Open label placebo: can honestly prescribed placebos evoke meaningful therapeutic benefits?

Kaptchuk, Ted J.; Miller, Franklin G.

doi:10.1136/bmj.k3889

Cited by 112 publications

(104 citation statements)

References 28 publications

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“…An emergent category of placebo investigation and treatment is open label, honestly prescribed placebo. A summary of OLP clinical studies in a range of conditions including pain and non-pain conditions—discussing both strengths and weaknesses—has been reported elsewhere910; table 3 summarizes evidence drawn exclusively from the subset of OLP trials in chronic pain. Patients are told that placebo treatments in RCTs can elicit positive responses in double blind studies, but that whether placebos “work” when patients are aware of receiving placebo is unknown.…”

Section: Placebo Treatments In Different Contextsmentioning

confidence: 99%

“…Finally, recent research has challenged the axiomatic presumption in biomedicine that eliciting placebo effects requires either deception in clinical practice or concealment in RCTs. In a recent series of small “proof of concept” RCTs with open label placebo (OLP), patients who received placebos subsequently achieved significant symptom relief 10…”

Section: Introductionmentioning

confidence: 99%

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Placebos in chronic pain: evidence, theory, ethics, and use in clinical practice

Kaptchuk

Hemond

Miller

2020

BMJ

Self Cite

139

155

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Despite their ubiquitous presence, placebos and placebo effects retain an ambiguous and unsettling presence in biomedicine. Specifically focused on chronic pain, this review examines the effect of placebo treatment under three distinct frameworks: double blind, deception, and open label honestly prescribed. These specific conditions do not necessarily differentially modify placebo outcomes. Psychological, clinical, and neurological theories of placebo effects are scrutinized. In chronic pain, conscious expectation does not reliably predict placebo effects. A supportive patient-physician relationship may enhance placebo effects. This review highlights “predictive coding” and “bayesian brain” as emerging models derived from computational neurobiology that offer a unified framework to explain the heterogeneous evidence on placebos. These models invert the dogma of the brain as a stimulus driven organ to one in which perception relies heavily on learnt, top down, cortical predictions to infer the source of incoming sensory data. In predictive coding/bayesian brain, both chronic pain (significantly modulated by central sensitization) and its alleviation with placebo treatment are explicated as centrally encoded, mostly non-conscious, bayesian biases. The review then evaluates seven ways in which placebos are used in clinical practice and research and their bioethical implications. In this way, it shows that placebo effects are evidence based, clinically relevant, and potentially ethical tools for relieving chronic pain.

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Section: Placebo Treatments In Different Contextsmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Placebos in chronic pain: evidence, theory, ethics, and use in clinical practice

Kaptchuk

Hemond

Miller

2020

BMJ

Self Cite

139

155

View full text Add to dashboard Cite

show abstract

“…A meta-analysis on open-label placebos, where patients are honestly informed they are being given placebos found positive clinical effects 8. However, few qualitative studies have explored patients’ or doctors’ perspectives on open-label placebos 18. We used nominal group technique,19–21 a qualitative consensus building technique, to explore and compare how patients and doctors conceive a range of placebogenic practices and why certain practices are more acceptable.…”

Section: Introductionmentioning

confidence: 99%

Placebos in primary care? a nominal group study explicating UK GP and patient views of six theoretically plausible models of placebo practice

Ratnapalan

Coghlan²,

Tan

et al. 2020

BMJ Open

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ObjectivesTo better understand which theoretically plausible placebogenic techniques might be acceptable in UK primary care.DesignA qualitative study using nominal group technique and thematic analysis. Participants took part in audio-recorded face-to-face nominal groups in which the researcher presented six scenarios describing the application in primary care of theoretically plausible placebogenic techniques: (1) Withholding side effects information, (2) Monitoring, (3) General practitioner (GP) endorsement, (4) Idealised consultation, (5) Deceptive placebo pills and (6) Open-label placebo pills. Participants voted on whether they thought each scenario was acceptable in practice and discussed their reasoning. Votes were tallied and discussions transcribed verbatim.SettingPrimary care in England.Participants21 GPs in four nominal groups and 20 ‘expert patients’ in five nominal groups.ResultsParticipants found it hard to decide which practices were acceptable and spoke about needing to weigh potential symptomatic benefits against the potential harms of lost trust eroding the therapeutic relationship. Primary care patients and doctors felt it was acceptable to harness placebo effects in practice by patient self-monitoring (scenario 2), by the GP expressing a strongly positive belief in a therapy (scenario 3) and by conducting patient-centred, empathic consultations (scenario 4). Deceptive placebogenic practices (scenarios 1 and 5) were unacceptable to most groups. Patient and GP groups expressed a diverse range of opinions about open-label placebo pills.ConclusionsAttempts to harness placebo effects in UK primary care are more likely to be accepted and implemented if they focus on enhancing positive patient-centred communication and empathic relationships. Using placebos deceptively is likely to be unacceptable to both GPs and patients. Open-label placebos also do not have clear support; they might be acceptable to some doctors and patients in very limited circumstances—but further evidence, clear information and guidance would be needed.

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“…Even when subjects are explicitly informed that an agent or suggestion is 'inert'-in that it has no direct biological relevance to illness-beneficial health-related outcomes are still realized [81][82][83][84][85][86][87][88]; these studies are challenging the Flexner-inspired narratives. Not only are medical journal editorials encouraging clinicians to stay well versed in the realm of placebo studies [89], some state that it is clearly ethical to foster the placebo effects, and are asking medicine-at-large whether or not it is ethical to allow "the patient suffer in the name of truth or to expose him or her to nocebo effects" [90].…”

Section: Beliefs Narrative Mindsetsmentioning

confidence: 99%

Narrative Medicine Meets Planetary Health: Mindsets Matter in the Anthropocene

Prescott

Logan²

2019

Challenges

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The emerging concept of planetary health—defined as the interdependent vitality of all natural and anthropogenic ecosystems (social, political, and otherwise)—emphasizes that the health of human civilization is intricately connected to the health of natural systems within the Earth’s biosphere. In the clinical setting, narrative medicine underscores the importance of absorbing, reflecting upon, and responding to the narratives—the stories—conveyed by patients. Education and interventions using the tenets of narrative medicine have demonstrated value to both patient and provider. Given the grand interconnected challenges of our time—compounded by misinformation and quasi-scientific narratives propagated by the ideology of neoliberalism—we argue that the principles and practice of narrative medicine can be applied on a larger scale, one with planetary health in mind. The role of beliefs, expectations, and agency—mindsets—in the link between narrative and planetary health are emphasized. We use a story of our own to demonstrate that the biological buffering capacity in response to a fast-food meal does not sit on a level socioeconomic playing field. Patient, community, and global health narratives are melding with powerful narratives set by commercial entities. The success of planetary health as a new concept will be strengthened by attention to the ways in which storytelling can influence positive change. No less important is an understanding of the ways in which stories contribute to what ails person, place, and planet.

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Open label placebo: can honestly prescribed placebos evoke meaningful therapeutic benefits?

Abstract: Results from small clinical trials suggesting that placebos can be ethically and effectively used in clinical practice warrant further study, argue Ted Kaptchuk and Franklin Miller

Cited by 112 publications

References 28 publications

Placebos in chronic pain: evidence, theory, ethics, and use in clinical practice

Placebos in chronic pain: evidence, theory, ethics, and use in clinical practice

Placebos in primary care? a nominal group study explicating UK GP and patient views of six theoretically plausible models of placebo practice

Narrative Medicine Meets Planetary Health: Mindsets Matter in the Anthropocene

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