The New Placebo: Prescribing Positive Expectations with Real Drugs

Reading time: 5 – 8 minutes

A recent study finds that many U.S. doctors regularly prescribe placebo treatments in the form of real drugs for medical care [1]. Most physicians surveyed view this practice as ethically permissible. The study also finds that many physicians are not fully transparent regarding the use of placebo treatments, and most commonly describe the placebo treatment to patients as a potentially beneficial medicine or treatment not typically used for their condition.

A placebo, Latin for “I will please”, is a substance or procedure given to a patient as medicine or therapy, but which has no specific therapeutic activity. More accurately, a placebo treatment is one that does not have understood biochemical, physiological, cognitive or emotional outcomes of the known, pharmacologically active interventions that might otherwise be prescribed. Placebos are frequently used in clinical trials to test new drugs: some participants receive a placebo (the control group) while others get the drug being investigated (the experimental group). The results of the experimental group are then compared to the control group in order to identify causal effects.

Historically, placebos were characterized as physiologically inert agents that had no pharmacological activity, such as sugar pills or saline injections. Today however, placebo treatments also include physiologically active agents, such as vitamins and over-the-counter analgesics, which are frequently prescribed to promote a positive expectation. Indeed, positive expectations are at the root of the “placebo effect”. The placebo effect is a measurable physical or emotional improvement in health or behavior that is not the result of any special property or characteristic of the medication or treatment that has been given. Put more simply, if a patient has a positive expectation about a treatment, they may see an improvement in their condition, even if there isn’t scientific evidence that the treatment works.

The study, published in the British Medical Journal, surveyed 1,200 internists and rheumatologists about attitudes and behaviors concerning the use of placebo treatments [1]. Researchers at the Department of Bioethics, National Institutes of Health (NIH), measured:

• whether physicians would use or had recommended a placebo treatment
• ethical judgements about the practice of placebo treatment
• what physicians’ recommended as placebo treatments
• how physicians’ typically communicate with patients about placebo treatments

Researchers found that of the 679 rheumatologists and general internal medicine doctors who responded to the survey, approximately half regularly prescribe placebo treatments (46 — 58%, depending on how the question was asked). Even more physicians (62%) believe the practice of placebo treatment to be ethically permissible.

Only a few physicians reported using saline (3%) or sugar pills (2%). Instead, most doctors are advising that patients take over-the-counter analgesics (41%) and vitamins (38%) as placebo treatments. Fewer doctors are prescribing antibiotics (13%) or sedatives (13%).

Among those physicians that prescribe placebo treatments to their patients, more than two-thirds (68%) said they usually describe the placebo treatment as “a medicine not typically used for your condition but might benefit you”. Only 18% of physicians introduced placebo treatments as “a medicine”; 9% indicated that they typically describe placebo treatments as “a medicine with no known effects for your condition.”

Prescribing positive therapeutic expectations

The data from this study suggests that there is a desire among the physicians surveyed to promote positive therapeutic expectations in their patients. Given the benign nature of vitamins and over-the-counter analgesics, doctors might believe that there is at least a possibility that such placebo treatments may have a beneficial pharmacological effect, despite the lack of scientific evidence. They may also feel the need to help the patient to feel like they are receiving care. Nonetheless, while vitamins and analgesics are relatively innocuous, prescribing antibiotics or sedatives when there is no clear medical necessity could have potentially important adverse consequences. The researchers conclude the study by suggesting that the [1]:

… perceived need to administer something in the absence of other proved effective treatments for chronic symptomatic conditions (that promotes a sense of treatment options and positive expectations in response to patients’ complaints) might motivate physicians to prescribe placebo treatments.

A principle limitation of this study is that it was included in a larger survey on complementary and alternative medicine. Thus, it is possible that the physicians who choose to respond to the survey are more favorably disposed to prescribe placebo treatments than most physicians. However, the authors indicate that their findings are consistent the the results of other published studies on placebo treatment [2-3]. Also keep in mind that this study surveyed 1,200 randomly selected U.S. rheumatologists and general internal medicine doctors and is likely not reflective of all medical specialties.

For more on the chemical consequences of belief and imagination, check out the Radio Lab episode Placebo.

If you were prescribed a placebo treatment without full disclosure, how would you feel about it? Do you think the practice is ethically permissible?

References

1. Tilburt et al. Prescribing “placebo treatments”: results of national survey of US internists and rheumatologists. BMJ. 2008 Oct 23;337:a1938. DOI: 10.1136/bmj.a1938
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2. Sherman and Hickner. Academic physicians use placebos in clinical practice and believe in the mind-body connection. J Gen Intern Med. 2008 Jan;23(1):7-10. Epub 2007 Nov 10.
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3. Hróbjartsson and Norup. The use of placebo interventions in medical practice–a national questionnaire survey of Danish clinicians. Eval Health Prof. 2003 Jun;26(2):153-65.
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