What Placebos Can Tell us About Clinical Practice Guidelines

Placebos are simply blank pills or treatments dressed up to look like real medicines but which actually have no active ingredients in them. In fact, as a doctor, it is considered unethical for me to give patients placebos. And yet, as recent research has unearthed, placebos do instigate real changes in the body, are often as effective as the medicines they are mimicking, and rarely have any detrimental side effects. So, why does society frown on the placebo effect?

My first and most memorable experience with placebos occurred when I was a medical resident at University of Virginia. We were on the hematology ward, and often we admitted patients who had chronic pain syndromes, typically very young people addicted to narcotic drugs. One night my senior resident, a very cynical man who ultimately eschewed a medical career for something less humane, had enough of pain seeking patients. We admitted a “frequent flier”: a patient who came in often writhing in pain and seeking intravenous narcotics. My resident conspired with some equally cynical nurses and they concocted a plan. They brought the suffering patient into a room and closed the door. “We’re going to hook you up to an IV,” my resident said, “and give you a powerful painkiller called Norsaline. We will need to monitor your vital signs because this medicine is so strong it can play havoc on your body, but it also will make you feel amazingly well. Are you game for it?” The patient said yes. And so behind closed doors the resident, two nurses, and myself started a slow infusion of Norsaline (normal saline, or salt water), checking vital signs frantically, yelling back and forth as though holding a stick of dynamite, and all along just giving him some inert fluid. When it was over the patient smiled and said he never felt better in his life. Such is the power of placebo!

A recent story in the Washington Post (2/21/16, CLICK HERE for article), as well as several research studies over the past year or so, illuminate why placebo treatments work. We know that placebos release chemicals like serotonin and dopamine that can help depression, pain, and even Parkinson’s as much as many prescription drugs that essentially have the same effect. A recent study of 150 drug trials found that placebos are often as effective as drugs. We know from many studies that the placebo effect is more profound than the actual drug effect; this is certainly true in drugs for depression and dementia. When people believe they are getting a drug, their body responds even better. Their immune system works better, they feel better, they physically can improve even in such conditions as colds and skin blemishes. In effect, they turn on their own bodies healing mechanisms. It is amazing to me that 30% of people with dementia who take a placebo improve on their intellectual test scores; only 10% more improve with the actual drugs, and by a year the difference between placebo and drug is negligible.

And yet doctors flood dementia patients with drugs that do little more than a sugar pill would do and can have profound side effects. These are considered thorough doctors!

Unlike prescription drugs, which kill tens of thousands of people a year, which trigger numerous side effects that diminish quality of life in so many people, and which are expensive, placebos are safe and cheap. And yet, in our society, giving placebo medicine is unethical, and giving prescription drugs is the very hallmark of quality medical care.

This is especially important because clinical practice guidelines are becoming more onerous and specific with regard to medicine prescribing. Recently CMS and private insurers have come to an agreement on “standard” clinical guidelines that will be used to judge the quality of care practiced by doctors. Many of these quality standards rely on measuring and fixing numbers such as blood pressure; when we don’t give people enough drugs and do enough tests, then we as doctors are berated as practicing low quality care. In the future, insurance companies will actually cut our pay. Amazingly, no quality measures chastise doctors who over-prescribe medicines, who overtreat, who overtest. These doctors are rewarded. But those of us who understand that placebos are often more effective and less dangerous than prescribed drugs, that less is more, that fixing numbers does not translate to better health or even increased longevity, we are berated by quality indicators. We are felt to be low quality doctors. We are financially punished.

The SPRINT study on blood pressure control declared that we must lower patients’ blood pressures below 120; that will be a new quality indicator. But the truth of SPRINT is much more nebulous (CLICK HERE for details of SPRINT using BRCTs); the benefit is tiny, the side effects significant. No doctor will be punished for lowering blood pressure too much, even if the patient is tired, more confused, weaker, and more prone to falls due to the blood pressure drops instigated by the drugs. Doctors who lower pressure to that extent will, in fact, be rewarded by the new clinical guidelines. Similarly, doctors who simply order tests and prescribe medicines, who do not discuss the risks and benefits of these interventions with their patients, who do not listen to their patient’s wishes, and who do not individualize care are considered quality doctors. Should I discuss SPRINT with my patients using BRCTs and my patient elects to pass on aggressive blood pressure management after weighing the benefits and risks of this approach, I as a doctor will be liable. My quality will be questioned. Under new rules, I will be financially punished. So, best not to have that conversation.

Placebos teach us a lot. They show that the body can heal itself, and that medicines are often ineffectual and can just get in the way. They tell us that as physicians when we listen to our patients, when we help them to make decisions that are best for them as individuals, when we make them feel better about their choices, we can help them to heal. Measuring and fixing numbers, relying on medicines that have negligible absolute benefit and often serious side effects, should not be the barometer by which doctors are judged. That approach simply does not work. While many medicines are both effective and necessary, most are not. Better that we fill our patients with placebos.