In an earlier episode of healthcare triage, we discussed how placebo controlled random randomized controlled trials showed that sugar doesn’t make kids hyper. Placebos, or fake therapies, are important because people who think they’re getting a treatment will often feel an effect. 

In the last trial discussed in that video, I talked about how parents who thought their kids had consumed a sugared beverage thought their kids were more hyper even when that beverage was really sugar-free. Sometimes treatment is all in your head. The placebo effect is powerful. It's also the topic of this weeks healthcare triage. 

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My colleague and friend, Austin Frakt has written extensively on the placebo effect. Links down below.
When we compare a treatment with a placebo, it's important to keep in mind that a placebo is not the same thing as an absence of treatment. In research settings, placebos are specifically designed to mimic treatment without the hypothesized few "active" ingredients, or procedural steps.
They still include a lot of components of care. Sometimes, we even compare one treatment with another, or with "usual care," the care that would be given in the absence of the treatment being tested.
In evaluating treatments, researchers go to considerable lengths to provide elaborate sham treatments for comparison, because care delivers cure by two pathways.
One is through our bodies. The other involves our minds: When we believe we are receiving care, we get better. Moreover, we do so more quickly and at a higher rate than if we receive no care at all.
The question addressed by placebo control trials is whether the second effect, the effect that operates only through belief, is the only effect of a given treatment. Does the active part of the treatment do anything more? Placebo control trials try to tease that out.
Look, there's no question that some treatments are better than placebos, but those cure through both pathways, including the one activated by placebos. At the same time, the placebo effect is not universal. Some studies show no difference between placebo control groups and no-treatment groups.
Although some of the ways in which placebos work are known, for instance, by activating natural neurochemicals that make us feel good, we don't truly understand when and how they do or don't.
Emergency physician David Newman, in his book, Hypocrites' Shadow, highlights some great examples of how placebos work.
To the research!
Studies of placebo pills show that taking more is better. Two sugar pills relieve more pain than one. Two pills provide more sedation than one, and two sugar pills heal stomach ulcers more quickly than one. Sugar pills!
Research shows that if you take a placebo pill and put a brand name on it, it works better than the exact same pill without the brand name printed on it.
Studies show that patients who don't skip doses of their placebo medication for cholesterol reduction survive longer than those who do skip doses. Of their placebo medication!
Finally, research shows that taking placebos has been associated with measurements of increased endorphins, which are our bodies natural pain relievers. Believing the pill works get the brain to do the job for us.
It's hard to reject the hypothesis that when we believe placebos will heal, they do, at least to some extent. Perhaps for this reason, our childhoods are full of placebo effects, and as parents, we deliver them to our children all the time.
I can't tell you how many times I've used moisturizer to cure all kinds of aches and pains for my boys. A bandage over my girl's scrape that didn't even break the skin can end her tears. Hugs and sympathetic tones go a long way too. These are all placebos.
Given all of this, it shouldn't be surprising that many physicians prescribe placebos. A study last year found that more than 10% of doctors in the United Kingdom used pure placebos, and nearly all used impure placebos, or unproven remedies in their careers. This mirrored other research which showed that 45% of German docs had used pure placebos, and 76% had used impure placebos in the last year.
In fact, doing so was common practice before World War Two, with supportive publications in the medical literature as late as the mid-50s. One of the reasons was that back then we had fewer recognized active-ingredient therapies. This practice faded away after the rise of placebo controlled trials that yielded treatments that were shown to be better than placebos, but it has resurfaced in new forms.
Today, our use of antibiotics for conditions that don't require them is a form of placebo prescribing. Acetaminophen, or Tylenol, for back pain appears to be a placebo effect as well. These may help patients feel better, but only because they believe they will do so. The active ingredient adds nothing.
To that extent, some doctors trick patients in an effort to achieve a placebo effect, most patients don't seem to mind. In a study published last year, only 22% of patients thought it was never OK for a doctor to prescribe some sort of placebo therapy.
Nevertheless, deliberately harnessing just the placebo effect by prescribing a treatment that does not have any additional direct physical effect is an ethically gray area.
The lesson of placebos is simple. The mind-body connection is strong. A lot of good can come from caring and feeling cared for. Sometimes we need, and can find, additional help from other therapies, but for a wide range of common problems, from earaches to knee pains to headaches, sometimes we don't.
When a clinical trial tells us that a therapy is equivalent to placebo, that doesn't necessary tell us that the therapy does little. It may tell us that the placebo does a lot. The therapy merely does nothing additional. The placebo effect can do a lot of the work, even when it comes to surgery - but that's for next week.
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