAM is a synonym for placebo. So funny one just has to cry.

    Compare and contrast her take with that of Jeremy Howick of the Centre for Evidence-Based Medicine (University of Oxford) in todays Times: “Placebos work… if doctors are happy prescribing them, we should take them.”

    Placebos don’t have to be deceptive to be clinically effective says Howick, quoting Kaptchuk’s “open” placebo study for irritable bowel syndrome.

    With Kaptchuk it seems like you pays your money and you makes your choice.

  7. #7 Denice Walter
    March 21, 2013

    @ Helianthus:

    Ha. Some woo-meisters speak as if ‘placebo’ incorporated a species of healing energy that is unleashed whenever woo transpires allowing the body to heal itself perhaps through the liberation of its own energy in resonant response. In other words, sympathetic magic.

    In other placebo-centric news:

    AoA has been in an uproar about a new study that reveals (gasp!) a 2% autism rate ( a phone survey/ see LBRB).

    Jake strikes back:
    ” And of course, Roy Richard Grinker is bringing dow the reputation of GW by using his academic stature to deny the autism epidemic once again”.

    I’m sure he actually believe that.

  8. #8 Denice Walter
    March 21, 2013

    I lost comments due to an error on my part:

    Helianthus:
    Some woo-meisters speak as if placebo were a means to liberate the healing energy that naturallyresides within the body. Probably through resonance. In other words, magic.

    In other news:
    AoA carries on about a new autism rate of 2 % based on a PHONE survey.
    Jake complains about Prof Grinker destroying GW’s reputation by ‘epidemic denialism’.

  9. #9 sophia8
    March 21, 2013

    mastitis in cattle (where did that one come from?)

    Can Homeopathy Cure Mastitis in Cows?

  10. #10 Denice Walter
    March 21, 2013

    Stevenson writes at Green Med Info and Gaia Health**.
    Here’s an article from the latter ( 2010):
    ” Big Pharma Scores Big Win: Medicinal Herbs Will Disappear in EU”
    She cites Verkerk ( ANH).

    ** talk about swampish sinkholes of unreason.

  11. #11 Dangerous Bacon
    March 21, 2013

    Can you do a phone survey of cows?

    (lows softly)

  12. #12 lilady
    March 21, 2013

    “….mastitis in cattle (where did that one come from?)”

    You’ve gotta love YouTube for testimonials….

    http://www.youtube.com/watch?v=PmI_Mb_bRoo

  13. #13 Denice Walter
    March 21, 2013

    There is one thing about placebos:
    when you actively pursue a treatment, follow a diet, execise as well as PAY for these interactions, you are motivated to believe that they have an effect.
    If you invest time, thought, energy, effort and money in something, you want to believe in it.

  14. #14 Todd W.
    http://www.harpocratesspeaks.com
    March 21, 2013

    @Denice Walter

    AoA carries on about a new autism rate of 2 % based on a PHONE survey.

    Well, they can criticize the CDC for conducting a phone survey, because they’re the CDC and, therefore, wrong. But when AoA conducts a phone survey, even when the results don’t say what they want them to say, the survey is slamdunk evidence that vaccines cause autism.

    Then again, in the same breath they criticize the study for being a “mere” phone survey, they also go on and on about “ZOMG! 1 in 50 now!” So is the survey reliable or not?

    Then there’s also Teresa Conrick’s “research” about Alzheimer’s and Autism sharing a connection: other than both starting with “A”, seniors and kids both get the flu vaccine! The horror! Right? Then again, Ms. Conrick is also the one who blamed thimerosal for her daughter’s eyes (which were blue at birth) changing color to a brownish green, rather than understanding that babies are commonly born with blue irises that change color as they age.

  15. #15 Denice Walter
    March 21, 2013

    @ Todd W.:

    Ms Conrick has produced the most baroquely inelegant and convoluted hypotheses that I have ever seen.
    That must be some osrt of an accomplishment.

  16. #16 Todd W.
    http://www.harpocratesspeaks.com
    March 21, 2013

    @Denice Walter

    Her technique can be summed up thusly: “! Research! Dots! Connect them!” and then she drops the mic and walks off stage.

    And on-topic, when, oh when!, will people stop citing Kaptchuk? Especially that study purporting to look at “not misleading people about placebos” that actually did mislead them?

  17. #17 Todd W.
    http://www.harpocratesspeaks.com
    March 21, 2013

    Whoops. Forgot that pointy brackets are HTML code delimiters. That should have been “[Random quotes that sound scary]! Research! Dots! Connect them!”

  18. #18 Bronze Dog
    March 21, 2013

    The absolute most I think I’d ever say about cancer and placebos is that a placebo might make the patient feel better about the subjective symptoms. It wouldn’t do anything whatsoever about the cancer itself or any of the objectively measurable symptoms. If the cancer coincidentally went into remission, I wouldn’t give the placebo any credit for it, but alties probably would, since they so commonly rely on the post hoc fallacy.

