Prescribing “Easy Fix” Placebo is Common

The following article was written by Dr. Peter Lurie, Deputy Director of the Health Research Group at Public Citizen.

When I was a resident doctor on the West Coast in the late 1980s, I worked for a while in a clinic for refugees, many of them from Southeast Asia. The staff had encountered a problem: Many of the patients felt weak after having their blood drawn and believed that they were short of blood for the rest of their lives. Some even refused to have their blood drawn.

Then, someone hit upon a solution: After each blood draw, patients were offered a red drink and told that their blood level was therefore repleted. Problem solved.

I was uncomfortable with misleading patients in this way, though most of my colleagues saw little problem with the practice. It’s just a harmless placebo, I was told.

Placebo, a Latin word meaning “I will please,” is used most formally to describe pills with no known chemical activity given to patients in a medical experiment (typically a sugar pill that resembles the treatment being tested). This allows the inherent activity of the active treatment to be tested. This is because, for certain conditions, such as pain, being told you have received the active treatment will make you more likely to believe the treatment is working. It is the harnessing of favorable patient expectations that is behind the administration of placebos to patients in the clinical setting.

In some instances, formally prescribing placebos was a sanctioned form of medical practice. At least in the mid-1980s, the official Dutch handbook on medicines actually included placebos of various colors; I was told they were used primarily for psychiatric patients.

New study sheds light on doctors’ placebo-prescribing habits

Until recently, little was known about how commonly placebo treatments are employed. But an article in the British Medical Journal (Oct. 23, 2008) provides the best estimate to date of the prevalence of the practice. The article detailed a study which identified a random set of 1,200 U.S. physicians specializing in internal medicine or rheumatology. Of these, 679 (57 percent) responded to a mailed questionnaire inquiring into their prescribing of placebos. Fifty-five percent of these physicians stated that, in the past year, they had used a placebo, defined as “a treatment whose benefits derive from positive patient expectations and not from the physiological mechanism of the treatment itself.”

However, many of these treatments were not actually placebos. For example, 41 percent of respondents reported recommending over-the-counter analgesics and 13 percent each reported sedatives and antibiotics, products that can have serious side effects.

Physicians most commonly described the “placebo” to their patients as “a medicine not typically used for your condition but might benefit you” (68 percent of those using such “placebos”), with smaller percentages describing the “placebo” as a “medicine” (18 percent), a “medicine with no known effects for your condition” (9 percent), and a “placebo” itself (5 percent).

Although not empirically explored by the study, there are a number of potential explanations for these findings. Most generously, physicians are trying to help patients by promoting positive expectations. But can’t this be done through empathetic, encouraging interpersonal interactions, rather than by deceiving the patient? And what if the patient, believing the “placebo” is working, defers taking a truly effective treatment?

Another motivation might be operating instead: to bring a prompt end to the therapeutic encounter by resorting to a now-traditional ritual — writing a prescription. But this can lead to patients developing a pill-for-every-ill expectation, leading in turn to more prescribing, be it unnecessary drugs or more placebos.

However tempting or well-meaning “placebo treatments” may be to doctors (because no patient goes to an appointment and demands one), it is an impulse best rejected. Deception in clinical medicine risks undermining the goodwill physicians currently enjoy with their patients — the very goodwill that is at the root of the apparent effectiveness of placebos. Better to take the time to honestly discuss the patient’s medical situation than to resort to the easy fix of a placebo.