‘It's not my greengrocer, it's someone from the medical profession’: A qualitative study regarding acceptability of deceptive and open‐label placebo prescribing in France

OBJECTIVES

To explore participants' views regarding clinical use of deceptive placebo (DP) and open-label placebo (OLP) treatments.

DESIGN

Qualitative thematic analysis.

METHODS

We conducted eight semi-structured interviews with healthy participants in an experimental trial comparing the efficacy of OLP and DP (Clinical trials n°NCT03934138). Interviewees' opinions were solicited following administration of placebos during the trial. Interviews were analysed using data-driven analysis.

RESULTS

We identified three themes. First, participants considered trust central in judging a placebo treatment to be acceptable. They expressed the importance of an implicit trust both in their health care professionals' (HCPs') competency as well as in the profession at large. A second theme was the perception of how placebo treatments might solve health problems. Acceptability of both types of placebo treatments was dependent on the perception patients had about the treatment solving their problem and/or doubts regarding the effectiveness of placebos The third theme encompassed perceived risks associated with placebo prescribing. Some comments viewed placebos positively as facilitating reduced medication intake. However, participants also identified the potential of placebos to generate adverse side effects.

CONCLUSIONS

Treatment acceptability by patients is a pre-requisite, alongside effectiveness, to harness OLPs in clinical care. Our study identified the importance of trust in HCPs prescribing placebos, the clinical effectiveness of placebos and the potential risks of these interventions in assessing their acceptability. Future research is needed to explore the contexts in which placebos might be used, and how best to communicate information about placebo interventions.

Patient and Provider Acceptability of a Patient Preauthorized Concealed Opioid Reduction

OBJECTIVE

Limited research of how to best taper opioids brings about an ethical and clinical dilemma. Experiments using overt and concealed administration of opioids have demonstrated the benefits of a concealed reduction to eliminate negative expectations and prolong analgesic benefits. This may allow for opioid tapering without significant increases in pain. Based on this, we investigated patient and provider acceptance of a concealed opioid reduction for chronic pain.

METHODS

We conducted a cross-sectional survey via REDcap with 74 patients, who are currently taking or have taken high dose opioids, and 49 providers using a validated questionnaire based on two hypothetical clinical trials comparing a patient preauthorized concealed opioid reduction vs standard tapering.

RESULTS

We found that patients and providers have positive attitudes toward a concealed reduction of opioid dosages. More than 60% of providers and patients surveyed viewed the hypothetical clinical trial as helpful to reduce pain, side effects, and withdrawal symptoms. Sixty-one percent of patients and 77.6% of providers recognized that there would be differences in pain relief depending upon which group the hypothetical participants would be enrolled in.

CONCLUSIONS

Patients and providers appear to understand the benefits of a concealed opioid reduction. Our findings support future randomized controlled trials that compare concealed and overt opioid tapering in patients with chronic pain. More research is needed to understand the difference in attitudes between research and clinical practice and to test the acceptability of a concealed reduction following a participation in an active clinical trial.

Open-label Placebos for Wound Healing: A Randomized Controlled Trial

Background

Open-label placebos are a novel treatment option, in which participants take placebos with full knowledge that they do not contain active medicine. Open-label placebo treatments have been shown to result in patient-reported symptom improvements, but they have not been tested on objectively measurable physiological outcomes such as wound healing.

Purpose

The current study aimed to determine whether open-label placebos improved wound healing in punch biopsy wounds compared with no treatment.

Methods

In a randomized controlled trial, 70 participants (mean age 27.6 ± 10.1, 58 female) were provided with information about the beneficial effects of placebos and given a 4 mm punch biopsy wound. Participants were then randomized to either an open-label placebo intervention (two placebo tablets twice a day for 10 days) or a no-treatment control group. Wounds were photographed at 7 days and 10 days to determine reepithelialization of the wound surface.

Results

No significant differences were observed between the open-label placebo and control conditions in the percentage of wound area healed or for the number of participants with fully reepithelialized wounds at 7 days (placebo 7/32 wounds healed, control 10/33 wounds healed, (χ2[1, N = 65] = 0.60, p = .440, φ = 0.10) and 10 days after wounding (placebo 17/32, control 25/33 wounds healed (χ2[1, N = 65] = 3.64, p = .056, φ = 0.24).

Conclusions

Open-label placebo treatment does not improve the healing rate of wounds. Open-label placebos may be beneficial for subjective patient-reported outcomes but do not influence wound healing.

Australian New Zealand Clinical Trials Registration

ACTRN12616000411448.

