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Placebo Treatments:
Misleading and Potentially Harmful
Posted: October 31, 2008
Prescribing placebos to fibromyalgia patients is an acceptable practice to half of the U.S. internists and rheumatologists who responded to a recent survey.1
And the primary reason that the survey respondents gave for using placebos (a sugar pill or substitute for a proven medication) was to enhance patient expectations. Sadly, only 20 percent of the 334 internists and 345 rheumatologists who responded indicated that they would never resort to the use of placebos.
Given the many medications on the market, you may wonder: Is it ethical for a doctor to prescribe you a placebo without your knowledge or informed consent? Although the results of this survey indicate just how controversial this issue is (at least when dealing with fibromyalgia patients), two large medical societies clearly oppose the deceptive use of placebos.
In 2004, the American Society of Pain Management Nurses and the American Pain Society issued a statement saying they "adamantly oppose the use of placebos in the assessment and treatment of pain in all patients." The American Medical Association (AMA) issued a position statement in 2006, which says, "Physicians may use placebos for diagnosis or treatment only if the patient is informed of and agrees to its use ... a placebo must not be given merely to mollify a difficult patient, because doing so serves the convenience of the physician more than it promotes the patient’s welfare."
When a physician prescribes a medication and tells you that it should help reduce your pain, studies have shown that people will usually feel much better, even if the medication is a sugar pill or placebo. Your "enhanced expectations" lead to a sense of hopefulness and this causes temporary alterations in the pain processing centers of the brain that can be objectively measured by brain imaging techniques.2 So in reality, a placebo may only be beneficial if your doctor uses words to persuade you that the medication will ease your painful suffering. It's commonly referred to as the "white coat effect" and it is strongly influenced by what your doctor (who wears the white coat) actually says when he or she gives you the prescription.
The point is, enhancing expectations does not have to be done through the deceptive use of placebos. "Physicians can avoid using a placebo, yet produce a placebo-like effect through the skillful use of reassurance and encouragement," states the AMA. Perhaps in today's managed care environment, doctors do not feel that they have the time to talk to their patients. Or maybe it is easier to whip out the prescription pad and recommend something that the physician knows is worthless. Whatever the reason, the patient is short-changed.
One of the most disturbing survey findings pertained to the frequent use of "active" placebos, which are agents with no known benefit but they may exert side effects. Only 2 percent of the physicians actually prescribed a sugar pill, while the most common active placebos were over-the-counter analgesics (45 percent), vitamins (38 percent), antibiotics (13 percent), and sedatives (13 percent).
Analgesics can be detrimental to the stomach (e.g., aspirin, ibuprofen, ketoprofen, etc.) or the liver (e.g., acetaminophen). Vitamins may not cause side effects, but are typically expensive and not covered by health insurance. Particularly disturbing is the use of antibiotics because it leads to the development of drug-resistant bacterial strains (e.g., MRSA). As for sedatives, they can be addicting, enhance the odds of traffic accidents, and magnify the memory fog.
Now don't rush off and assume your physician is prescribing placebos to you. As a patient, you can protect yourself from receiving a placebo in place of known effective therapies for chronic pain and your other symptoms. The majority of physicians who prescribed placebos were vague about what they were giving their patients. As an example, a physician might say, "This medicine is not typically used for your condition but might benefit you." So whenever a physician hands you a prescription slip or makes a recommendation for a supplement, you should always ask:
- What exactly is this medication/supplement and how will it work to reduce my pain (or whatever symptom is being treated)?
- Are you aware of any published studies that document the effectiveness of this medication over that of a placebo for treating fibromyalgia or a chronic pain?
- If your doctor answers yes, then ask:
What percentage of the patients in the study received significant symptom improvement with the agent? - If your doctor answers no, then ask:
What makes you think this will work for me if it did not work for other fibromyalgia or chronic pain patients?
- If your doctor answers yes, then ask:
If your doctor is rushed for time or provides a vague and difficult-to-interpret response, keep your cool and remain considerate (doctors do run on tight schedules). Ask if you may speak to the nurse or the physician assistant (if your doctor has one) to receive literature or a patient resource on the medication. If this does not work or if all of your questions have been answered but you still feel confused about the purpose of the prescribed medication, you can always look it up on the government's Consumer Health MedlinePlus website. Unfortunately, so many medications prescribed for fibromyalgia are actually indicated for nonpainful conditions. Before you fill the prescription, you can also consult your pharmacist, although he or she will not know your physician's rationale for prescribing a given medication.
1. Tilburt JC, et al. BMJ [Epub ahead of print] Oct. 24, 2008.
2. Benedetti F. Eval Health Professions 25:369-386, 2002.
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