MD, PhD, FMedSci, FRSB, FRCP, FRCPEd.

I have often discussed the fact that many proponents of so-called alternative medicine (SCAM) have in recent years adopted the following argument: even if our SCAM were just a placebo, it would still be useful. After all, placebo effects are real and increasingly backed by sound science. The argument is deeply flawed, yet it convinces many lay people.

A recent article by Fabrizio Benedetti, the leading researcher in the area of placebo, is addressing exactly this issue. I feel that it is sufficiently important to quote it extensively here:

… a number of biochemical pathways, such as endogenous opioids and cannabinoids,5,6 and brain regions, like the prefrontal cortex, have been found to be involved in placebo analgesia. Likewise, dopamine and the basal ganglia circuitry have been found to mediate placebo responses in Parkinson’s disease. Although this is wonderful news for science, this may not be the case for society. The number of nonmedical organizations and healers that rely on this hard science, and actually justify their odd and bizarre procedures, has increased over the past few years. The main claim is that any procedure boosting patients’ expectations, which represent the main mediator of placebo effects, is acceptable because it can activate the same biochemical pathways and neural networks that have been made credible by hard science…

The crucial point here is that when hard science started investigating placebo effects, it unconsciously produced a shift in quackery thinking. In fact, charlatans are becoming more and more aware that their bizarre interventions could work through a placebo effect. Indeed, whereas hard science has so far denied any scientific basis for nonconventional therapies, now the very same hard science certifies that the placebo effect has scientific grounds. Therefore, quacks are no longer interested in showing that their pseudo-interventions work; rather, they justify their use on the basis of the possibility that these bizarre interventions may induce strong placebo effects…

… A first point that should be emphasized is that placebos do not cure, but rather, they may sometimes improve quality of life. There is plenty of confusion on this point, and unfortunately, many claim that they can cure virtually all illnesses with placebos. Hard science tells us that placebos can reduce symptoms such as pain and muscle rigidity in Parkinson’s disease, yet the progression of the disease is not affected; for example, in Parkinson’s disease, neurons keep degenerating even though some symptoms can be reduced for a short time.4 The second point is related to the first. The type of disease is crucial, and we need to make people understand that pain is different from cancer and that anxiety differs from infectious diseases. The psychological component of some illnesses can indeed be modulated by placebos, but placebos cannot stop cancer growth, nor can they kill the bacteria of pneumonia. The third point is related to the difference between real placebo effects and spontaneous remissions. So far, hard science has studied the placebo effect within a time span of hours/days, thereby limiting our knowledge to short-lasting effects. Consequently, long-lasting effects can be often attributed to spontaneous remissions.

In addition to these three important points, we should also make patients understand that a diagnosis is required before any sort of therapy. An apparently trivial pain may conceal a danger; thus, it must never be treated unless a diagnosis has been made before, and this can be made only by physicians. Moreover, not only should we discuss and consider the positive effects of placebos and the impact they may have in clinical trials and medical practice, but we should also pay much of our attention to the negative counterpart, that is, the misuse and abuse by quacks, charlatans, shamans, and nonmedical organizations. Thus, we need to inform the whole society that the benefits following a nonconventional healing procedure are attributable to a placebo effect in most of the cases. Last but not least, we need to be more honest on the real efficacy of many pharmacological and nonpharmacological treatments, acknowledging that some of them are useful whereas some others are not: This will boost patients’ trust and confidence in medicine further, which I believe are the best foes of quackery…

…Unfortunately, quackery has today one more weapon on its side, which is paradoxically represented by the hard science–supported placebo mechanisms. This new “scientific quackery” can do a lot of damage; thus, we must be very cautious and vigilant as to how the findings of hard science are exploited. The study of the biology of these vulnerable aspects of mankind may unravel new mechanisms of how our brain works, but it may have a profound negative impact on our society as well. We cannot accept a world where expectations can be enhanced with any means and by anybody. This is a perspective that would surely be worrisome and dangerous. I believe that some reflections are necessary in order to avoid a regression of medicine to past times, in which quackery and shamanism were dominant. Unfortunately, the new knowledge about placebos by hard science is now backfiring on it. What we need to do is to stop for a while and reflect on what we are doing and how we want to move forward. A crucial question to answer is, Does placebo research boost pseudoscience?

