The placebo effect: So strong, doctors don’t even have to lie!

Almost everyone has heard about the placebo effect – the finding that treatment that have no particularly relevant effect (like a sugar or vitamin pill, or a behavioral equivalent) can make patients feel better. The placebo effect is actually the reason that all FDA approved drugs have to go through a double-blind placebo-controlled clinical trial before being approved for use – It has to be shown that using a specific medication is more beneficial than a non-active placebo even when the experimenter (or doctors) and the patient have no idea which treatment the patients are receiving. Otherwise, companies could simply continuously create placebos, show that they produce improvements in patients, and bring in the dollars.

Until now, it’s been assumed that in order for placebos to work, the patients have to be told that they are effective medications, amounting to an unethical lie by the doctors that prescribe them. This is the reason that very few doctors use pure placebos, though in a recent survey more than 50% of doctors reported using mild prescriptions (like over-the-counter pain medications) that they don’t believe are actually relevant to the condition as “impure placebos.” Given the large placebo effect, we can expect that these treatment, even if unethical, resulted in significant improvements in conditions that those same doctors were unable to treat using conventional methods. Still, it doesn’t feel good to know your doctors have to lie to you to make you feel better, right? Well they might not have to.

This fake placebo pill might make you feel better

A very recent study conducted at Harvard and published in the journal PLoS One examined whether placebos would still work for irritable bowel syndrome (IBS) patients even if they were explicitly told that the pills were inactive. The 80 IBS patients were randomly selected to receive either no treatment (the control condition) or a pill they were told was inactive “like a sugar pill” without any medication in it. Patients in the placebo condition were also told about the placebo effect and that such inactive sugar pills have been shown to produce significant mind-body self-healing processes. The placebo pills were marked with clear labels that read “placebo pills” so that there would be no confusion and so that patients would be constantly reminded that they pills they were taking were placebo pills 2 times a day. Amazingly, the placebo effect was still found to be present.

At the end of 3 weeks of treatment, participants in the placebo group reported significantly greater improvement in their symptoms on a number of different scales used for IBS as well as an overall Quality of Life measure. Even more amazingly, nearly twice as many patients in the placebo condition (59% versus 35%) reported that the treatment gave them “adequate relief” from their IBS symptoms!!! Patients got better taking pills that did nothing even though they knew that the pills were completely inactive. In fact, the effect was so great it was similar to the effects commonly seen with actual approved medications for IBS.

Conclusion and implications

Overall, these findings are encouraging on a number of fronts: If confirmed by future studies and using other conditions, these results suggest that doctors don’t have to lie to their patients since the placebo effect is strong enough to work even when patients are aware of it as long as the person giving the treatment is trusted. In fact, even this last piece should probably be put to the test since as far as I know, it has never been put to the test itself. Still, there is a whole body of literature in psychology telling us that when people of authority, people we respect, tell us to do something we react favorably.

Unfortunately, this has resulted in some pretty disturbing results including Stanley Milgram’s 1960s studies that revealed the power of authority in directing people to harm others (if you’ve never looked into these experiments you really should – here’s a video link to get you started). However, this time the results suggest that doctors may be able to help patients for whom there is no specific approved treatment. Obviously this is of interest to me because of the relatively low success in clinical addiction treatment. It may actually also suggest that a number of the treatments we’re using now – especially those that have never been subjected to a Randomized Placebo-Controlled Clinical Trial – may in fact simply be placebos. I have my own sneaking suspicions about some specific treatments…

Like every other study, this one is not without limitations. First of all, these results have to be replicated with other conditions and in other hospitals with other patients before doctors should feel comfortable simply prescribing placebos. There could be specific aspects of this sample that made the results so convincing. Indeed, even the no treatment condition got some benefit from their interaction with the medical and research staff involved in the study (or maybe just due to the passage of time). It’s as if we are now comparing the placebo effect to the time/human-interaction effect, gradually making our way towards some “no-effect” condition.  We also want to see these sort of results with a larger sample, and although conducting a double-blind trial isn’t possible (one group takes pills and the other doesn’t so everyone knows who is in what condition), I’m certain that future experiment will figure out more subtle controls.

Still, this study definitely indicates that giving placebos openly can work for patients who are open to it. It should also make everyone aware that just because someone tells you a treatment is objectively helpful doesn’t mean it is. In the end though, if the psychological placebo effect brings about actual improvement in symptoms, shouldn’t we consider it effective?

Citation:

Ted J. Kaptchuk, Elizabeth Friedlander, John M. Kelley, M. Norma Sanchez, Efi Kokkotou, Joyce P. Singer, Magda Kowalczykowski, Franklin G. Miller, Irving Kirsch, Anthony J. Lembo1 (2010) Placebos without deception: A randomized controlled trial in irritable bowel syndrome. PLoS One, 5,

These Fake Pills May Help You Feel Better – Science Now

Does current smoking among health care providers limit their ability to dissuade smoking to the general public?