  19. #19 Krebiozen
    March 21, 2013

    Stevenson’s article is one of the most jaw-droppingly dumb I have read in a long time. Homeopaths and acupuncturists make a living by persuading patients to mistake a placebo effect for a real effect of their treatment.

    A paper on placebo use came out today:Placebo Use in the United Kingdom: Results from a National Survey of Primary Care Practitioners

    Placebo use is common in primary care but questions remain about their benefits, harms, costs, and whether they can be delivered ethically. Further research is required to investigate ethically acceptable and cost-effective placebo interventions.

  20. #20 Krebiozen
    March 21, 2013

    The press release from Southampton University about that paper is also interesting:

    “This latest study with the University of Oxford demonstrates that doctors are generally using placebos in good faith to help patients,” says Professor George Lewith, co-lead author of the study from the University of Southampton. “Other previous published studies by Southampton have clearly shown placebos can help many people and can be effective for a long time after administration. The placebo effect works by releasing our body’s own natural painkillers into our nervous system. In my opinion the stigma attached to placebo use is irrational, and further investigation is needed to develop ethical, cost-effective placebos.”

    That’s not quite how I see placebos. Has it really been demonstrated that placebos work, “by releasing our body’s own natural painkillers into our nervous system”? I thought much of what is called “the placebo effect” isn’t really an effect at all, but an illusion collectively caused by regression toward the mean and various cognitive biases. If we are talking about subjective changes due to suggestion, perhaps we should call them that, and abandon the term “placebo effect” altogether as hopelessly misleading.

  21. #21 Mike Olson
    Sherrard, Illinois
    March 21, 2013

    Hi there! Lay person here. I have a liberal arts degree and worked as a lab tech in the Navy. I read popular science books, (some of which various science bloggers have written) and “Scientific American.” Just trying to give you an idea of my background. I read a book called something like, “Hacks, Quacks and Big Pharma flacks.” Which seemed to truly contradict the notion that placebos did nothing to help a person feeling better. Simply believing a med or procedure would work better or make a person feel better actually induced immunological responses…according to the book. Responses to name brand drugs were quicker than generics, as I recall.

    I don’t bring this up to contradict any argument against snake oil salesmen( or women), but rather to suggest that a premise of, “Placebos just make a person feel better it they don’t make them better,” is probably wrong. At least from what this ill informed, somewhat literate lay person has read.

    Can anyone clarify this for me?

  22. #22 Narad
    March 21, 2013

    mastitis in cattle (where did that one come from?)

    Taken apart by SkeptVet here.

  23. #23 Alan Kellogg
    Soon to be repurposed City Library
    March 21, 2013

    Drugs don’t heal people, drugs make it easier for people to heal themselves.

  24. #24 Beamup
    March 21, 2013

    I read a book called something like, “Hacks, Quacks and Big Pharma flacks.” Which seemed to truly contradict the notion that placebos did nothing to help a person feeling better. Simply believing a med or procedure would work better or make a person feel better actually induced immunological responses…according to the book.

    You can measure certain physiological responses, certainly. What nobody’s yet been able to do convincingly is show that they are MEANINGFUL rather than simply measurable.

    The classic example is that acupuncture produces changes in the brain visible in an fMRI. Well, sure. The brain registers that it’s feeling something. Does this mean that acupuncture actually does anything meaningful? No, in order to say that you’d have to measure an actual clinical outcome.

    In short, saying “placebo works, look, I can measure a change in this lab value” can be accurately translated as “look, placebo doesn’t really do anything, since the most effect I can find is in some random lab value rather than talking about a clinical result.”

  25. #25 St Thomas
    March 21, 2013

    https://www.youtube.com/watch?feature=player_embedded&v=ntWO7jnOcWE

    How placebo prescribing may work in practice.

  26. #26 Leigh Jackson
    March 21, 2013

    @ Krebiozen, 18,19

    The oh-so-cautious official conclusion of the study regarding the scientific and ethical status of placebos belies the two co-leads loud and laudatory public endorsement of GPs use of placebos.

    The only unequivocal thing the study recommends is further research on placebos. Hardly surprising given that Lewith heads one of the two co-funders of the study.

    “The Southampton Complementary Medical Research Trust was specifically established to raise money and aid the research development at the Complementary Medicine Research Unit at the University of Southampton.”
    http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1193549/

    And turkeys do not vote for Christmas:
    http://www.drrogersprize.org/files/bio-lewith.php

  27. #27 Denice Walter
    March 21, 2013

    I would so totally NOT go with concept of the placebo effect being an expression of endogenous opiates.

