Problematic Covid-19 vaccine trials in times of vaccine nationalism

Thanks to an impressive R&D effort, three vaccines for Covid-19 have been conditionally approved by stringent regulators as of February 2021, and sixteen have entered the WHO evaluation process. However, they all need to keep on being evaluated in clinical trials. The WHO Ad Hoc Expert Group on the Next Steps for Covid-19 Vaccine suggested that countries with limited or no access to an effective vaccine could ethically permit placebo-controlled trials, even if effective vaccines were already being marketed elsewhere. Here, I argue that inclusion in a placebo-controlled trial is ethically sound for those who would be in any case ineligible for vaccination outside the trial, and as long as the access to the vaccine outside the trial depends on a transparent and just allocation framework. Conversely, carrying out placebo-controlled studies in countries where vaccines are not (or are insufficiently) available because of unequal global allocation, would be unethical, as an ethical strategy cannot be built on an unethical premise.

Effect of Electroacupuncture vs Sham Treatment on Change in Pain Severity Among Adults With Chronic Low Back Pain: A Randomized Clinical Trial

IMPORTANCE

Chronic low back pain has high societal and personal impact but remains challenging to treat. Electroacupuncture has demonstrated superior analgesia compared with placebo in animal studies but has not been extensively studied in human chronic pain conditions.

OBJECTIVE

To evaluate the treatment effect of real electroacupuncture vs placebo in pain and disability among adults with chronic low back pain and to explore psychophysical, affective, and demographic factors associated with response to electroacupuncture vs placebo in treating chronic low back pain.

DESIGN, SETTING, AND PARTICIPANTS

This double-blind randomized clinical trial was conducted between August 2, 2016, and December 18, 2018, at a single center in Stanford, California. Primary outcomes were collected at approximately 2 weeks before and after intervention. Participants included English-speaking adults with at least 6 months of chronic low back pain, pain intensity of at least 4 on a scale of 0 to 10, and no radiculopathy. Data analyses for this intent-to-treat study were conducted from June 2019 to June 2020.

INTERVENTIONS

Twelve sessions of real or placebo (sham) electroacupuncture administered twice a week over 6 weeks.

MAIN OUTCOMES AND MEASURES

The main outcome was change in pain severity from baseline to 2 weeks after completion of treatment, measured by the National Institutes of Health PROMIS pain intensity scale. A secondary outcome was change in the Roland Morris Disability Questionnaire (RMDQ). Baseline factors potentially associated with these outcomes included psychophysical testing (ie, thermal temporal summation, conditioned pain modulation, pressure pain threshold), participant's self-report (ie, widespread pain, coping strategies, expectations, self-efficacy, and pain catastrophizing), and demographic characteristics (eg, age, sex, and race).

RESULTS

A total of 121 adults were recruited to the study, among whom 59 participants (mean [SD] age, 46.8 [11.9] years; 36 [61.0%] women) were randomized to real electroacupuncture and 62 participants (mean [SD] age, 45.6 [12.8] years; 33 [53.2%] women) were randomized to sham electroacupuncture. At baseline, the mean (SD) PROMIS T-score was 50.49 (3.36) in the real electroacupuncture group and 51.71 (4.70) in the sham acupuncture group, and the mean (SD) RMDQ score was 10.16 (4.76) in the real electroacupuncture group and 10.03 (5.45) in the sham acupuncture group. After adjusting for baseline pain scores, there was no statistically significant difference between groups in change in T-scores 2 weeks after completion of treatment (real electroacupuncture: -4.33; 95% CI, -6.36 to -2.30; sham acupuncture: -2.90; 95% CI, -4.85 to -0.95; difference: -2.09; 95% CI, -4.27 to 0.09; P = .06). After adjusting for baseline RMDQ, there was a significantly greater reduction in RMDQ in the real electroacupuncture group (-2.77; 95% CI, -4.11 to -1.43) compared with the sham electroacupuncture group (-0.67; 95% CI, -1.88 to 0.55; difference: -2.11; 95% CI, -3.75 to -0.47; P = .01). Within the real electroacupuncture group, effective coping at baseline was associated with greater RMDQ reduction (r = -0.32; 95% CI, -0.54 to -0.05; P = .02), and White race was associated with worse outcomes in PROMIS score (β = 3.791; 95% CI, 0.616 to 6.965; P = .02) and RMDQ (β = 2.878; 95% CI, 0.506 to 5.250; P = .02).