__________________________________________________________________

I am immensely thankful to Prof Benedetti to make such clear and long-overdue statements. They will be most helpful in refuting the myth that homeopathy, para-normal healing, reflexology, acupuncture, chiropractic, etc., etc. are legitimate and uselful therapies, even if they are not better than a placebo. Using placebo therapies in routine care is not in the best interest of either the patient or progress.

57 Responses to Does placebo research boost pseudoscience?

  • Doesn’t Placebo mean “fake?” If it is fake and works that would mean the underlying medical issue was not totally real, more mental vs physical pain? I am confused, does patient believe he/she has a medical problem but a fake pill (patient not knowing it is fake) will fix it? Why would a placebo be issued? I am starting to think my 3 meds could be placebos.

    • Doesn’t Placebo mean “fake?”
      No!

      • Ok, I need to research more, why I asked. Maybe you you can point me to better sites besides using google, I am a layperson being serious. Placebo really confuses me. I read your site everyday for learning and a few others.

        • https://www.amazon.co.uk/Placebo-Effects-Fabrizio-Benedetti/dp/0198705085/ref=sr_1_1?keywords=benedetti+fabrizio&qid=1568795354&s=books&sr=1-1
          Fabrizio Benedetti has written much about the subject; he is excellent. you probably also find articles by him for lay people on the Internet.
          The book is good but not all that easy to understand, if you are non-medical.

          • Thank you, 2 generations of this mental crap we deal with. Think genetics.

          • The other site I read really had a nice post about you, science based medicine, by Harriet Hall. I admire her because we are both Air Force veterans. I have medical issues but they are really not real, my mental state. They are real but you can train your brain to overcome them, unlike physical diseases, cancers and broken bones. I have been a victim of what your book speaks of. Money victim only, thankfully. The book you recommended will be read, not medically smart but can research unknown with an open mind.

          • @Jim

            The Benedetti book is good, I’m sure, but it’s very expensive and you did say “I am a layperson being serious”, which I translate in the context of Edzard’s “The book is good but not all that easy to understand, if you are non-medical” to mean you, Jim, will possibly find it difficult to follow.

            Take a look at the Wikipedia entry for “placebo”. It covers the essential ground very reasonably.

            I’m not sure exactly what it is about “placebo” that confuses you. Maybe it’s the need to appreciate that a placebo (an “inert substance or treatment which is designed to have no therapeutic value”) is a thing, whereas the “placebo effect” is the consequence of (wrongly) attributing an apparent change in a medical condition to treatment with a placebo.

            I doubt that your 3 meds are placebos. When you consult a doctor with a medical problem they’re honour-bound to make the most accurate possible diagnosis of that problem and prescribe the most appropriate treatment. They’re also obliged to seek your informed consent for any treatment, any deceiving a patient by telling them you’re prescribing an active pharmaceutical when you’re giving them a placebo is probably unethical.

            All these issues are covered in the Wikipedia article. Do give it a try!

          • thanks Frank

    • Benedetti et al: Teaching neurons to respond to placebos (2016)

      “A placebo can be defined as the administration of an inert treatment along with a positive psychosocial context inducing positive expectations of clinical improvement. Thus, the crucial element of a placebo is the psychosocial context around the patient and the therapy (Benedetti, 2013, 2014).”

      Positive expectation is the hope or belief that one will be helped by a treatment.

      Inert treatment: fake treatment? “Inert” is precise. “Fake” is not precise, but it’s colloquially close. A placebo is not what it is believed or hoped to be.

  • Why are you against physiotherapists, osteopaths etc etc, or don’t you realise they perform acupuncture? Maybe it is time you leave things to actual health professionals and stop playing dr Google.

    • Is this to me or Dr Ernst? I am not a doctor, I google for research, have a very reasonable understanding of what is real and what is make believe from studying and again studying, than researching and researching. Dr Ernst is admired as the only Professor of alternative medicine, 40 yrs experience and only man on earth that has most scientific published papers in this field. I google, Dr Ernst does not google, he is what we find when we google or when another scientist researches pubmed, the google site for scientists.

      • @Jim and Julian

        “Is this to me or Dr Ernst?”

