The Placebo Effect

Survey: Half of US doctors use placebo treatments
By MARIA CHENG, AP Medical Writer

LONDON – About half of American doctors in a new survey say they regularly give patients placebo treatments — usually drugs or vitamins that won't really help their condition. And many of these doctors are not honest with their patients about what they are doing, the survey found.

That contradicts advice from the American Medical Association, which recommends doctors use treatments with the full knowledge of their patients.

"It's a disturbing finding," said Franklin G. Miller, director of the research ethics program at the U.S. National Institutes Health and one of the study authors. "There is an element of deception here which is contrary to the principle of informed consent."

The study was being published online in Friday's issue of BMJ, formerly the British Medical Journal.

Placebos as defined in the survey went beyond the typical sugar pill commonly used in medical studies. A placebo was any treatment that wouldn't necessarily help the patient.

Scientists have long known of the "placebo effect," in which patients given a fake or ineffective treatment often improve anyway, simply because they expected to get better.

"Doctors may be under a lot of pressure to help their patients, but this is not an acceptable shortcut," said Irving Kirsch, a professor of psychology at the University of Hull in Britain who has studied the use of placebos.

Researchers at the NIH sent surveys to a random sample of 1,200 internists and rheumatologists — doctors who treat arthritis and other joint problems. They received 679 responses. Of those doctors, 62 percent believed that using a placebo treatment was ethically acceptable.

Half the doctors reported using placebos several times a month, nearly 70 percent of those described the treatment to their patients as "a potentially beneficial medicine not typically used for your condition." Only 5 percent of doctors explicitly called it a placebo treatment.

Most doctors used actual medicines as a placebo treatment: 41 percent used painkillers, 38 percent used vitamins, 13 percent used antibiotics, 13 percent used sedatives, 3 percent used saline injections, and 2 percent used sugar pills.

In the survey, doctors were asked if they would recommend a sugar pill for patients with chronic pain if it had been shown to be more effective than no treatment. Nearly 60 percent said they would.

Smaller studies done elsewhere, including Britain, Denmark and Sweden, have found similar results.

Jon Tilburt, the lead author of the U.S. study, who is with NIH's bioethics department, said he believes the doctors surveyed were representative of internists and rheumatologists across the U.S. No statistical work was done to establish whether the survey results would apply to other medical specialists, such as pediatricians or surgeons.

The research was paid for by NIH's bioethics department and the National Center for Complementary and Alternative Medicine.

The authors said most doctors probably reasoned that doing something was better than doing nothing.

In some cases, placebos were given to patients with conditions such as chronic fatigue syndrome. Doctors also gave antibiotics to patients with viral bronchitis, knowing full well that a virus is impervious to antibiotics, which fight bacteria. Experts believe overuse of antibiotics promotes the development of drug-resistant strains of bacteria.

Some doctors believe placebos are a good treatment in certain situations, as long as patients are told what they are being given. Dr. Walter Brown, a professor of psychiatry at Brown and Tufts universities, said people with insomnia, depression or high blood pressure often respond well to placebo treatments.

"You could tell those patients that this is something that doesn't have any medicine in it but has been shown to work in people with your condition," he suggested.

However, experts don't know if the placebo effect would be undermined if patients were explicitly told they were getting a dummy pill.

Brown said that while he hasn't prescribed sugar pills, he has given people with anxiety problems pills that had extremely low doses of medication. "The dose was so low that whatever effect the patients were getting was probably a placebo effect," he said.

Kirsch, the psychologist, said it might be possible to get the psychological impact without using a fake pill. "If doctors just spent more time with their patients so they felt more reassured, that might help," he said.

Some patients who had just seen their doctors at a clinic in London said the truth was paramount.

"I would feel very cheated if I was given a placebo," said Ruth Schachter, an 86-year-old Londoner with skin cancer. "I like to have my eyes wide open, even if it's bad news," she said. "If I'm given something without being warned what it is, I certainly would not trust the doctor again."



The Pros vis-à-vis Cons notwithstanding; Let us just remember that the Doctor- Patient relationship is sacred. Honesty is always the best policy in dealing with patients especially with regards to their treatments.

Clinical Eye

Here are some of the latest news that caught my eyes...


General Anesthesia Tied to Developmental Woes in Kids

Youngsters under the age of 3 who had hernia surgery showed almost twice the risk of behavioral or developmental problems later compared to kids who hadn't had surgery, a new study finds.

Researchers suspect that exposure to general anesthesia during these operations might have played a role in the jump in risk, according to lead author Charles DiMaggio, an assistant professor of clinical epidemiology at Columbia University College of Physicians and Surgeons' Mailman School of Public Health in New York City. More...





Dr. Marc Bessler, right, and Dr. Daniel Davis performed a new kind of weight-loss surgery that passes a stapler down the throat to staple the stomach.

Toga (for transoral gastroplasty) is a new weight-loss surgery... click herefor more.




Magnet device aims to treat depression patients...



If it sounds like science-fiction, well, those woodpecker-like pulses trigger small electrical charges that spark brain cells to fire. Yet it doesn't cause the risks of surgically implanted electrodes or the treatment of last resort, shock therapy.

Called transcranial magnetic stimulation or TMS, this gentler approach isn't for everyone. The Food and Drug Administration approved Neuronetics Inc.'s NeuroStar therapy specifically for patients who had no relief from their first antidepressant, offering them a different option than trying pill after pill.

Read the entire article, here.

Pain in My Heart

VIOXX- pain killer or heart killer?




The painful saga of the pain medicine continues...