CONCLUSIONS AND RELEVANCE

This randomized clinical trial found no statistically significant difference in change in PROMIS pain score in real electroacupuncture vs sham electroacupuncture. There was a statistically significant treatment effect for the secondary outcome of RMDQ compared with sham electroacupuncture. Effective coping skills and non-White race were associated with response to electroacupuncture.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02890810.

TIDieR-Placebo: A guide and checklist for reporting placebo and sham controls

BACKGROUND

Placebo or sham controls are the standard against which the benefits and harms of many active interventions are measured. Whilst the components and the method of their delivery have been shown to affect study outcomes, placebo and sham controls are rarely reported and often not matched to those of the active comparator. This can influence how beneficial or harmful the active intervention appears to be. Without adequate descriptions of placebo or sham controls, it is difficult to interpret results about the benefits and harms of active interventions within placebo-controlled trials. To overcome this problem, we developed a checklist and guide for reporting placebo or sham interventions.

METHODS AND FINDINGS

We developed an initial list of items for the checklist by surveying experts in placebo research (n = 14). Because of the diverse contexts in which placebo or sham treatments are used in clinical research, we consulted experts in trials of drugs, surgery, physiotherapy, acupuncture, and psychological interventions. We then used a multistage online Delphi process with 53 participants to determine which items were deemed to be essential. We next convened a group of experts and stakeholders (n = 16). Our main output was a modification of the existing Template for Intervention Description and Replication (TIDieR) checklist; this allows the key features of both active interventions and placebo or sham controls to be concisely summarised by researchers. The main differences between TIDieR-Placebo and the original TIDieR are the explicit requirement to describe the setting (i.e., features of the physical environment that go beyond geographic location), the need to report whether blinding was successful (when this was measured), and the need to present the description of placebo components alongside those of the active comparator.

CONCLUSIONS

We encourage TIDieR-Placebo to be used alongside TIDieR to assist the reporting of placebo or sham components and the trials in which they are used.

[Analysis on Current State of Acupuncture Clinical Trials with Sham Acupuncture Design in Western Countries]

The design of "sham acupuncture" is necessary in clinical trials of acupuncture for confirming its effectiveness in the treatment of different disorders. The authors of the present paper made a comprehensive analysis on "sham acupuncture"or "placebo acupuncture" in clinical trials of acupuncture therapy in western countries from 1) the definition and background of sham acupuncture, 2) current state of acupuncture clinical trials with sham acupuncture design in different countries, 3) current situations of acupuncture clinical trials with sham acupuncture design in Germany, and 4) current state of large sample, randomized controlled clinical trials of acupuncture therapy with sham acupuncture design in other western countries. The authors of the present paper also make an analysis on the developing trends of acupuncture clinical trials with sham acupuncture design and put forward some problems existing in current acupuncture researches.

Ethical Overview of Placebo Control in Psychiatric Research - Concepts and Challenges

Permissibility of placebo controls in psychiatric research is raising everlasting controversies. The main ethical issue remains: whether, when, under what conditions, and to what extent is it justifiable to disregard subject's present (best) interest for the presumably "greater" ones. In relation to this main ethical concern, two distinct arguments arose: proponents of placebo controls trials (placebo ortxodoxy) and proponents of active controls trials (active-control orthodoxy). More recently, in new ethical guidelines, Declaration of Helsinki and International Ethical Guidelines for Biomedical Research Involving Human Subjects, a "middle way" approach was formulated, acceptable to both sides of the argument, saying placebo controls can be justified under certain conditions: when and only when, they firstly present undisputed methodological reasoning, and secondly, fulfill certain ethical considerations - mainly regarding the permissibility of accompanied risks. These ethical evaluations are inevitably contextual and evoke the need for the principle of proportionality. In scope of recent findings of substantial and progressively increasing placebo response in psychiatric research, contextual factors are identified and both theoretical and practical challenges are discussed.

[Exploration into the preparation of placebos used in Chinese medicinal clinical trial]

Placebo-controlled clinical trials have been more and more emphasized in traditional Chinese medicine (TCM) researches, while the preparation of TCM placebos is still to be improved. For this work, some elements should be taken into consideration comprehensively, including the design of clinical trial, the characteristics of researched disease, the nature of testing drugs, and the way of medication, etc. And the technological process for placebo manufacturing should be selected properly depending upon the basis of the above elements. Un-biased foodstuff is good as excipient for TCM placebos preparation. The placebo should be made in dosage-form similar to that of the testing drug as possible, if there are difficulties for simulating them in appearance and smell completely. However, its potential pharmacological activity meeting to the acceptance of researchers should be ensured.