By Christopher Russell

In 2003, the US Department of Health and Human Services (USDHHS) set a goal of reducing cigarette smoking among US adults (18 years +) to 12% by 2010, which if achieved would halve the adult smoking prevalence rate reported in 1998 (24%). Achieving this current smoking reduction may depend on the extent to which health care providers (doctors, nurses, and such), who are charged with promoting smoking cessation and dissuading the uptake of smoking among to the general public, are themselves current smokers. For example, health care providers’ anti-smoking and pro-quit messages will likely be more persuasive and credible to the smoking public when the messengers practice what they preach about smoking. Such messages may also better motivate quit efforts if the health care providers have had personal success in quitting smoking using the methods and information they are now endorsing. Conversely, smokers may intuit that when health care providers advise quitting but continue to smoke themselves despite enjoying ready access to all the resources, information, and tools which should facilitate quitting, then smokers, without this luxury of access to education and resources, will be even less likely to successfully stop smoking.

Therefore, significant strides in increasing the number of quit smokers and never smokers in the general population may somewhat depend on reducing current smoking among the health care providers who act as both educators and trusted role models to the general public. It is therefore important to know how the prevalence of smoking among health care providers compares to the prevalence of smoking in the general population, which health care providers are charged to reduce.

Current smoking among health care providers

Using US population survey data, a recent study published in Nicotine and Tobacco Research reports estimated changes in the prevalence of current smokers, former smokers, and never smokers among eight groups of health care provider  – physician, physicians assistant, registered nurse (RN), licensed practical nurse (LPN), pharmacist, respiratory therapist, dentist, and dental hygienist – between 2003 and 2006/07. While the majority of these health care providers have never smoked a single cigarette, the authors report that, in 2006/07, approximately one in every five licensed practical nurse (20.55%) and respiratory therapist (19.28%) was a current smoker. Current smoking rates among LPNs and respiratory therapists were marginally higher than the rate of current smoking in the general population (18.01%) and near double the Healthy People 2010 goal of 12% current smoking in the general population. Four groups of health care provider – physicians (2.31%), dentists (3.01%), pharmacists (3.25%), and registered nurses (RNs) (10.73%) were all on course to be below the 12% prevalence goal. Furthermore, seven of these eight health care groups in 2006/07 showed higher quit rates than was found in the general population (52%) – only LPNs had a lower quit rate (46%). However, the concern from a public health perspective, is that while current smoking rates among these health care groups and in the general population have dropped considerably when compared to data reported in a similar cohort study in 1990/91, these decreases in current smoking appear to have leveled off in recent years; current smoking did not significantly decrease in any health care profession or in the general population between 2003 and 2006/07.

An important methodological note about this study is that results reflect weighted population estimates (WPE), not actual data. WPEs allow researchers to make inferences about an entire population group given only some data for that group simply by scaling up the actual data, (i.e. data reported by around 4000 health care providers in each collection year were used to estimate smoking statuses for over 2 million actual individuals). Of course, this technique likely overgeneralizes behavior in the sampling group, but is nonetheless a standard, valuable tool of health epidemiologists when they want to make inferences about how entire populations are behaving. Indeed, many of our health policies have derived from WPEs.

Current smoking among licensed practical nurses

Among the most important findings of this study is that one in five licensed practical nurses in the US is currently smoking. Of the estimated 754,000 LPNs in the US, this equates to roughly 155,000 current smokers in this profession, illustrating that health campaigns designed to depict smoking as socially unacceptable, readily available access to education and empirical research on the health consequences of smoking, working in smoke-free health care campuses, and being charged with task of persuading clients to stop smoking, all appear insufficient to reduce current smoking among LPNs and respiratory therapists to below the rate of current smoking in the general population.

In contrast, 10.73% of registered nurses are current smokers. The discrepancy between LPNs and RNs begs two questions: why are LPNs nearly twice as likely as RNs to be current smokers, and should we expect RNs will be better able than LPNs to persuade current smokers to quit and dissuade smoking to would-be smokers? Certainly, researchers should now ask whether a health care provider’s smoking status is related to his ability to produce cessation in health care recipients. If we assume that health care workers have a central role to play in producing mass behaviour change of whatever kind, then it is plausible to reason that reducing smoking prevalence at the national level will significantly depend on first reducing smoking prevalence among health care providers, our first responders to public health concerns. Testing this hypothesis seems the logical extension to capitalise on these smoking prevalence data.