        Quite! Why do so few authors of comments find it so difficult to start their post by a simple indication of who (and what) they’re responding to?

        • Frank: “Why do so few authors of comments find it so difficult to start their post by a simple indication of who (and what) they’re responding to?”

          When I reply to a post, I expect it to line up (indented) under the post to which I am applying.

          You make a good point though. Perhaps it is simply good practice to start by indicating the name of the person to whom you are replying as it isn’t always clear and lining the posts up can be difficult, particularly when there are a lot of replies.

          I resolve.

          • @Ron Jette

            The problem is that the indentation system is only good for about five levels, and it swiftly becomes confusing when the number of replies is large. You say yourself that it can be difficult to see the line up, and a long comment or series of comments at the lowest level makes it almost impossible.

            No system for arranging comments is perfect. Personally, I rather like the approach of numbering comments in the order they’re submitted, and responses refer to the number of the comment to which they’re responding. (This system is used, e.g., on FreethoughtBlogs.com.)

    • Why are you against physiotherapists, osteopaths…

      ??? Nobody mentioned either! Are you sure you’re replying on the page (or website) you intended?

  • I’m very pleased by this clarification by Benedetti. Long overdue.

  • Frank,

    That Wikipedia article has made me understand much more. Thanks

  • Let us know when you have evidence that placebo can do what homeopathy has done for 200 years: 1) Cause new symptoms in a healthy person that wear off after they stop taking the remedy (a repeatable scientific experiment that anyone can do) 2) Cause long-term cures of long-term chronically sick people and acutely ill people is epidemics; 3) Cure pre-verbal babies, pets, livestock, plants and people in comas, 4) cause an aggravation (worsening) of existing symptoms before resulting in a complete cure.

    • Roger: “Cure pre-verbal babies, pets, livestock, plants and people in comas,”

      Okay, I’ll give you that. “Curing” plants and livestock in a coma sounds reasonable.

      Thanks for my morning smile.

    • Roger

      Placebo can do none of those things. And neither can homeopathy. You’re claiming it can. Prove it. We’ll wait.

      (And “l’ve seen it happen!” will only get you laughed at.)

  • Every time a reputable doctor or scientist says the words “powerful placebo effect” in the mainstream press, it empowers the quacks.

    I really don’t understand the hype behind “powerful” placebo effects when no clinically meaningful effects have been demonstrated objectively for any disease. Claims about improving quality of life are suggestive at best if all of the reporting biases have not been controlled.

    Yes there are modest neurotransmitter increases due to expectancy effects. This is not healing, it is psychology. There are no ongoing clinically relevant effects for Parkinson’s disease patients, or it would already be an approved therapy.

    Likewise, sure there is a conditioning effect of placebo on short term endogenous pain relief. This is a system that has been shaped by thousands of years of evolution to allow us to move to safety and get on with things after suffering acute injury. That is the key point: acute injury, not chronic pain. The placebo effect always disappears in the long term for long term conditions.

    Too many people seem to deny all the other facets of psychology and bundle all of the non-specific biases of subjective health reporting into the placebo effect. A box ticked on a symptom questionnaire is not a patient experiencing a symptom, yet this is frequently assumed to be the case in published reports of clinical trials. Many people seem to want to believe in a powerful placebo effect, rather than messy reporting biases. Double blinded trials control for a lot more than just the placebo effect.

    Those people who fancy themselves as champions of science need to call out all of the poor methodology and questionable inferences (in reputable publications) they come across, not just the easy route of criticising quacks that the mainstream already accepts as bunk.

  • ScienceBasedMedicine wants us to believe they have solutions for illness. What the pharma industry has is temporary solutions for SYMPTOMS of illness. These meds cure nothing, they MIGHT alleviate symptoms in the short term, while creating long term illnesses.

    Do no harm.

    https://health.alot.com/wellness/30-risky-prescription-medicines–15575?isVertical=1&isLong=0&camp_id=52772&kwp_0=1248617&kwp_4=3963213&kwp_1=1649760&fbclid=IwAR0_T8tN-eu6WQsWoBanLDAeZAZze8GZa2-sPlJKH85kxB_dbfvWbgs_idg&s=4

  • bah… not from me. You were using Ad Hominem replies long before I ever posted here. The evidence is in the message history.
    You seem to revert to it when you don’t have a sound reply.