[Study on key problems in the positive control design methods of acupuncture and moxibustion ]

To probe into the design method of the clinical studies with positive control of acupuncture and moxibustion, the several key problems are analyzed, which include the definition of positive control, form of the control, statistical and design types, proper application of positive drugs, and properly use placebo control method to counteract weaknesses of studies, reasonably select observation indexes so as to show characteristics of Chinese medicine. The authors indicate that only fully thinking these key problems, can provide clinical evidence of acupuncture and moxibustion with high quality and convincingness.

[Thinking about the conclusion of no difference between the acupuncture and sham-acupuncture in the clinically therapeutic effects on migraine abroad]

For the conclusion of "no difference between the acupuncture and sham-acupuncture in the clinically therapeutic effects on migraine abroad", by description of definition of sham-acupuncture (placebo acupuncture), the following principle needed by ideal placebo acupuncture, and definition, parts, functions and clinical effects of shallow needling, whether or not can shallow needling be used as the control method of sham-acupuncture in the clinical acupuncture study are explored, the results indicate that "the called sham-acupuncture (placebo acupuncture)" control method, i.e., "needling acupoints or non-acupoints on the superficial lay of skin with minimal stimulating amount" is very possibly activates the regulative action of the whole body through "superficially needling the skin part", to exert the therapeutic action. Therefore, this control method is not a proper control method of placebo acupuncture, and can not be used as the control method for sham-acupuncture (placebo acupuncture) in clinical acupuncture studies. Thus, the conclusion of "no difference between the acupuncture and sham-acupuncture in the clinically therapeutic effects" made by this placebo acupuncture control method naturally may be overturned.

Is There a Placebo Problem in Antidepressant Trials?

In psychiatry, particularly in antidepressant clinical studies, placebo-controlled trials often yield results that are very difficult to interpret because of robust placebo responses. Meta-analyses of trials in major depressive disorder (MDD) suggest that drug-placebo differences in response rates range from 11% to 18%. However, in trials of marketed antidepressants present in the FDA databases, antidepressant drugs were superior to placebo in only 45 out of 93 RCTs (48%), and the placebo response overall appears to have increased over time. This gradual increase in placebo response rates may lead to delays in bringing new antidepressant treatments to the market, increased costs of antidepressant drug development and, in some cases, decisions to stop the development of certain compounds, or FDA decisions to not approve new treatments. A number of possible contributing factors to this significant placebo response in MDD have been identified, but further studies are needed. Many of the remedies used by researchers to minimize the placebo response, such as lead-in periods or shortening the duration of study visits, have failed to show consistent benefits. From our analysis of published studies, it appears that expectations about the speed of response may be shaped by the duration of the trial and that most of the placebo response occurs in the first half of the trial, regardless of its duration. These observations have led us to develop a novel approach to the placebo response problem called the Sequential Parallel Comparison Design.

Nutzen aus klinischer Forschung: auch für Patienten und Probanden?

The Convention on Human Rights and Biomedicine, its Additional Protocol, the European Parliament's Good Clinical Practice (GCP)-Directive as well as the German Medicines Law and GCP-Decree all require certain forms of "benefit" for participants of clinical trials and other forms of clinical-evaluative research. However, they do not provide any attempt to define e. g. "direct benefit" or group benefit -- contrary to our text. It additionally discusses qualitative and quantitative aspects and the inherently probabilistic nature of any benefit from clinical research. Clinically most relevant study types and designs (such as placebo-controlled trials; diagnostic studies of phases 1 - 3) do not offer any potential individual benefit at least for parts of the samples, they are at best beneficial for the group of similarly affected patients. At present those trials if including incapacitated adults not able to give informed consent are forbidden by German law, a situation different from that of trials involving minors.

APS position statement on the use of placebos in pain management

In the spring of 2003, the board of directors of the American Pain Society asked the APS Ethics Committee to formulate a position statement for the Society concerning the use of placebos in clinical practice (cf, reference ). A subset of the Ethics Committee under my direction composed such a statement based on the available scientific and ethical literature. We then sought feedback from the entire ethics committee as well as numerous prominent voices in the literature and presented the statement to the membership for discussion at the 2004 annual APS meeting in Vancouver, British Columbia, at both a symposium and an ethics special interest group meeting. The resultant document was approved by the APS Board and is published here for widespread distribution to the membership.