  28. #28 S
    March 21, 2013

    Doctors that prescribe placebos to their patients should be paid with placebo cash. Turnabout is fair play, right?

  29. #29 Krebiozen
    March 21, 2013

    Mike Olson,

    Simply believing a med or procedure would work better or make a person feel better actually induced immunological responses…according to the book.

    I think this is a common misconception. Most clinical trials compare an active treatment to a placebo, and it is easy to assume that any measured changes in patients in the placebo arm of the study are caused by the placebo. If you look at clinical trials that include a ‘no treatment’ arm, you will usually find that patients who have no treatment do just as well as those given a placebo.

    My favorite example is this study which is often cited as evidence that sham knee surgery (making an incision and then simply sewing it back up) is as effective as lavage (washing out the joint) and debridement (basically scraping out the joint), thus demonstrating the awesome power of the placebo. However:

    The authors found that all three treatment groups fared equally: each reported subjective symptomatic relief, but no objective improvement in function was noted in any of the groups.

    In other words, none of these interventions had any objective effect on knee function, only on subjective assessment of pain, and we don’t even know if patients given no treatment at all might have reported a similar reduction in pain over time, since the study lacked a no treatment group. The placebo wasn’t awesome at all, it was as useless as the surgical interventions.

    Similarly, you can find lots of studies of alternative therapies that are essentially placebos, for example therapeutic touch, that have no consistently measurable effect on an objective measure, for example, wound healing, as in this study. If you can find a study that shows a placebo has a consistent and significant objectively measurable effect as compared to no treatment I would be very interested.

  30. #30 Krebiozen
    March 21, 2013

    Leigh Jackson,
    Thanks for the information on the authors of that placebo study, which confirms my suspicions.

  31. #31 Denice Walter
    March 21, 2013

    Interestingly, one of the winners of the prize in 2007 was
    Abram Hoffer of Orthomolecular fame.
    If his ideas win a prize, I’d hate to read what the runners up and losers promulgate.

  32. #32 Mike Olson
    March 21, 2013

    Krebiozen

    Thank you. What you’ve reported sounds very similar to what was written in the book. I’d thought it had been mentioned in that same book, however, that if persons had some sort of infection and were given antibiotic, their immune system would respond with a given set of antibodies. Over time, even if they were given a placebo that appeared similar to the antibiotic, their bodies would still respond with the same antibodies.

    It seemed like an odd effect…perhaps I read it wrong. The author did indicate that essentially all persons are susceptible to the placebo effect and it had nothing to do with being “weak minded” or some defect of character. Again your response seems to be in the same vein as what he had written.

  33. #34 Narad
    March 21, 2013

    @Will: That tangentially reminds me that back when I was an undergrad, we were sneaking Zilog chips to Roald Sagdeev.

  34. #35 lkr
    March 21, 2013

    Homeopathic cures for mastitis in cattle
    PLUS
    Raw milk for ADD, allergies, colds, etc. etc. in unvaccinated kids
    — what could go wrong?

  35. #36 Darwy
    Røde grøde med fløde
    March 22, 2013

    A telephone survey for cows?

    Let me fire up the grill… I think we’re having steaks tonight…

  36. #37 herr doktor bimler
    March 22, 2013

    Homeopathic cures for mastitis in cattle
    I am waiting for the acupuncture version. Tell you want, *you* stand behind Buttercup and stick the needles in, *I’ll* watch from a safe distance.

  37. #38 Martin
    March 22, 2013

    HDB: That sounds likely to result in the joke whose punchline is “If you can persuade my wife I was going to milk that cow, I’ll buy a tractor from you.”

  38. #39 Krebiozen
    March 22, 2013

    Mike Olson,

    Over time, even if they were given a placebo that appeared similar to the antibiotic, their bodies would still respond with the same antibodies.

    I suspect you mean ‘antigen’, not ‘antibody’, and I think you are referring to learned histamine release. Our immune system does seem to be susceptible to Pavlovian conditioning to some extent – this study found you can condition a rat’s immune systems to respond to an audiovisual cue, for example. It’s interesting, but I don’t see how that means placebos ‘work’ in the sense of having an objective effect on the body. It sounds to me as if the author of that book is looking for explanations of how placebos ‘work’, when the best evidence suggests that they don’t.

  39. #40 Krebiozen
    March 22, 2013

    Maybe I should declare myself as a lapsed placebo-effect believer – a few years ago I was hopeful that the field of psychoneuroimmunology would revolutionize medicine, but I have been sorely disappointed.

    Another example I find interesting is in a TV show, ‘Miracles For Sale’ (blocked in the UK) in which Derren Brown’ teaches a man many of the tricks of faith healing. The section I am thinking of is where he goes out on the street and ‘heals’ people – you will find it starting at 56:38 – the very first person who is ‘healed’ reports a pain in his leg reduces from a level of 10 down to zero. That’s pure suggestion, but I would be willing to bet that there was no objective improvement in his leg. I think that’s the extent to which placebos ‘work’.