    Pharma meds are quackery

  • Thank you, Professor.
    The science behind placebo effects may be useful to control pseudoscience if used to communicate and convincingly explain to people who seek this kind of treatments the real limits of these practices. But using this knowledge to oppose to them may exacerbate their radical positions as well. A more inclusive strategy may be to let them understand clearly that anything whose efficacy relies only on placebo effects (a placebo treatment) can be useful only for some minor conditions and symptoms, and NOTHING ELSE. In this way, their belief is not denied of existence (which may trigger radicalization), but simply reinterpreted and “resized”, opening, for them, to the possibility of reintegration into modern medical care. The critical step is to reconcile with modern medicine, because once one has the chance to experience on themselves the efficacy of modern treatments instead of pseudoscientific ones (without the interference of some radical beliefs), then these practices would gradually disappear by themselves. For this, the role of the doctor and their communicative skills is central.

    • EBM is highly over rated

      Read it and weap
      http://psychrights.org/research/digest/Misc/FDAPsychDrugApprovalProcessSpielmansKirschARCP2014.pdf

      “CONCLUSION
      The FDA’s framework for evaluating clinical trials allows drugs with minimal efficacy in terms of
      symptomatic improvement—and no benefit in terms of quality of life or social functioning—to
      enter the marketplace as approved treatments. The published medical literature inflates the apparent efficacy of antidepressants (and other psychiatric drugs) while downplaying or altogether
      hiding adverse events. We have proposed a number of ways in which the FDA could raise its
      standards for approving drugs and more effectively disseminate data to clinicians, researchers, and
      potential consumers of medication.
      A cynic may believe—perhaps with ample justification—that making our suggested changes
      would simply lead to other questionable maneuvers and subterfuge on the part of drug sponsors.
      Nonetheless, we believe that some attempt at reform is likely better than throwing up our hands
      and declaring that we must accept living with lax FDA drug approval standards and poor data
      reporting both by the FDA and in the wider literature.”

      • As has often been stated, problems (real or imagined) with medicine validate pseudomedicines like homeopathy in exactly the same way that aircraft accidents validate flying carpets as a means of transport.

        • Keep telling yourself that as patients continue to die from “safe” prescription drugs.

          https://www.breastcancer.org/research-news/fda-warns-about-probable-carcinogen-in-zantac
          “The manufacturer of Zantac, a division of Novartis, has reportedly decided to halt distribution of the drug until the issue is resolved.”

          https://www.biospace.com/article/releases/ahf-calls-on-gilead-to-set-up-10-billion-fund-for-victims-harmed-by-its-tdf-based-drugs/
          “TDF is a key drug used for treatment of patients with HIV and AIDS and is also used (under the brand name, Truvada—TDF and emtricitabine) by uninfected individuals as part of the HIV prevention strategy known as PrEP. However, the medication causes damage, sometimes permanent and sometimes fatal to the kidneys and bones.

          “Gilead acknowledges it put out an inferior drug with significant and harmful side effects while it sat on the superior TAF-based alternative drug. Gilead must be held accountable for putting its profits over public health, that is why we have filed these legal actions,” “

          • @RG

            Did you not read the things you link to or are you simply unable to comprehend that they do not corroborate your unreasonable ideas?

          • @RG

            Still doesn’t validate pseudomedicines like homeopathy.

          • My question is this. If SBM is so right, why do they continue getting it wrong ?

            http://psychrights.org/Research/Digest/NLPs/The-Case-Against-AntipsychoticsWhitaker2016.pdf

            Conclusion
            “This paper makes a case that antipsychotics, on the whole, worsen long-term
            outcomes. The drugs may provide a short-term benefit, and it is clear that once
            patients are on the medications, there is an increased risk of relapse, for some
            period of time, when discontinuing the medication. But there is also a long line of
            research that tells of treatment that may increase a person’s biological vulnerability
            to psychosis and impair functioning over the long-term.
            Sohler’s review also reveals that there is an absence of research that tells of
            medications that improve functional outcomes over the long term. This absence,
            given the obvious desire by psychiatry to report such positive results, is compelling
            evidence on its own that these medications, when it comes to affecting aggregate
            outcomes, do more harm than good.”

