Is there a place for placebos in clinical practice?

Would the elderly be better off if they were given more placebos?

Placebos are useful in the medical care of the elderly, although the exact definition of a "placebo" or "placebo effect" is difficult to define precisely. They have an important role as control treatments in research trials, but a non-specific "placebo effect" may also be beneficial part of many physician-patient interactions. Physicians also give them deliberately according to several studies worldwide to satisfy patient demands or because they believe in a "placebo effect" among other reasons. A significant placebo effect has been observed among older patients in clinical trials of antidepressants (12-15%), and in treatments of Parkinson's disease (16%). Placebos activate serotonergic pathways in the brain used by antidepressants. In Parkinson's disease, the administration of a placebo stimulates dopamine release in the dorsal (resulting in motor effects) and ventral striatum (which influences expectation of reward). Much of our understanding of the placebo effect comes from studies of placebo analgesia which is influenced by conditioning, expectation, meaning and context of the treatment for the patient, and patient-physician interaction. It is anatomically medicated by brain opioid pathways. Response to "sham" acupuncture in osteoarthritis may be an example of its use in the elderly. Placebos have often been considered a deception and thus unethical. On the other hand, some physicians and ethicists have suggested conditions for appropriate uses for placebos. A placebo might offer the theoretical advantage of an inexpensive treatment that would not cause adverse drug reactions or interactions with other medications, potentially avoiding complications of polypharmacy.

Attitudes of medical students to placebo therapy

BACKGROUND

Studies have described opposing perceptions of placebo use, with laypersons for and health-care workers against it. Opinions of medical students have not previously been elicited. This study was based on online electronic survey on beliefs, knowledge and attitudes about placebo therapy, that is, use of placebo in clinical practice, rather than in randomized controlled clinical trials.

METHODS

The participants were preclinical (years 1, 2) and clinical (years 3-5) medical students. Descriptive analyses and chi2 tests were used to compare the opinions of preclinical and clinical students with statistical significance set at P < 0.05.

RESULTS

Four hundred and two (35.6%) out of 1153 students responded, of which 181 were preclinical and 221 were clinical students. Two hundred and eighty-five (70.9%) students felt that placebo therapy was acceptable and 134 (33.3%) believed that it was beneficial in organic disease. Fifty-two (12.9%) students felt that it was ethical to prescribe placebo for organic disease with known definitive treatment, 259 (64.4%) for organic disease with no known treatment and 328 (81.6%) for psychogenic disease. More preclinical than clinical students approved of placebo therapy (odds ratio 2.140 (95% confidence interval 1.161-3.944), P = 0.015) and opined that it was ethical to prescribe placebo therapy to organic diseases for which there was appropriate treatment (odds ratio 1.800 (95% confidence interval 0.992-3.266), P = 0.053). A greater number of clinical when compared with preclinical students said that there is evidence that placebo therapy has a beneficial effect on organic disease (odds ratio 2.299 (95% confidence interval 1.468-4.405), P < 0.001).

CONCLUSION

Our medical students felt that placebo therapy is acceptable in certain situations. We identified their erroneous acceptance of placebo therapy in organic diseases, for which there is established treatment, as an area to be addressed in our undergraduate curriculum.