    As to whether this is clinically useful, I think that’s debatable. In the sense that a placebo may persuade a patient to go away and stop bothering a doctor, then perhaps they have a use. On the other hand prescribing antibiotics for viral infections as a sort of placebo has contributed to the spread of resistant bacteria, and feeling better when you’re not can be dangerous, in asthma for example.

  40. #41 Krebiozen
    March 22, 2013

    To confuse matters I wrote above in #39, “I suspect you mean ‘antigen’, not ‘antibody’”, when I meant, “I suspect you mean ‘antigen’, not ‘antibiotic’. Hopefully you got my drift.

  41. #42 Dr. Nancy Malik
    Gurgaon, India
    March 22, 2013

    Placebo is an inactive dummy/inert pill (substance such as lactose/saline which do not alter the disease condition) prescribed to the patient for enhancing he non-specific effects of the treatment and/or the doctor does not want to disturb the course of action of previously prescribed medicine till it completes its own run.
    Ref: http://drnancymalik.hpathy.com/2012/08/17/understanding-evidence/

  42. #43 Bronze Dog
    March 22, 2013

    One additional aspect I think is worth mentioning when it comes to subjective improvement in pain and the like: Some people are naturally polite, encouraging, or adverse to confrontation. If they see a doctor working to help them, they might report improvement, even if there is none, to avoid impugning the doctor’s competence. That’s probably one of the more subtle components of the placebo effect: Some patients will lie, understate, or exaggerate to make the doctor feel better.

    Add in the popular altie methods of blaming the victim, and some will feel pressured to always report improvement and cover up symptoms in order to avoid being shamed by their quack, guru, and/or altie friends.

  43. #44 Krebiozen
    March 22, 2013

    I see we have been subjected to a no-doubt hit-and-run visit from Nancy Malik who has been described as a “homeopathy shill, fact-blind delusional crank and serial comment spammer” . I suppose that’s appropriate for a post about placebos.

  44. #45 Beamup
    March 22, 2013

    @ Nancy:

    That is not accurate. The concept of a placebo is very much broader. A nice chat with a “practitioner” who assures you they can fix anything that’s wrong, for example, would very much qualify by the standard definition.

    Of course, I can’t expect anyone who claims to practice “evidence-based homeopathy” to understand that. The only legitimate evidence-based view of homeopathy is that it is completely bogus and does nothing… because it is, in fact, a placebo.

  45. #46 Krebiozen
    March 22, 2013

    Bronze Dog,

    Some patients will lie, understate, or exaggerate to make the doctor feel better.

    I agree, and none of these are helpful to the patient in the slightest. They may even discourage her/him from giving the doctor important information about her/his condition.

  46. #47 Todd W.
    http://www.harpocratesspeaks.com
    March 22, 2013

    Guys, you’re being too hard on Nancy Malik. You see, she’s describing homeopathy: an inactive dummy/inert pill (e.g., lactose) that does not alter the disease condition.

  47. #48 Tom Herling
    March 22, 2013

    Audio engineers will often rely on placebo effect to placate some impossible client who, during a recording session wants more “purple”–our code for some inaudible but highly desired effect.

    So knowing that an audio console usually has several redundant controls, we show our client a knob that does nothing, and let them operate it so they have control over the amount of “purple.” Then we rehearse a couple of times (“Did you get it?” we ask, “Almost, let’s try it again,” says the client) until we get it “right” and can head home, but only after we’ve reached our desired amount of billable hours.

  48. #49 Leigh Jackson
    March 22, 2013

    Re: placebo, qua endogenous opiates cum psychoneuroimmunology cum clasical conditioning.

    Would be interested to hear views on the work of Fabrizzio Benedetti. Typically, for example:
    http://rstb.royalsocietypublishing.org/content/366/1572/1790.long

    In similar vein, Zubieta/Stoler:
    http://www.ncbi.nlm.nih.gov/pubmed/19338509?dopt=Abstract

  49. #50 Krebiozen
    March 22, 2013

    Leigh Jackson,
    I’ll read and respond to the material you linked to in more detail in a day or two when I have had time to ponder it properly, as it’s an area that still greatly interests me.

    Briefly, placebos do appear to have an effect on perceived pain, but I wonder if that is as significant as the authors you refer to think. If I stomp on someone’s foot it may increase their endorphin levels and/or distract from a pain elsewhere in their body, and this effect would also probably be blocked by an opiate antagonist like naloxone. I suspect the effect of placebos on subjectively assessed conditions such as pain may be similar to this. The important question is whether this is clinically useful, and I’m not sure it is.