The Knowledge of Contextual Factors as Triggers of Placebo and Nocebo Effects in Patients With Musculoskeletal Pain: Findings From a National Survey

Backgrounds: Contextual factors (CFs) have been recently proposed as triggers of placebo and nocebo effects in musculoskeletal pain. CFs encompass the features of the clinician (e.g. uniform), patient (e.g. expectations), patient-clinician relationship (e.g. verbal communication), treatment (e.g. overt therapy), and healthcare setting (e.g. design). To date, the researchers' understanding of Italian patients' knowledge about the role of CFs in musculoskeletal pain is lacking. Objectives: The aim of this study was to investigate attitudes and beliefs of Italian patients with musculoskeletal pain about the use of CFs in clinical practice. Methods: A national sample of Italian patients with musculoskeletal pain was recruited from 12 outpatient private clinics in Italy. An invitation to participate in an online survey was sent to patients: a) exhibiting musculoskeletal pain; b) aged 18-75; c) with a valid e-mail account; and d) understanding Italian language. Survey Monkey software was used to deliver the survey. The questionnaire was self-reported and included 17 questions and 2 clinical vignettes on the patients' behavior, beliefs, and attitudes towards the adoption of CFs in clinical practice. Descriptive statistics and frequencies described the actual number of respondents to each question. Results: One thousand one hundred twelve patients participated in the survey. Five hundred seventy-four participants were female (52%). The average age of patients was 41.7 ± 15.2 years. Patients defined CFs as an intervention with an unspecific effect (64.3%), but they believed in their clinical effectiveness. They identified several therapeutic effects of CFs for different health problems. Their use was considered ethically acceptable when it exerts beneficial psychological effects (60.4%), but it was banned if considered deceptive (51.1%). During clinical practice, patients wanted to be informed about the use of CFs (46.0%) that are accepted as an addition to other interventions to optimize clinical responses (39.3%). Moreover, patients explained the power of CFs through body-mind connections (37.1%). Conclusion: Patients with musculoskeletal pain had positive attitudes towards the use and effectiveness of CFs when associated with evidence-based therapy. They mostly perceived the adoption of CFs in clinical practice as ethical.

From substance to process: A meta-ethnographic review of how healthcare professionals and patients understand placebos and their effects in primary care

Research suggests that a 'placebo' can improve conditions common in primary care including pain, depression and irritable bowel syndrome. However, disagreement persists over the definition and clinical relevance of placebo treatments. We conducted a meta-ethnographic, mixed-research systematic review to explore how healthcare professionals and patients understand placebos and their effects in primary care. We conducted systematic literature searches of five databases - augmented by reference chaining, key author searches and expert opinion - related to views on placebos, placebo effects and placebo use in primary care. From a total of 34 eligible quantitative, qualitative and mixed-methods articles reporting findings from 28 studies, 21 were related to healthcare professionals' views, 11 were related to patients' views and two were related to both groups. In the studies under review, healthcare professionals reported using placebos at markedly different frequencies. This was highly influenced by how placebos were defined in the studies. Both healthcare professionals and patients predominantly defined placebos as material substances such as 'inert' pills, despite this definition being inconsistent with current scientific thinking. However, healthcare professionals also, but less prevalently, defined placebos in a different way: as contextual processes. This better concurs with modern placebo definitions, which focus on context, ritual, meaning and enactivism. However, given the enduring ubiquity of substance definitions, for both healthcare professionals and patients, we question the practical, clinical validity of stretching the term 'placebo' towards its modern iteration. To produce 'placebo effects', therefore, primary healthcare professionals may be better off abandoning placebo terminology altogether.

Should placebo be used routinely for chronic pain in older people?

As research expands our understanding of underlying placebo mechanisms, interest turns to the clinical application of placebos. Whether placebos are appropriate and effective in the management of chronic pain in older people deserves considerable attention. The evidence suggests that adults of any age are responsive to placebos, and that placebo treatments can be effective for many conditions prevalent in older people. Though placebos in general already seem to be used with some regularity in medical practice, the use of placebos alone for chronic pain is probably unjustified unless other treatments are inadvisable or have been exhausted. However maximising the mechanisms that underpin placebo analgesia such as expectancy or the psychosocial context should be encouraged and would be considered a feature of good clinical practice. It would also be anticipated that older people may see an additional benefit with placebo treatments when such treatments reduce existing or planned medication regimes, as older people typically experience more comorbidities, increased susceptibility to adverse drug reactions, and altered pharmacological responses to drugs. Further research is still needed in placebo-related treatment paradigms for the management of chronic pain in older people.

Elite athletes' attitudes towards the use of placebo-induced performance enhancement in sports

While an increasing number of research is devoted to the understanding of placebo effects in sports, athletes' experiences with and attitudes towards the use of placebo for performance enhancement remain poorly understood. In this study, 79 elite athletes from different sports were surveyed on five issues related to placebo use in sports. Results showed that 47% of the athletes have experienced placebo effects in the past. A majority of the athletes (82%) thought that placebos could affect their sports performances. A wider use of placebos in sport settings was endorsed more by those who have experienced placebo effects in the past than those who did not (P = .005). Regardless of past experience with placebo, more than half of the athletes (53%) would accept an unknown but legitimate substance from the coach, and 67% of them would not mind a placebo-linked deception if that was effective. These findings confirm that most elite athletes believe in the power of placebos in enhancing sports performance, and those having a positive past experience exhibit slightly more favourable attitudes in contrast to those without such experiences.