Saturday, November 28, 2009

Placebo, nocebo.

Just now, Parliament is taking evidence on alternative medicine. One piece of evidence was given by Boots the Chemist, the largest pharmacy chain in the UK. When asked why they sold alternatives medicines alongside real ones, they replied that it was not because they worked, but because they were popular.

To quote Ben Goldacre of the Guardian, "The best moment was Dr Peter Fisher from the (NHS-funded) Royal London Homeopathic hospital explaining that homeopathic sugar pills have physical side-effects – so they must be powerful."

This association of bad effects with the administration of small amounts of ingested water is known as the nocebo effect - the opposite of the placebo effect

People tend to dismiss the placebo effect as if it did not matter or could not effect cures. This is silly. Any number of people will come forward and testify that they were made better by homeopathy, acupuncture, foot massage, drinking their own urine and all the other imaginative procedures that collectively are known as alternative or complimentary medicine. In clinical trials it is seldom that these treatments have no effect, but that is also the case when deliberately chosen agents with assuredly no activity are used. Patients are often unable to distinguish between the real drug and dummy drug; they can get both beneficial effects and side effects from the placebo.

The placebo effect is enhanced by time spent with the patient, a sympathetic manner, touching, smiling, self-confidence and listening - things that alternative practitioners are good at. When I was a young doctor we didn't have many drugs that worked. We had morphine and aspirin, but none of the non-steroidal drugs except indomethacin and phenylbutazone, which were pretty toxic. We had a few antibiotics, but not the wide array of kill-anything drugs that we have now; we were still using chloramphenicol, which destroyed the bone marrow of a predictable number of patients and tetracycline, which gave you brown teeth. We had no decent diuretic, and digitalis was the only heart drug. The drugs we had for high blood pressure made everyone ill, one way or another. We had a few cytotoxic drugs, but we gave them in tiny doses because we had no way of keeping patients alive if we had used today's doses. We had to rely on our bedside manner.

Thankfully, most illnesses get better by themselves and the doctor relied on his bedside manner to convince the patient that it was he, and not time, that had effected the cure. So, by all means, let's make use of the placebo effect,

But we run into a problem. Isn't it deceitful to give the patient the impression that sticking pins in them or manipulating their neck or rubbing their feet will make them better? Yes it is. Alternative practitioners either lie to themselves or lie to their patients. Does this matter? I leave the reader to judge.

But doctors can make use of the placebo effect. Not by lying to patients but by spending time with them and having a sympathetic manner. Often I hear of doctors who do not get up when the patients enters the room, do not make eye contact, but stare at their computer screen and type out a prescription almost as soon as the patient's bottom has hit the seat.

Certainly in oncology it pays to spend time with patients. When I was treating kidney cancer with interleukin-2 I was impressed with the results obtained by a doctor in New York. Then I saw that the dose that he used was many times greater than I was using. I couldn't believe that it was possible to get this very toxic drug into patients. I asked him how he did it. He replied that he sat with the patient throughout the whole infusion, holding their hand.

A good bedside manner will enable patients to take full rather than attenuated doses of toxic drugs. Often single center clinical trials produce much better results than when the drug is used in the community. I believe this is in part because of the placebo effect of going to a world-renowned center and being greeted by a kindly old gentleman with a beard who gives you a bear hug when he greets you.


Burke said...

Shortly after I was diagnosed with cll, I decided to try some alternative medicine: "immune-boosting" concoctions consisting of various vitamins, minerals, herbs, and oils, etc. It was costing me about $200 per month.

After a few weeks, I stopped taking this stuff because my stomach had started bothering me. A few weeks later, I saw my hem/onc and my counts had dropped so much she wanted to start chemo. But I decided to wait 3 more months.

When I saw her 3 months later, my counts had dropped no further, so she said, "see you next time." I stayed on W & W for another year before having to begin treatment.

I then responded to FCR very well.

Today, I find myself thinking that it was pretty stupid of me to be trying to "boost" my immune system when my cancer was located there. Seems to me that all I was doing was boosting my cancer.

So much for alternative medicine.

Anonymous said...

I have personally witnessed this phenomenon many times and agree that a physician who becomes involves and takes time with their patients often obtains better results no matter what the disease or treatment.

I'm not sure that i would call this a placebo effect, though that is simply a matter of semantics.

I do agree, however, that when care is taken with a therapy in a limited cohort of patients that better results may well accrue than may occur in the community at large.

In my practice, hand holding during the infusion of occasionally disagreeable medications has gone far toward improving patient tolerance and consequently results obtained.

I fear that this aspect of medical care will slowly go the way of the Dodo.

While I was receiving chemotherapy for my CLL I was able to spend several hours talking to one of my own patients receiving treatment in a nearby "chair" who was quite distressed by her situation and by the side effects of the regimen that she was receiving. It seemed to have help and I was grateful that I was there as my own therapy was not troublesome to me at all.


Anonymous said...

The kindly doc with beard gave bear hugs and a prescription for champaigne the first time we met him. I understand that too is SOP for him.

However, in addition to the placebo effect of the bear hugs, I think cherry-picking candidates for clinical trials is also responsible for some of the more spectacular results at this institution. Researcher bias is alive and well, and the major reason why multi-center trials are necessary.

Anonymous said...

The only doc I know of who famous for giving bear hugs is at MD Anderson and his initials are MK. Perhaps that is who the reference is to.

I heartily dislike being hugged by people I don't know or know only slightly or professionally. That physical closeness is more than a bit uncomfortable for me.

My CLL guru who is just wonderful, surprised me twice by hugging me. I told my wife that he was giving me 'the hug of death' because both instances came after delivering bad news.

Please, people, give me so space! If I am married to you, or am related you you (and like you as well), I may tolerate it.

Otherwise, back off!

Thank you.