It is more important to know what sort of person has a disease than what sort of disease a person has. -Hippocrates

It is more important to know what sort of person has a disease than what sort of disease a person has. -Hippocrates

Nonspecific INERT

1300s & earlier PLACEBO: L. I Shall Please In Psalms: Placebo Domino I shall please the Lord Early 1900s Used in both Allopathic and Homeopathic trials 1 st modern description of Placebo Effect real psychotherapeutic effect produced 1500s Physician's duty was to "cure occasionally, relieve often, console always" In Canterbury Tales: Placebo is the sycophantic brother in The Merchant s Tale 1930s Use in Clinical Trials as sham treatments Clinical trials with No Sig Diff between drug & placebo Late 1700s Vis mediatrix naturae 1 st use of word Placebo 1 st clinical demonstration of the Placebo Effect 1940s Still defined as "wellmeaning fraud", "morally useful, but innocuous" Terms Placebo reaction & Placebo response coined Early 1800s Late 1800s "Epithet given to please the patient" Blinding introduced into pharmaceutical trials Sugar pills Elixirs Pharmaceutical syrups 1955 Roughly 1960-1990s The Powerful Placebo "Nuisance variable" in clinical research First use of the term Placebo Effect Past 20 years to current "Placebo Effect" is being actively studied to clarify mechanisms & context Experimental studies Neurobiological models Imaging participating effects of rituals, symbols, & clinician interaction J Neurosci Pain Everything looks great, you can put your shirt back on and I ll get you a prescription for placebos Wait crap they re not gonna work now Nat Rev NeurosciHandb Exp Pharmacol Am Psychol, 1985 The Science of Placebo Ann Rev Psychol, 2008

BMJ Ann Intern Med N Eng J Med The doctor-patient relationship is critical to the placebo effect -Irving Kirsch J Consult Clin Psychol Ann Rheum Dis Ann Rheum Dis

Morbidity, mortality, symptom improvement, cost reduction & quality of life Examples: Pain, RTP, Nausea Strength of Recommendation Recommendation is Based on A Consistent & good-quality patient-oriented evidence B Inconsistent or limited-quality patient-oriented evidence C Consensus, usual practice, opinion, disease-oriented evidence Intermediate, physiologic, or surrogate end points that may or may not reflect improvements in patient outcomes Examples: BP, ROM, strength properly continue to do It is important to distinguish the very respectable, conscious use of placebos. The effects of placebos in RCTs has been shown to be very large. Their use in the correct place is to be encouraged. What is inefficient is the use of relatively expensive drugs as placebos -Archie Cochrane 1972 "Because medicine has been so concerned with its scientific growth, too little attention has been paid to advancing the art of medicine, to which therapy with placebos belongs, and consequently knowledge of the use of placebos has not progressed significantly. -Leslie A, Am J Med, 1954 Holistic vs Reductionist Systems approach

healing healing healing should not healing should not healing should not

or An Evidence-Based Approach In clinical practice, where a majority of patient visits are for conditions that cannot be explained on a pathophysiological basis, and for which no specific treatment is available, it is essential that physicians understand the concepts and principles of placebos & placebo effects and, when appropriate, use them correctly -Carruthers et al, 2000 Commitment to Excellence