The physician/investigator's obligation to patients participating in research: the case of placebo controlled trials

Some authors argue that the ethics of medical care and the ethics of research differ, and that it is a mistake to conflate the two. They propose “that medical research and medical treatment are two distinct forms of activities, governed by different ethical principles.” This raises the question of whether physicians who are also clinical investigators may separate their role as physician from that of researcher when they are involved in clinical trials, thereby avoiding the obligations required in the physician-patient relationship. Miller and Brody suggest that medical training is to blame for what they believe is the physicians’ tendency to confound the obligations of research and practice. “Physician-investigators, after all, went to medical school” they explain. They believe that considering research with patients outside the ethical framework of the physician-patient relationship may be “difficult and threatening” to physicians who have “psychological needs” to consider the ethical obligations flowing from their relationship with their patients.

How Informed Is Consent in Sham-Controlled Trials of Acupuncture?

OBJECTIVES

We sought to investigate whether, and if so, how published sham-controlled trials of acupuncture report on the information given to patients about true and sham interventions. We asked acupuncture therapists to provide original patient information leaflets in order to study how interventions were described in more detail.

METHODS

Forty-seven (47) published sham-controlled trials of acupuncture collected for a systematic review on sham techniques were screened to determine whether they reported on information given to patients about study interventions; any such information was extracted. We contacted authors of published studies and other researchers in the field and asked them to provide copies of original patient information leaflets. Information given to patients about true and sham interventions was extracted.

RESULTS

Ten (10; 21%) of the 47 published studies included some information on how patients were informed. None of these studies appear to have used the term "sham" or "placebo" and most appear to have suggested that two types of acupuncture were compared. In the 16 original patient information leaflets obtained, the way patients were informed varied greatly: 7 leaflets explicitly included words such as "sham," "placebo," or "dummy." Others described the control intervention as not meeting all criteria of acupuncture. Finally, one group of studies simply suggested that different types of acupuncture were being compared.

CONCLUSION

Our results indicate that (1) only a minority of published trials report on information given to patients about true and sham interventions and (2) that information strategies vary considerably and are often not fully explicit. This has not only ethical relevance but also might influence results of trials.

Is it ethical to conduct placebo-controlled clinical trials in the development of new agents for osteoporosis? An industry perspective

To represent industry on the topic of this conference, position papers were obtained from six pharmaceutical and biotechnology companies. Despite their holding a wide range of positions in the market with regard to prevention and treatment of osteoporosis, all companies were unanimous in their concerns about the ability to conduct randomized placebo-controlled clinical trials (PCTs) in the future. The clinical research environment contains conflicting directives. Regulatory agencies strongly prefer (even insist on) PCTs as a requirement for drug approval, while many physicians, human studies institutional review boards, and informed patients believe that it is no longer ethical to place osteoporotic patients on placebo because effective therapies are now available. PCTs offer the best means of calibrating the absolute efficacy of a new agent and identifying its side effects against a "neutral" background. Are comparison-controlled clinical trials (CCTs) using an approved drug the answer? No. Examples are given that illustrate that such trials require very large numbers of patients to show "non-inferiority" (approximately 15,000-20,000) or "superiority" (approximately 30,000) compared with an existing approved therapy. Such studies are not only impractical, but also accumulate a greater number of fractures during the course of clinical research in both the new treatment and control (active comparator) groups than would occur in PCTs. Total adverse experiences and exposure of patients to investigational agents is considerably greater when CCTs rather than PCTs are used. Based on this analysis, industry recommends that regulatory approval of new agents for osteoporosis be based on (1) conduct of PCTs in patients at low risk for fracture (e.g., T-score < -2.5 and no previous osteoporotic fracture); (2) use of bone mineral density as an end-point for the indication "to preserve or improve bone mass"; (3) a 2-year, rather than 3-year, trial period; (4) demonstration of no adverse effect on bone quality preclinically; (5) extrapolation of clinical trial results to higher risk patients; (6) an option for the sponsor to perform additional fracture end-point studies postapproval to obtain an indication for "treatment to reduce the risk of fractures specifically in the spine, hip, or both"; and (7) the option to file for a "prevention" claim before a "treatment" claim.

Context effects. Powerful therapies or methodological bias?

