Placebos in chronic pain: evidence, theory, ethics, and use in clinical practiceBMJ 2020; 370 doi: https://doi.org/10.1136/bmj.m1668 (Published 20 July 2020) Cite this as: BMJ 2020;370:m1668
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“Medicine is occasionally cure, often relieves, and always consoles.” Paré (1510-1590), a French barber surgeon.
Kaptchuk and colleagues carefully examined the effect of placebo treatment in chronic pain during three different conditions (double blind RCTs, deceptive placebo experiments, and open label placebo) to review theories of placebo effects.(1) However, their conclusion went further and deserves comment.
Firstly, could Kaptchuk and colleagues explain and document the “clinically meaningful” effect of placebo as expressed in their conclusion pledging for placebo use. Indeed, placebos do not have long-lasting or powerful objective clinical effects (quality of life, pain medication tapering …). The subjective patient reported alleviation is small, observed in only one third of the subjects and only under certain conditions (if you slip a placebo into a person’s drink, it does not work).(2)
Secondly, they rightly stressed “developing an optimal patient centered relationship is important” but wrongly ended with “regardless of whether it improves clinical outcomes” overlooking that psychotherapy (a term they overlooked) has been robustly evidence based for long.(3) Psychotherapy must focuses on the cognitive, affective, and behavioral components of the pain experience which is associated with psychosocial comorbidities. It helps patients to increase their feelings of control or feelings of self efficacy.(4) Sadly, very few patients with chronic pain have access to psychotherapy and a placebo cannot replace it. Further, I’m afraid that the term “optimal patient centered relationship” is flying in the face of real life practice. Are clinicians adequately trained for being open, listening, removing barriers, sharing authority, promoting active participation of the patient by the expression of his/her values and last but not least, analyzing if there is no misunderstanding by rephrasing (“reflective listening”)?(5) Are visits long enough for implementing these technical skills when accounting for the growing burden of administrative tasks?
Thirdly, could Kaptchuk and colleagues explain how to bill for a placebo?
1 Kaptchuk TJ, Hemond CC, Miller FG. Placebos in chronic pain: evidence, theory, ethics, and use in clinical practice. BMJ. 2020;370:m1668.
2 Braillon A. Placebo is far from benign: it is disease-mongering. Am J Bioeth. 2009;9:36-38.
3 McArdle JM, George WD, McArdle CS et al. Psychological support for patients undergoing breast cancer surgery: a randomised study. BMJ 1996;312:813-4.
4 Dalton JA, Coyne P. Cognitive-behavioral therapy: tailored to the individual. Nurs Clin North Am. 2003;38:465-vi
5 Braillon A, Taiebi F. Practicing "Reflective listening" is a mandatory prerequisite for empathy. Patient Educ Couns 2020. Online Apr 4. doi:10.1016/j.pec.2020.03.024
Competing interests: No competing interests