Why are licensed practical nurses twice as likely as registered nurses to be currently smoking?

If one’s smoking status is important for persuading change in others, we need to know why smoking is more prevalent among LPNs than RNs, why LPNs have a lower quit ratio than the general population, and so, which factors should be addressed to reduce current smoking among LPNs to below the 12% level. The authors of this study suggested that LPNs’ fewer years in education and lower annual income may be associated with their current smoking status since they mirror socioeconomic factors known to associate with higher smoking rates. Comparably large proportions of LPNs and RNs are female, thus ruling out an important effect of gender. In my opinion, given that nicotine produces positively reinforcing psychoactive effects and that smokers commonly report smoking to alleviate affective distress, another consideration may be that LPNs and RNs differ in their exposure to stressful work events and environments, and/or differ in their emotional reactivity and sensitivity to these events, and/or differ in their bias to perceive work events as stressful. Furthermore, as smoking staus is known to be associated with socioeconomic status and socioeconomic status is known to be associated with many health and wellbeing factors including stress, then stress may be important both as a direct influence on smoking behavior and indirectly as a mediator of the effects of socioeconomic variables on smoking behavior. A good start to exploring these hypotheses would be to simply ask LPNs and RNs of their main reasons for smoking in short open-ended interviews; if reliable differences in smoking attributions emerge then we may begin the harder task of counseling LPNs to think of smoking in ways which alter their reasons to smoke, the reasons which may currently be maintaining smoking in one in five LPNs.

Questions for the reader; please give your comments below

1)      Why do you think current smoking is more prevalent among licensed practical nurses than in the general population?

2)      Does a health care provider’s status as a current smoker make him/her more or less able to persuade smoking cessation in others?

3)      Will reducing current smoking nationally depend on reducing current smoking among health care providers?

References:

U.S. Department of Health and Human Services. (2003). Healthy People 2010, Retrieved from http://www.healthypeople.gov/

This report is free to download at: http://www.healthypeople.gov/document/pdf/uih/2010uih.pdf

Sarna, L., Bialous, S. A., Sinha, K., Yang, Q., & Wewers, M. E. (in press). Are health care providers still smoking? Data from the 2003 and 2006/2007 Tobacco Use Supplement-Current Population Surveys. Nicotine and Tobacco Research.

How doctors treat doctors with drug use problems: Addiction treatment that works

Physician Health Programs (PHP) are reporting an astonishing success rate when it comes to providing addiction treatment for addicted doctors:

  • Only about 20% of doctors ever test positive after being admitted to the program within a 5 year period.

  • More than 70% maintain their license and continue working within the same 5 year period.

These are the kind of addiction treatment results we want!

I’ve been saying for a long time that I believe in the theory promoted by Dr. McLellan, who until recently was the deputy-director of the Office of National Drug Control Policy (ONDCP). Doctor McLellan promotes a long-term view of addiction treatment, more like a chronic disease than anything that can be cured in a few visits (although this view only holds for some addicts).

I’ve also known for a while that the American Medical Association is supposed to be having great success at addiction treatment for addicted doctors. I’ve been meaning to contact someone at the AMA to find out how they did it. Now I don’t need to thanks to this recent bit of addiction research.

Addiction research on treatment for addicted doctors

A recent research article surveyed the vast majority of PHP’s and found that, not surprisingly, the things that we know work in addiction treatment do indeed produce results. The solution may not be easy, but it’s pretty simple:

  • Early detection and assessment brings the addicted doctor, their family members, colleagues, and employers together. Getting the problem out in the open early makes it easier to deal with than having to be secretive about it. The doctors get  an option, leave the profession or sign up for a 5 year treatment program to deal with their addiction.
  • Formal addiction treatment using the most appropriate and effective treatment centers In contrast to our criminal justice addiction pipeline, the majority of physicians (69%) receive 90 day residential treatment, while the rest receive intensive outpatient treatment. The PHPs also receive frequent status reports on each physician in treatment to assure adherence. To find treatment that works, use our Rehab-Finder.
  • Long-term support and monitoringAfter treatment, the physicians continue with aftercare that includes 12-step support, regular counseling meetings, and monitoring that includes random drug testing.

That’s it!  So simple yet so effective.

As addiction research continues to improve, I’m sure we’ll be able to bring these numbers up even higher than the 70% success rate currently reported. Still, you have to admit, 70% is amazing!!!

So if you want to know how to stop drinking and drugging, do like the doctors do and commit to long-term addiction treatment.

There are obvious differences between most addicts and the doctors in these programs (most people don’t have such a clear distinction between losing their livelihood and getting help), but the solution is most likely very similar.