            Soooo, evidence based medicine has not created a cure at all, only customers. How convenient for Pharma.

          • so from 1 paper on a very specific issue you make a conclusion about all EBM?
            stop trying to convince us that you are a moron!

  • Wrong Edzard

    I could post links all day long about how Pharma is being taken to court for dangerous meds, causing long term chronic illness, and in some cases KILLING people. I’ve been doing this very thing for weeks now, have you even noticed ?

    • all I noticed is that your comments make less and less sense.

      • EE
        Really ?
        Tell me if this makes some sense to you. Those whom prescribe to EVM have been fooling themselves, or been fooled by the pharmaceuticals. Open your eyes and wake up.
        https://onlinelibrary.wiley.com/doi/full/10.1111/jep.12147

        “If EBM were the revolutionary movement it was hailed as, we would expect more than benefits demonstrated in specific cases. We would expect population‐level health gains, such as those that occurred after the introduction of antibiotics, improved sanitation and smoking cessation 14. Unfortunately, there is little evidence that EBM has had such effects.”

        “In relation to depression, independent meta‐analyses pooling unpublished as well as published data now show that SSRIs are no more effective than placebo in treating mild‐to‐moderate depression, the condition for which they have been most commonly prescribed 30, 31.
        So how is it that for over a decade we were convinced by the evidence into thinking these treatments were superior? How could there have been ‘an evidence myth constructed from a thousand randomized trials’ 25 and how did we fall for it?”

        “Who funds randomized trials and does the funding source matter?
        Firstly, it has become apparent that most of the medical evidence base has been funded by industry, although often these financial relationships have not been disclosed. Between two‐thirds and three‐quarters of all randomized trials in major journals have been shown to be industry funded 32, 33.
        Secondly, there is strong evidence that industry‐funded studies produce results that differ from independently funded studies. Compared with independent trials, industry‐sponsored trials exaggerate treatment effects in favour of the products preferred by their sponsor 34-37.
        Although industry influence has been pervasive across medicine, psychiatry has been at the epicentre of much of the controversy about funding source bias and conflict of interest (e.g. 38-40). Among randomized, double‐blind, placebo‐controlled studies in psychiatric journals, those that reported conflict of interest were five times more likely to report positive results”

        “Heres et al. reviewed industry‐funded randomized trials comparing atypical antipsychotics to determine if a relationship existed between the sponsor and the study outcome 41. It did. Ninety per cent of trials showed superiority of the sponsor’s drug. The resultant circularity was illustrated in the study’s title ‘Why olanzapine beats risperidone, risperidone beats quetiapine, and quetiapine beats olanzapine’; in pairwise comparisons of different trials examining the same two drugs, the sponsors’ drug almost always triumphed. This implausible result was not due to publication bias. The studies had just been designed in a way that would virtually guarantee the favoured drug would ‘win’ – for example, the comparator drug was dosed too low to be effective, or so high that it would produce intolerable side effects. Exclusion or inclusion of specific patients, placebo lead‐in periods, short follow‐up, selection of imputation techniques, the use (or not) of adjustments and selective outcome reporting also allows for magnification of effect‐size estimation.”

        “We have demonstrated that unfavourable trials are frequently left unpublished and so are unavailable to doctors and patients. Through processes of selective publication and manipulation of study design, industry‐sponsored studies are weighted to be favourable to their product. Simply put, industry‐sponsored evidence is incomplete and biased. Most intervention studies are industry sponsored. This means that the overall evidence about many interventions is incomplete and biased. As a result patients may be given less effective, harmful or more expensive treatments. We have proposed some possible remedies, including that the EBM movement explicitly downgrade any research produced by those with a vested interest in the results.”

        In other words. EBM is a SCAM

        EE, are this registering with you ? …. anybody.
        I recommend to anyone searching out the truth… read the full page, written by two doctors.

        • RG

          So. Who is making these claims and discoveries?

          Doctors.

          Who are behind the AllTrials initiative?

          Doctors.

          This has NOTHING to do with AltMed.

          As ever, aircraft crashes do not validate magic carpets.