This article provides an analysis of the way in which placebo effects could be investigated and taken into account, supported by a description of some of the major articles that have been published on this topic. Based on conceptual, theoretical, and methodological issues, the authors highlight some of the reasons for current controversies regarding the nature of placebo effects. They suggest the use of the term context effects to overcome some of the negative connotations associated with the term placebo and to highlight the therapeutic nature of the health care context, and they present the major findings and limitations from their systematic review of the therapeutic effects of health care interactions. Recommendations for future research are proposed.

Study design in osteoporosis: a European perspective

The advent of effective agents for the treatment of osteoporosis has led to the view that placebo-controlled trials to test new agents for efficacy are no longer appropriate. Rather, studies of superiority, equivalence, or non-inferiority have been recommended. Such studies require very large sample sizes, and the burden of osteoporotic fracture in a trial setting is substantially increased. Studies of equivalence cannot be unambiguously interpreted because the variance in effect of active comparator agents is too large in osteoporosis. If fracture studies are required by regulatory agencies, there is still a requirement for placebo-controlled studies, although perhaps of shorter duration than demanded at present.

I need a placebo like I need a hole in the head

In this issue of the Journal of Law, Medicine & Ethics Peter Clark provides a comprehensive and sound ethical analysis of clinical trials examining the treatment of advanced Parkinson's disease with fetal tissue transplantation. These studies raise profound questions about how clinical trials of surgical interventions ought to be conducted. At stake is not only the ethical basis of such trials, but differing views as to the proper role of science in medicine and its limitations.

Experience with the broader debate on the ethical permissibility of placebo controls has taught us that the choice of control treatment is an aspect of trial design in which ethical and scientific issues overlap. Accordingly, I will highlight, and perhaps expand upon, three issues raised by Clark: What scientific questions ought clinical trials of surgical interventions ask? How should the ethical analysis of risk for such trials be conceived? And, are surgical patients a vulnerable population?

Placebo surgery for Parkinson's disease: do the benefits outweigh the risks?

In April 1999, Dr. Curt Freed of the University of Colorado in Denver and Dr. Stanley Fahn of Columbia Presbyterian Center in New York presented the results of a four-year, $5.7 million government-financed study using tissue from aborted fetuses to treat Parkinson’s disease at a conference of the American Academy of Neurology. The results of the first government-financed, placebo-controlled clinical study using fetal tissue showed that the symptoms of some Parkinson’s patients had been relieved. This research study involved forty subjects, nineteen women and twenty-one men; all suffered from Parkinson’s disease for an average of 13.5 years. In the study, each subject underwent neurosurgery: “four tiny burr holes, drilled through the wrinkle lines above the eyebrows into the skull, to clear a pathway to the brain. But only half received injections of fetal cells into the putamen, the region of the brain that controls movement; the other half received nothing. One year later, three members of the placebo group said their symptoms had improved.” In two-thirds of the transplant recipients, the fetal tissue took hold and seemed to establish a new network to produce the missing neurochemical dopamine.

Credibility of a newly designed placebo needle for clinical trials in acupuncture research

OBJECTIVE

To test the credibility of a newly designed placebo needle for acupuncture research.

DESIGN

Analysis of data on credibility of true and placebo interventions of a randomised, placebo-controlled, patient- and evaluator-blind clinical trial.

PATIENTS AND SETTING

The study was carried out at a university department for physical medicine and rehabilitation. 68 patients (age 48.1 +/- 14.1 years, mean +/- SD) fulfilling the criteria of the International Headache Society for tension-type headache were enrolled into the study.

INTERVENTIONS

Group 1 (treatment) was assigned to traditional needle placement and manipulation, whereas in group 2 (control) a new placebo device was used.

OUTCOME PARAMETERS

After the first treatment with real or placebo acupuncture, patients were asked to fill in a questionnaire on credibility. In addition, after 3 or 4 treatments, patients were asked for the feeling of needle insertion and deqi.

RESULTS

No difference between real and placebo acupuncture was detected with respect to the credibility of the treatment (p > 0.05). Needle insertion was recognised in all patients in the real acupuncture group and in all but 4 patients of the placebo group (p < 0.05). deqi was reported by 84% of patients in the real acupuncture group and by 34% of patients in the placebo group (p < 0.001).

CONCLUSION

Acupuncture with the placebo needle device described here is of high credibility, and does not differ from that of real acupuncture treatment. However, to achieve comparable prick sensations in both treatment conditions, careful training with the placebo needle is needed. Furthermore, from these results arise new questions with respect to the placebo response of placebo needles. Further investigations are warranted to test if placebo needles are active controls.