More proof we need more money for addiction treatment:

We need to press our representatives to increase funding for addiction treatment and addiction research so that we can find the most efficient, yet effective, way to offer this kind of addiction treatment to the general population. By reducing the problems, we’d be able to cut into the $500 Billion a year drag addiction is putting on our economy. The effort will pay back for itself in no time.

Citation:

DuPont, R.L., Carr, G., Gendel, M., McLellan, A.T., Skipper, G.E. (2009). How are addicted physicians treated? A national survey of physician health programs. Journal of Substance Abuse Treatment, 37, 1-7.

Is anonymity the final shame frontier in addiction?

I’m a drug addict and a sex addict, and as far as I’m concerned, staying anonymous let’s me remain buried in shame, and a double life, that keeps me always one step ahead of those close to me. Did I say too much? Did I give away my secrets? None of those  questions matter when everyone knows everything there is to know about you. For a disease couched in anxiety, obsessions, and compulsive behavior, there’s very little that can be more triggering.

The difficulty of confessing addiction

Obviously I’m not naive to the consequences of confessing to others, and I’ve had a few very uncomfortable conversations that ended in people losing my number or superiors telling me they didn’t need to know. When it comes to the former, it’s their choice, and it might be a wise one, but having those who stay close to me know my truths keeps me safe by making me accountable and protects others from being hurt. And I can hurt with the best of them. Maybe that’s why when it comes to physician treated addicted physicians, there are no secrets, no anonymity, the family and employers are made part of the process. Some notable addiction providers (like Journey Healing Centers and others) have programs that explicitly involve the family in the treatment process as well. Getting the secrets out works to break away from the shame.

We’re only as sick as our secrets, even together

On an organizational level, I understand the need for anonymity to avoid having any specific member represent the group. But that logic only holds when everyone is told to remain anonymous. Otherwise, the entire group represents itself, which is, if nothing else, truthful. If one person slips, relapses, or goes into a homicidal rampage, it only makes the rest of us look bad if no one knows that millions others are “the rest of us.”

Over and over I hear people talk about the secret of their addiction and the lies they have to tell to cover up their shameful acts. Unfortunately, that only contributes to the stigma of addicts and makes it all the more difficult  to get some perspective on the actual problem: We do things we don’t want to over and over regardless of how much they hurt us or those around us

If you’ve read anything on this site, you know that I believe in many factors that contribute to addiction, including biology, environment, experience, and their interactions. Still, when it comes down to it, the misunderstanding of addiction is often our number one problem. And anonymity does nothing to reduce that misunderstanding.

How we can make a difference

Media portrayals only exacerbate the problem as they show us stories of addicted celebrities who are struggling but then leave the story behind before any recovery occurs. That way we only get to see the carnage but have to look pretty hard to see anything more.

But we can change all this with a small, courageous, action. We can let those around us know that we’re addicts, that we’re doing our best to stop our compulsive behavior and that we want them to hold us accountable. If we slip, we can get back up because we don’t compound the shame of a relapse with lies we tell, and those around us know that even a relapse can be overcome because they’ve seen those examples over and over in all the other “confessed” addicts around.

It’s time to leave the addiction “closet” and start living. We may not be able to change who we are easily, but we can change the way we go about living and make it easier on ourselves and on others. By breaking our anonymity, we can help assuage our own shame and let everyone know that addiction is everywhere and that it can be successfully overcome.

Just a thought…

More from AHSR – Addiction research to increase treatment success

Okay, there was almost too much to cover in a single post today. Actually, hold the almost. I want to cover a few of the basic things we talked about today, but many of the rest will have to be incorporated into future posts.

Yesterday, I wrote about talks having to do with new ideas about necessary steps to improve treatment. Today, the main speaker hit on one of the factors discussed yesterday:

How can we improve the length of time that patients stay in drug treatment?

We know from research that one of the best predictors of success in treatment is longer retention. Some of today’s ideas were revolutionary and some not, but here’s a partial list –

  • Plan treatment lengths that are longer – This is especially true for outpatient treatment. If patients think of longer treatment from the outset, even if they don’t hit the intended mark, they’re likely to stay longer than if no end goal was set (this is called anchoring in psychology).
  • Send out appointment reminders and make phone calls – it works for dentists and doctors!
  • Start treating to patient strengths instead of just trying to fix their weaknesses – If you’ve never heard of motivational interviewing, you should read up, it’s all there.
  • Allow patient choice in treatment – The notion that patients shouldn’t have any say in their own treatment should be seriously questioned.
  • Provide small incentives (one way this is done is known as contingency management).
  • Create contracts and provide social reinforcement (like plaques and certificates).

That’s probably a good enough list for now. If we could put all these things to use, we’d already see a significant increase in client retention AND satisfaction.

I had a great day, more tomorrow!!!