  50. #51 Politicalguineapig
    March 23, 2013

    Here cookie

  51. #52 Leigh Jackson
    March 23, 2013

    Krebiozen,
    Thanks. We think alike. Howick and Lewith speak as if it’s all a done deal: placebos do produce clinical benefits and the mechanism is understood. They are calling on the GMC to allow free prescription of placebos on the basis that it already happens and that research like Benedetti’s validates the practice.

    I trust that the GMC has a fuller picture than I do on the overall state of science in these matters, but my own (non-physician, non-researcher) position is profoundly sceptical.

  52. #53 Melissa G
    March 23, 2013

    So, speaking of placebo effects, and it’s evil Mirror Universe twin, nocebo here’s a Slate article about wind farms and people who live near them freaking out.

    My question is, why don’t people ever ascribe HEALTH benefits to stuff like this??? Why isn’t it ever, “Infrasound cured my cancer!” or “Cell phones boost your brainpower!!!” or the like? Humans seem to be primed to accept the negative about stuff we don’t fully understand, rather than the positive. I would *think* it’s maybe a trait that helped us survive the dangerous predators and poisonous new foods or something… only people seem ready to accept ANY health claim for weird foods that taste disgusting (goji berries, anyone? :P).

    What’s up with people, y’all?

  53. #54 Krebiozen
    March 23, 2013

    Melissa G,
    You reminded me of this story from South Africa in which a microwave tower was alleged to be causing continuing, “headaches, nausea, tinnitus, dry burning itchy skins, gastric imbalances and totally disrupted sleep patterns”, before it was revealed it had been turned off for the previous six weeks. That’s another fine example of a nocebo effect.

    I have been reading the studies Leigh referred to, and some others, but I’m feeling more confused, if anything. For example they found that only 30-40% of patients respond to placebos, and that some types of placebo-induced analgesia are blocked by naloxone (which is an opioid inverse agonist, not an antagonist as I stated above) while others are not. It seems weird to me that the human body can produce effective endogenous analgesics, but only does so when it believes it has been given an external treatment. Even if this is correct, a drug for pain (or nausea etc.) that is ineffective in up to 70% of patients doesn’t seem very useful to me.

    By way of taking a step back from this, I looked at the Wikipedia article on placebos for the first time in several years, and found it very useful. It discusses, for example, Hróbjartsson and Gøtzsche’s Cochrane review (PMID: 20091554) of placebos that concludes:

    We did not find that placebo interventions have important clinical effects in general. However, in certain settings placebo interventions can influence patient-reported outcomes, especially pain and nausea, though it is difficult to distinguish patient-reported effects of placebo from biased reporting. The effect on pain varied, even among trials with low risk of bias, from negligible to clinically important. Variations in the effect of placebo were partly explained by variations in how trials were conducted and how patients were informed.

    Oddly, Wikipedia mentions criticisms of this review on the grounds that:

    Their meta-analysis covered studies into a highly mixed group of conditions. It has been reported that for measurements in peripheral organs the placebo effect seems to be more effective in achieving improvements in physical parameters (such as decreasing hypertension, improving FEV1 in asthma sufferers, or decreasing prostatic hyperplasia or anal fissure) than in improving biochemical parameters (such as cholesterol or cortisol) in various conditions such as venous leg ulcers, Crohn’s disease, urinary tract infection, and chronic heart failure. Placebos also do not work as strongly in clinical trials because the subjects do not know whether they might be getting a real treatment or a sham one. Where studies are made of placebos in which people think they are receiving actual treatment (rather than merely its possibility) the placebo effect has been observed. Other writers have argued that the placebo effect can be reliably demonstrated under appropriate conditions.

    Can placebos really achieve improvements such as “decreasing hypertension, improving FEV1 in asthma sufferers, or decreasing prostatic hyperplasia or anal fissure”? That question led me to this meta-analysis, which did a MEDLINE search for placebo-controlled studies on “peripheral disease processes”. However, I note that they state:

    Because the selected trials did not include untreated control groups, we restricted the dataset to trials on stable disease conditions, from which the effects of placebo treatments could be estimated by baseline changes within the placebo groups.

    No untreated control groups again, which leaves me feeling somewhat underwhelmed by the barely significant placebo effects on physical parameters they found in this and on reanalyzing Hróbjartsson and Gøtzsche’s data. I’m reminded of studies on homeopathy and acupuncture which show barely statistically significant effects that would be of little clinical usefulness even if they were reliably reproducible which they are not. I suspect many of the results Benedetti, Zubieta, Stoler et al have been pursuing are little more than artefacts in noise.

