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| Archive : Summer
2006 |
YOU, A RESEARCH SUBJECT:
Take the pill the pleasant doctor gives you // Feel better, just as you thought you would // Suffer the side effects she warned you about // Confuse trial results because your sugar pill works just as well as the genuine article.
The Placebo Problem [page 4]
 By
Rachael Moeller Gorman // Illustrations by Leigh Wells
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One improvement would expand studies to include a no-treatment arm, with subjects on a waiting list who are monitored but not treated, even with a placebo. That would provide a baseline against which the placebo effect can be measured and help sort out whether a drug works through placebo pathways. Another possibility, suggested by research into patient expectations, is to give a new drug surreptitiously, through an existing IV or disguised as something else. That, too, could help determine how much of a patient’s improvement comes from a placebo. (Doctors would inform patients that they may or may not receive the drug at different points in the trial.)
Randomizing researchers so they see an equal and arbitrary set of patients is another idea. That way, an experimenter whose personality is warm and empathetic—and thus may generate a large placebo effect—is involved with the same number of patients as a more stoic experimenter. Patient expectations, too, could be manipulated. “You could tell some people they’re getting the drug when they’re really not, and tell others they’re getting nothing though they are getting it and so on,” suggests Wager. That would let researchers factor out the expectation aspect of the placebo effect, another step in determining how different elements of a trial affect the results.
If the goal in RCTs is to minimize the placebo effect to obtain more standardized data across all trials, in other areas of medicine it might pay to exploit it—for example, as a tool to help pharmacologists design more effective drugs. “We typically have a machine model for how drugs work—you take the drug and it does something to you,” explains Wager. “But that’s not really the case at all. Drugs interact with your expectations and beliefs in an ongoing process. You need to ask, how effective is a drug when you believe X about it?” In some cases, what a patient believes could become part of the treatment plan—say, by giving more suggestible people a lower drug dosage than that prescribed for those who are less susceptible.
Physicians might also use the placebo effect to improve care—for example, by taking advantage of research showing that a doctor’s compassion may produce a measurable improvement in the patient. “Great doctors can do great things in 10 minutes,” says Kaptchuk. “It’s not just about good drugs.”
 Dossier
1. “Sham Device v Inert Pill: Randomised Controlled Trial of Two Placebo Treatments,” by Ted J. Kaptchuk et al., British Medical Journal, Feb. 18, 2006. Kaptchuk’s study which found that the placebo effect not only exists but also that its magnitude differs depending on the type of placebo given and that each placebo produces unique side effects.
2. “Powerful Placebo: The Dark Side of the Randomised Controlled Trial,” by Ted J. Kaptchuk, The Lancet, June 6, 1998. A thought-provoking history of the placebo and its tumultuous relationship with randomized controlled trials.
3. Science of the Placebo: Toward an Interdisciplinary Research Agenda, edited by Harry Guess, Arthur Kleinman, John Kusek and Linda Engel [Blackwell BMJ Books, 2002]. An exciting series of articles on the biological, cultural and ethical aspects of the placebo effect by researchers in various fields that resulted from a groundbreaking National Institutes of Health conference in 2000.
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Illustrations by Leigh Wells
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