Widespread use of pure and impure placebo interventions by GPs in Germany

Abstract

To collect data on the use of placebo interventions by GPs in Germany.Methods. A questionnaire was mailed to 400 randomly selected GPs in Bavaria. Non-responders were reminded by telephone after 4 weeks and were given a second copy of the questionnaire after a further 3 weeks. Results. In all, 208 completed questionnaires were returned. The majority of GPs (88%) have used a placebo at least once in their practice; 45% have used pure placebos, such as saline injections and sugar pills, at least once last year; the median frequency of use was 5 [interquartile range (IQR), 2-10]. The use of impure placebos during the past year was more common: 76% of GPs have used impure placebos, i.e. medical interventions that have pharmacological or physical activity but have no intrinsic effect (e.g. pharmacological or physical action) on the patient's disease or its symptoms, with a median frequency of 20 times per year (IQR, 10-50). The main reason for the use of placebo was a possible psychological effect, followed by the expectation of patients to receive a treatment. For the majority of GPs placebo interventions were ethically justified if they were used for a possible psychological effect.Conclusions. Placebo interventions are a widely accepted part of medical treatment in German general practices and are used primarily for their psychological effects. Impure placebos are used much more frequently than pure placebos.

Placebo use in the United Kingdom: results from a national survey of primary care practitioners

“…[5] The latest survey of placebo use was published after the systematic review and found 45% of German GPs had used pure placebos and 76% had used impure placebos in the last year. [12] Hence the results of our UK survey are internationally consistent.…”

“…[4,7,10,11,12] Pure placebos are interventions such as sugar pills (which are available commercially [31]) or saline injections without direct pharmacologically active ingredients for the condition being treated. Impure placebos are substances, interventions or 'therapeutic' methods which have known pharmacological, clinical or physical value for some ailments but lack specific therapeutic effects or value for the condition for which they have been prescribed.…”

“…[4,7,9,10,11,12] We piloted our questionnaire with GP colleagues at Oxford and Southampton (n = 21) to ensure face validity. The questionnaire asked respondents to note how frequently (if at all) they used placebo interventions.…”

“…Surveys in various countries suggest 17% to 80% of doctors have prescribed 'placebos' in routine clinical practice, [1,2,3,4,5,6,7,8,9,10,11,12] yet placebo use outside the context of a clinical trial with full informed consent is generally considered unethical. [13,14,15,16] The only survey of placebo use in the UK was a 1976 qualitative study restricted to Welsh practitioners.…”

Impure placebo is a useless concept

“…The basic paradox with the term "placebo effect" is that, by definition, a placebo -an inert substance or procedure -cannot elicit an effect [5,6]. A further problem arises if "placebo" is understood as an upper level category that is divided into two lower level categories, "pure" and "impure" placebos [7,8]. In several surveys these two categories were taken for granted; yet their problematic nature has also been acknowledged: "What is considered to be an impure placebo varies considerably among studies and it is unclear and subjective when an intervention is a placebo or an active or effective intervention.…”