Vioxx's Heart Risk Lingered Long After Use Ended

By Steven Reinberg
HealthDay Reporter

MONDAY, Oct. 13 (HealthDay News) -- When the pain killer Vioxx was pulled from the market in 2004 over concerns that it increased the risk of heart attack, stroke and death, many assumed that stopping the drug would end the risk.

But a new study finds that "the risk was increased close to twofold, and the risk persisted for approximately a year," said co-author Dr. Robert Bresalier, a professor of medicine at the M.D. Anderson Cancer Center in Houston.

"The good news is that, after a year, the risk seemed to go back down toward normal," he said.

However, the study's researchers and other experts also believe that long-term use of most non-aspirin painkilling drugs in this class -- called non-steroidal anti-inflammatory drugs (NSAIDs) -- also boost users' risks of heart attack, stroke and death to some degree.

NSAIDs include cox-2 inhibitor drugs such as the now-banned Vioxx and Bextra, as well as the remaining cox-2 on the market, Celebrex. Those drugs target the cyclooxygenase 2 (cox-2) enzyme involved in inflammation.

NSAIDs also include less targeted anti-inflammatory medications such as ibuprofen (Advil, Motrin) and naproxen (Aleve).

The report was published online in the Oct. 14 issue of The Lancet.

For the study, Bresalier's group followed people who had participated in the international APPROVe trial, which compared Vioxx to placebo over 3 years in an attempt to see whether the drug could cut the recurrence of cancerous colon polyps. The trial was stopped early in 2004 because of the increased risk for heart attacks and stroke.

The researchers in the new study were able to contact 84 percent of the almost 2,600 people who had participated in the trial.

They found that a year after discontinuing Vioxx, ex-users still had a 79 percent increased risk of heart attack, stroke or death compared with those who had received placebo.

This finding was consistent with the increased risk observed during the trial, where the odds for cardiovascular trouble was more than double for those taking Vioxx. For individual patients, the risk of heart attack or stroke was doubled during the year after stopping the drug. The increased risk of dying was 31 percent compared with those who had taken placebo, the researchers noted.

Bresalier's group did find that Vioxx was able to reduce the recurrence of colon polyps, but this benefit has to be weighed against the increase in cardiovascular risk, they said.

Bresalier suspects that long-term use of all non-aspirin NSAIDs can raise the odds of cardiovascular trouble to some extent.

"Similar data has been evident for some of the other cox-2 inhibitors," he noted. "In fact, it seems to be a class effect for most if not all NSAIDs. There is a dose-dependent risk with Celebrex as well, whose magnitude was not that much different from Vioxx," he said.

Bresalier believes that certain patients should not take high doses of these drugs over a long period. "If you have a history of cardiovascular disease, speak to your doctor to understand the relative risks and benefits. If you're somebody who really needs to take these drugs because of chronic pain or severe arthritis, be aware of the issues. But you shouldn't be afraid to take these drugs if you need them," he said.

For people who take these drugs only intermittently -- for short-term pain relief, for example -- the risk is very small, Bresalier said. "It doesn't mean if you take one or two pills you're going to get a heart attack. For the vast majority of people taking these drugs, these are very good and safe drugs," he said.

Dr. Eric J. Topol, director of the Scripps Translational Science Institute and Chief Academic Officer of Scripps Health in La Jolla, Calif., was not surprised that the risk for heart attack and stroke continued even after Vioxx was stopped.

"What this does is help further demonstrate not only the risk of Vioxx, but the temporal duration," Topol said. "Now, we have compelling data that the risk extends a year after stopping the drug," he said.

Topol, who was one of the first to sound the alarm about Vioxx, is not sure that this is a class effect of all cox-2 inhibitors, however.

"There was always a signal that it [the risk] was worse for Vioxx that other cox-2 inhibitors. Whether or not other drugs like Celebrex shared that isn't known. That has not been demonstrated in studies of Celebrex. But you have to be suspicious, particularly since high doses of Celebrex have heart attack and stroke risk. But there's never been a study to show that it's a long-lasting liability," he said.

In response to the Lancet study, Vioxx manufacturer Merck issued the following statement: "Merck believes that this post-hoc analysis using limited data from a prematurely terminated study needs to be interpreted very cautiously and in the context of the rest of the data from the extensive clinical development program for Vioxx."

THINGS YOU DON’T WANT TO HEAR IN SURGERY

- Better save that. We'll need it for the autopsy.

- "Accept this sacrifice, O Great Lord of Darkness!"

- Wait a minute, if this is his spleen, then what's that?

- Hand me that ... uh ... that uh..... thingie

- Oops! Hey, has anyone ever survived 500ml of this stuff before?

- There go the lights again...

- "Ya know, there's big money in kidneys… and this guy's got two of'em.

- Everybody stand back! I lost my contact lens!

- Could you stop that thing from beating? It's throwing my concentration off.

- What's this doing here?

- I hate it when they're missing stuff in here.

- That's cool! Now can you make his leg twitch?!

- Well folks, this will be an experiment for all of us.

- Sterile, shcmerile. The floor's clean, right?

- The “5-second rule” applies to organs, too – right?

- What do you mean he wasn't in for a sex change...

- “Oh, you mean HIS right…”

- OK, now take a picture from this angle. This is truly a freak of nature.

- This patient has already had some kids, am I correct?

- Nurse, did this patient sign the organ donation card?

- Don't worry. I think it is sharp enough.

- What do you mean "You want a divorce"!?!

- FIRE! FIRE! Everyone get out!

- Damn! Page 47 of the manual is missing!

Warts Up, Doc?

Doctors were at a loss for explanations when an Indonesian fisherman grew warts out of his arms and feet that resembled tree branches. But according to Britain's The Sun newspaper, Dede's growths are going away, thanks to the help of an American dermatologist.


--SUPRI, Reuters / Corbis