  • @RG

    Why are you so keen to posit your “Don’t look here, look there instead?” red herrings? It seems to me that you are desperate to try to deflect attention away from pseudomedicine. Surely someone who actually believed this guff would be trying to draw people towards it, not deflect them away from it. Is this because you know that SCAM is fraudulent?

  • Steve Tonkin

    I don’t make any claims to confirm nor deny CAM…. or SCAM as you here refer to it.

    I have stated here more than once, that I have tried Acupuncture and Chiropractic means to help with a life long (since I was 19) chronic low back problem (herniated discs). In those two particular remedies, I found NO real benefit. Why would I promote them ? You are correct, I don’t promote CAM. That said, if others find benefits in those therapies, why should I doubt them ? On the contrary, I am happy for them.

    I have also indicated here that medical science had no answers for my situation. Truth be told, the meds my doctor was giving me would likely have killed me by now had I continued consuming them.
    Beyond myself, Medical Science attempted to pull the plug on my fathers life 20 years premature. Medical Science has no answers for my sons Schizo, no answers for my wife’s sciatic pain, in fact I found that most of the science based remedies were detrimental to me and and the health of my loved ones. My mother lived a couple more years with Chemo treatments for MM cancer, but at what cost ? I believe she may likely have done just as well with some other form of less toxic and costly treatment.
    Please tell me, why should I prescribe to SBM more than any other medicine ? Where is the evidence, I just don’t see it.

    Finally, I have indicated here previously that reflexology, and Paida & Lajin have given ME relief from many of the symptoms of chronic back pain, without toxic meds, without injections, without surgery. I do not promote these self adhered remedies here actively. I’ve leaned other coping mechanisms that would likely bore you, but I get along pretty good now.

    My purpose here is to discredit Big Pharma, I do it till EE & his blocks me from posting.
    Gooday

    • if I had a herniated disc since the age of 19 with continuous pain, I would have consulted an experience surgeon at the age of 21.

    • Please tell me, why should I prescribe to SBM more than any other medicine ? Where is the evidence, I just don’t see it

      I am sorry that you and those close to you have happened to suffer from specific problems that medicine is currently limited in its ability to address. It doesn’t follow, however, that medicine based on no evidence should be better than medicine based on evidence. Indeed, evidence is there in abundance if you are prepared to see it.

      Back pain and schizophrenia continue to be difficult problems to address, not least because both of them tend to be life-long, and therefore treatment can only be aimed at trying to manage the symptoms and find ways of coping with them. For schizophrenia, particularly, what most people want is simply never to have to encounter it, so as long as the individuals are kept out of sight then the general public is happy and not interested in funding research, decent care or anything else; the poor schizophrenic, on the other hand, is usually not well-enough organised to have an effective political voice.

      Melanoma, however, is an instance where medical research is starting to make a big difference. It has always been rather a difficult tumour to treat, not least because it is highly variable in its behaviour. Some people respond very well to chemotherapy but it has not been possible to predict who that will be without trying one drug after another, and most don’t respond at all in any useful way. That strategy results in a lot of people suffering side-effect with only a few benefiting (though many people with advanced melanoma would rather grasp at the possibility of a chemo response than not). Happily this is changing. Indeed, the results of a trial conducted by the Royal Marsden Hospital in London (co-incidentally where I am having my own treatment) were announced a few days ago at the European Society of Medical Oncology meeting in Barcelona. The subjects were patients with advanced melanoma, and they were given a combination of two immunotherapy treatments (I think nivolumab and ipilimumab). The five-year survival rates were over 50%, which is astonishing in comparison to what we were seeing just a few years ago.

    • @RG

      FYI, they are both nouns but the similarity pretty much ends there. Here are the deets courtesy of Oxford.

      an·ec·dote (noun)
      /ˈanəkˌdōt/

      • a short amusing or interesting story about a real incident or person. “He told anecdotes about his job.”
      • an account regarded as unreliable or hearsay. “His wife’s background has long been the subject of rumour and anecdote.”

      ev·i·dence (noun)
      /ˈevədəns/

      • the available body of facts or information indicating whether a belief or proposition is true or valid. “The study finds little evidence of overt discrimination.”

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