  54. #55 Leigh Jackson
    March 24, 2013

    We feel happy if good stuff happens to us: “here is something to help you feel better” – a placebo. The good stuff here is someone saying they can help us to feel better: lo and behold we do feel a little better! The placebo works? Nope. The good news worked – subjectively.

    Turn it all round: if we feel good then good stuff will happen to us. This is what needs to be true if a placebo is to cause objective clinical benefits. The good news that someone has something to help us makes us happy and then our feeling of happiness leads to our bodies repairing themselves.

    Obviously too good to be true except at the margins of bodily health. And then not at all easy to demonstrate.

    As for the idea of non-deceptive placebos, pull the other one. If you can see you are only getting a toothpick prick of your skin and not an acupuncture needle into your flesh you are not going to get the magical placebo benefit of acupuncture; now are you? For the magic trick to work you need deception.

  55. #56 Dr. Nancy Malik
    Gurgaon, India
    March 24, 2013

    @beamup

    Efficacy is the extent to which the medical treatment/intervention has the therapeutic effect under ideal test conditions

    1. Specific (pharmacological/physiological) effects: patients getting better because of the therapeutic effects of the medical treatment/intervention.
    2. Non-specific (psychological/placebo) effects:The body’s healing response is activated

  56. #57 Chris
    March 24, 2013

    And Nancy “robospammer” Malik, homeopathy is literally nothing and does not help with anything except to transfer cash from the patient’s wallet to your bank account.

  57. #58 Krebiozen
    March 24, 2013

    Nancy Malik,

    Non-specific (psychological/placebo) effects:The body’s healing response is activated

    Maybe I’m lucky, my body activates its healing response automatically, without any need for particular psychological conditions or a placebo, and rarely requires assistance from active outside agents. Why would the body require a placebo to persuade it to activate its healing response?

  58. #59 Denice Walter
    March 24, 2013

    @ Krebiozen:

    No no no!
    The placebo activates the inherent bioenergetic sytem (TM) which has been a-slumbering, its Xi ( qi, ki, mana, prana, life energy et al) obviously requires raw food, hand waving, energy medicine, alkaline water, chakra balancing, body work, acupuncture etc to inspire its get-go to get going.

    But for some reason, they never taught us about that at our universities. I wonder why?

    -btw- how are the foxes?

  59. #60 Khani
    March 24, 2013

    #53 I know at least one person who finds the sound of a wind tower to be very pleasant. Sometimes he drives out to one and sits under it for a while, listening–he says he finds it relaxing. Cheaper than therapy, right?

    Their sound remind me a bit of a washing machine, or maybe the ocean, personally.

  60. #61 Shay
    The Illinois upland corn prairie
    March 24, 2013

    We live six miles from a wind farm. It ruins the view but it hasn’t driven anybody here crazy. Yet.

  61. #62 Krebiozen
    March 24, 2013

    Denice,

    The placebo activates the inherent bioenergetic sytem […]

    It seems like a serious design fault to me, having these marvelous inherent painkilling and healing abilities that only do their thing when we think something else is responsible.

    -btw- how are the foxes?

    There haven’t been many out and about recently; the mothers stay underground with their young at this time of year. We did see one with hair loss, probably sarcoptic mange today, the first we have seen in quite some time, which is worrying, though it may be an interloper from elsewhere, attracted by all the food available here.

    A few years ago we sent for some free fox mange medicine from an animal welfare charity, which turned out to be a homeopathic medicine i.e. a small bottle of distilled water. My wife used it, despite my skepticism, and I had to grudgingly admit it did seem to help though I suspect any real improvement was because of the bread and jam the medicine was administered on, which maybe provides some nutrients that the standard urban fox diet is lacking. Subsequent experience suggests that plenty of chicken scraps work just as well, which makes me wonder if it isn’t sarcoptic mange at all, but some sort of vitamin deficiency. Or perhaps placebos work on foxes, which neatly brings us back to the topic in hand.

  62. #63 Khani
    March 24, 2013

    #61 Ruins the view? I honestly find them very beautiful. I grew up on the prairie but I still find the flatness to be rather oppressive at times, and the wind towers add a nice vertical element, to me.

    Sometimes when I’m driving down the highway with wind towers on either side of my I do a little evil laughter and shout “THE POWER!!!! THE POOOOOWERRR!!!!!”

    … it’s a very long drive to visit my parents and with all the caffeine and sugar I consume to help stay awake, I get a little… funny.

  63. #64 Shay
    March 24, 2013

    Granted, there isn’t much of a view here unless you’re really into corn and soybeans. But what there is, was prettier before all them dang towers got put up.

  64. #65 Denice Walter
    March 24, 2013

    @ Krebiozen:
    I’m glad to hear that they’re still around…and multiplying.

    Nearby, our *suburban* foxes ( they all drive tiny black Jeeps and Range Rovers**) hang around a park on both banks of a small river that’s about 10 miles long- it has woods, sports fields and bike/ walking paths but also borders on many backyards- which means that they often “interact” with humans.
    Thus, the ex feeds them expensive cat food and my friend observes them when riding her bike or walking her son’s dog.
    The foxes I’ve seen look quite healthy. Probably all that expensive cat food and whatever they steal from the garbage of wasteful people whose backyards they inhabit.
    Foxes- living the high life.

    ** not really

  65. #66 Khani
    March 24, 2013

    #64 Corn and soybeans here, too, and where I grew up. I still prefer the towers–elegant white arms reaching to the sky.

  66. #67 Narad
    March 24, 2013

    I still prefer the towers–elegant white arms reaching to the sky.

    Yah, but do they explode like proper silos?

  67. #68 Shay
    March 24, 2013

    I can’t help it, Khani…they make me think of triffids.

  68. #69 Khani
    March 25, 2013

    #67 Well, sometimes they catch fire and their arms fall off.

    #68 Hee! Well, if one ever leans over and gobbles me or the car up, you may say “I told you so” with complete vindication!

    Perhaps they’re merely moving their armies into position prior to takeover…

  69. #70 Narad
    March 25, 2013

    Well, sometimes they catch fire and their arms fall off.

    I suppose that’s something. Sadly, a blog devoted to such events seems to have gone dormant.

  70. #71 Krebiozen
    March 25, 2013

    Denice,

    Foxes- living the high life.

    It’s funny to think of foxes having a sort of class system that mirrors that of the humans they coexist with. As I have no doubt mentioned before, the Thames flows west to east, so historically the further east you went the more polluted it was, resulting in the west to east spectrum of descending residential desirability we still see in London. I would like to imagine fat foxes in the wealthier west London suburbs lapping up dregs of Bollinger and nibbling at scraps of Beluga caviar, but in reality that class of Englishperson prefers to pursue foxes with horse and hounds, so I doubt they are particularly fox-tolerant. The foxes in my manor walk with a Cockney strut, drop their aitches and sprinkle their barks with glottal stops*. They are rougher and tougher than those effete west London foxes, having to live on the odd scraps of a kebab, burger or curry discarded by a drunk, apart from those lucky ones that frequent our back yard.

    * Or so I like to imagine.

  71. #72 Krebiozen
    March 25, 2013

    These videos, about the construction of the London Array of wind turbines, are well watching if you enjoy having your mind boggled by impressive feats of engineering.

  72. #73 Dr. Nancy Malik
    Gurgaon, India
    March 25, 2013

    Upto the end of year 2010, there have been 270 studies published in 106 medical journals including 11 meta-analysis, 8 systematic reviews including 1 cochrane review (out of approximately 20 systematic reviews published) and 93 DBRPCT (out of approximately 225 RCT published) in evidence of homeopathy.
    Ref: http://drnancymalik.wordpress.com/article/scientific-research-in-homeopathy/

  73. #74 Grant
    http://sciblogs.co.nz/code-for-life/
    March 25, 2013

    Dr. Nancy Malik,

    “[…] in evidence of homeopathy.”
    … with the overall conclusion that it doesn’t work.

    I think something got left out there, eh?

    (I’ve little doubt her private list is biased to her interests, of course.)

  74. #75 Grant
    March 25, 2013

    (Should say doesn’t work beyond a placebo effect, but you all know that right?)

  75. #76 JGC
    trying to cut to the chase
    March 25, 2013

    Dr. Malik, let’s simplify the discussion as much as possible: what in your opinion is the single most compelling piece of evidence demonstrating that homeopathy is more effective at treating non-self-limiting illnesses than are placebo’s (i.e., that it actually works)?

  76. #77 Dr. Nancy Malik
    Gurgaon, India
    March 25, 2013

    @JGC
    There are different types of research. You can’t compare apples with oranges.
    There are meta-analysis and systematic reviews http://drnancymalik.wordpress.com/article/meta-analysis-and-systematic-reviews/
    There are research models http://drnancymalik.wordpress.com/article/research-models-in-homeopathy/
    There are DBRPCTs and there are obeservational studies. Which one you like to discuss?

  77. #78 Chris
    March 25, 2013

    Awww, how cute. Robospammer Malik is referencing its own website. All in the effort to advertise ways to transfer cash from the wallets of the credulous to its own bank account.

  78. #79 MI Dawn
    March 25, 2013

    Dr Malik: We don’t want to compare apples and oranges. We are asking for studies published in reputable peer-reviewed journals, that either have been or can be reliably replicated by other researches.

    So unless you are claiming that your site articles are the same as those done in that literature I’m not going to follow your links.

  79. #80 Science Mom
    http://justthevax.blogspot.com/
    March 25, 2013

    There are different types of research. You can’t compare apples with oranges.

    Surely you don’t think that non-answer is going to fly here do you? The question was very straightforward. Please do the courtesy of answering it.

  80. #81 Science Mom
    http://justthevax.blogspot.com/
    March 25, 2013

    @ MI Dawn, just to let you know, “Dr.” Malik isn’t a doctor at all, just another homeopath crank.

  81. #82 JGC
    March 25, 2013

    There are different types of research. You can’t compare apples with oranges.

    You can’t compare fruit to fruit? Why not?

    Which one you like to discuss?

    As I stated previously I’d like to discuss what you believe to be the single most compelling study or piece of evdence demonstrating homeopathy is effective at treating illnesses that are not self-limiting.

    I’d hope this would take the form of a well designed and appropriately controlled blinded clinical study (but from your suggestion that homeopathy requires a ‘different type of research’ I doubt this would be the case.)

  82. #83 Mark James
    Newcastle
    March 25, 2013

    I’ve really enjoyed reading the debate between Krebiozen and Leigh Jackson. But do feel that there is a lot more to placebos than a subjective response of feeling better. Placebos cannot cure cancer, diabetes, cardiovascular disease etc. But they can improve pain perceptions. Specifically in sport and exercise.
    A reliable study by Beedie et al., demonstrated that although caffeine does improve performance, the expectations specifically influence how well you will do
    http://europepmc.org/abstract/MED/18091009
    McClung & Collins show that there are little differences between a supplement compared to a positive expectancy. http://europepmc.org/abstract/MED/17876973

    There are many more in the sport and exercise field where a placebo can improve an athletes performance. If the person can run faster does that not mean the placebo has worked?

  83. #84 MI Dawn
    March 25, 2013

    @Science Mom: yeah, I know. But since she’s so fond of the title (and maybe can use it legally where she is?) I thought I’d go ahead and call her by it. If she practiced in the US, I wouldn’t.

  84. #85 Grant
    March 25, 2013

    Good reminder re her degree – I once took her to task with it on my blog, checking out what she had and whatnot. I can’t edit my earlier post, but strike the ‘Dr.’ portion.

  85. #86 Mephistopheles O'Brien
    March 25, 2013

    Mark James – perhaps you’ve seen the Disney movie “Dumbo”. Did the magic feather work?

  86. #87 Krebiozen
    March 26, 2013

    Mark James,

    If the person can run faster does that not mean the placebo has worked?

    It depends on what you mean by “worked”. I’m certainly not denying that placebos can have subjective psychological effects. Nor would I deny that those subjective psychological effects can affect a person’s neurochemistry, physiology or behavior, including sports performance, but so can a pep talk from a coach, being chased by a hungry predator and a million other things.

    I think the mechanism behind these effects is interesting, but I’m not convinced think they are clinically useful or ethical on their own, in the form of a sugar pill or a saline injection, for example. I also think it is worth maximizing these effects when a patient is given an active treatment as Orac suggested in the OP. Hypnotherapy is essentially a way of harnessing this element of the ragbag of things that are collectively referred to as “the placebo effect”, but without the need to deceive the patient. So are therapies like counseling, massage, yoga or taking a walk in the sunshine.

    BTW, the first study you linked to is a good example of the confusing results we see in this area; giving caffeine to cyclists improved performance, but more so when the cyclists were told they had not been given it? The effect size of being told they had been given caffeine when they had not was very small 0.7%, which isn’t very impressive. I wonder if this is just noise, or perhaps poor blinding.

    I don’t have access to the full text of the second study, so I can’t see how big the effect sizes were, but it would be interesting to know, though what the study really shows is that the ‘performance enhancing’ supplements they were testing had no effect above placebo. It would be interesting to compare the effects of a placebo with the effects of superstitious amulets like a pair of lucky socks, visualization, a pep talk etc. etc.. I strongly suspect the exact same phenomenon is involved.

  87. […] The “myth” of placebo effects […]

  88. #89 Antilusional
    April 12, 2013

    “Dr” (cough) Nancy Maliquack isn’t being disclosing her cherry picking.

  89. #90 KR
    TN
    May 14, 2013

    Ughh, I loathe Heidi Stevenson. Her articles drive me bonkers. And whenever anyone brings up the obvious holes and omissions in her research about anything she blindly points her finger at people and accusing them of “fear mongering”. If you happen to best her or bring up an irrefutable point she will delete your comment and attack your rhetoric saying it doesn’t follow [her] rules of “debate”.

    People who are so one sided and biased about important issues should not be allowed to inform the public at large and present their ideas as the only true scientific “fact”. Impressionable people listen to this garbage, find a few emotional choice phrases to cling to and then use them in every subsequent argument as the be-all-end-all when the truth is: the surface has to be tapped.

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