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Thread: homeopathy, the placebo effect, and mainstream medicine.

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    homeopathy, the placebo effect, and mainstream medicine.

    I think homeopathy may work, but only really by acting as a placebo, but the thing I can't really resolve is, is there a place in mainstream medicine for a flat out placebo approach option for doctors.

    Somewhere I once read that GPs used to write placebo prescriptions(something like a aspirin), sometimes, but are not allowed to now(well here in the UK); I don't know what the facts are for that. Anyone know?

    I think basically it is a form of deceit, which doesn't seem right, but on the other hand might actually help the patient, and save money...


    edit: sorry for starting a heavy thread, Where's the delete button?
    Last edited by WaxRubiks; 2017-Dec-23 at 06:42 AM.
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    Well the problem is the ethical issues of giving a patient medicine that does not work.
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    Quote Originally Posted by Mudskipper View Post
    I think homeopathy may work, but only really by acting as a placebo, but the thing I can't really resolve is, is there a place in mainstream medicine for a flat out placebo approach option for doctors.

    Somewhere I once read that GPs used to write placebo prescriptions(something like a aspirin), sometimes, but are not allowed to now(well here in the UK); I don't know what the facts are for that. Anyone know?

    I think basically it is a form of deceit, which doesn't seem right, but on the other hand might actually help the patient, and save money...


    edit: sorry for starting a heavy thread, Where's the delete button?
    Homeopathy can't work, and the physical/chemical impossibility behind it is the smallest of its problems.
    The real problem is that it's a symptomatic ....... something (I won't call it a cure nor a therapy since it's neither): it doesn't addresses causes, only effects.
    You've got nausea ?
    From a homeopathic point of view the cause of nausea (vertigo ? food poisoning ? gastrointestinal virus ? three gallons of beer ?) doesn't matter, you gulp down some magic water and keep gulping it down till you feel (note: feel , not are ...) better.
    That's not a cure.
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    Quote Originally Posted by UntrainedObserver View Post
    Homeopathy can't work, and the physical/chemical impossibility behind it is the smallest of its problems.
    The real problem is that it's a symptomatic ....... something (I won't call it a cure nor a therapy since it's neither): it doesn't addresses causes, only effects.
    You've got nausea ?
    From a homeopathic point of view the cause of nausea (vertigo ? food poisoning ? gastrointestinal virus ? three gallons of beer ?) doesn't matter, you gulp down some magic water and keep gulping it down till you feel (note: feel , not are ...) better.
    That's not a cure.
    you dismiss placebo at your peril. Homeopathy may be the best example but there's the white coat effect too. And placebo provides total cures too by whatever mechanism you believe in. And nocebo is just as powerful. The fascinating thing is how these physical effects manifest in most or all people. If you believe something will work, from advice to pills to lifestyle changes, they do work.
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    "Pure" placebo use is still widespread in the UK.
    The General Medical Council doesn't give guidance one way or another about doctors using placebos, though in its guidance on medical ethics it does place emphasis on truth-telling and full disclosure to an extent that I think pretty much precludes the deceptive use of placebo.

    Trouble is, the placebo effect (and its dark twin, the nocebo effect) is hugely misunderstood by both the lay public and by most practising doctors, including the authors of the paper I linked to.

    The placebo effect is present even when you administer active drugs. It's not some magical effect restricted to sugar water and drugs of unproven efficacy. A guy called Fabrizio Benedetti has done some marvellous work on the placebo effect (see his book Placebo Effects for more detail). Benedetti performed really complicated clinical trials in which he compared the effect of real drug which the patient knew to be real drug, with real drug administered without the patient's knowledge, with real drug the patient was told was inactive, with inactive substance the patient was told was inactive, with inactive substance the patient was told was real drug ... and so on.
    If you receive a real analgesic drug which you know to be an analgesic and in which you have confidence, it'll work better than if you receive the same drug but no-one tells you you're receiving it. In a model using dental pain, just knowing you're getting a good drug is worth the equivalent of 8mg of morphine in extra analgesic effect. That's a huge and clinically extremely relevant effect - if you'd had abdominal surgery, it's the equivalent of the sort of dose you might get to load your system to a good level before fine adjustment was made with additional increments.
    The effectiveness of real drug is also enhanced by the epiphenomena surrounding its administration - injections work better than oral drugs (even if the achieved blood levels are the same); big pills work better than small pills; preparations labelled as being expensive work better than the same drug marked as being cheap and generic; doctors with confidence get more effect from the same drug than if they seem doubtful; drugs administered by senior doctors work better than those administered by junior nurses.

    So that's the first thing - every doctor is using the placebo effect every time they administer or prescribe a drug. But most of them don't know they're doing it, which means they can mess it up in ways that are completely avoidable.

    Second thing relates to what the paper I linked to called "pure" placebos - inactive drugs administered as if they were active. We can certainly do this, and it's evident that a lot of doctors do it on occasion. But it's risky, because it involves some sort of a lie (even if it's purely at the level of lying by omission, as in the old standby, "I'm going to give you this prescription for something which has helped a lot of people in the past and may help you.") The problem arises when the lie is found out, and the patient objects to being tricked, or deduces that the doctor has made some sort of inference about the nature of the patient's symptoms. Then you get a loss of faith, and then you lose the placebo effect on any active drug you subsequently prescribe. In fact, if the patient doesn't trust the doctor, you will get nocebo effects - all those side-effects in the packing insert become more likely. And if the general population comes to believe that doctors regularly trick them with inactive drugs, we'll lose the placebo effect on active drugs generally, and will need to use higher doses, which will ramp up drug costs and the incidence of side-effects.
    So the game of using inactive placebo simply isn't worth the candle, both in terms of tainting the trust patients have for their doctors, and in terms of degrading the useful activity of real drugs.

    Grant Hutchison

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    Quote Originally Posted by profloater View Post
    you dismiss placebo at your peril. Homeopathy may be the best example but there's the white coat effect too. And placebo provides total cures too by whatever mechanism you believe in. And nocebo is just as powerful. The fascinating thing is how these physical effects manifest in most or all people. If you believe something will work, from advice to pills to lifestyle changes, they do work.
    Irrelevant.
    A metric ton of crap covered by a thin veil of gold is still crap. And guess what ? If your magic system of choice works no better than placebo in each and every case, we're talking about crap.
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    Quote Originally Posted by UntrainedObserver View Post
    Irrelevant.
    A metric ton of crap covered by a thin veil of gold is still crap. And guess what ? If your magic system of choice works no better than placebo in each and every case, we're talking about crap.
    I'm not sure, despite the invective, what your argument is. It is clear that you believe that homeopathic theory has zero validity. I agree. I understand that has been well established by the evidence of many well constructed experiments. However, I also understand that there is some evidence that the use of homeopathy, in some instances, can provide a beneficial placebo effect. The only way I can make sense of your remarks is to imagine that you see no value whatsoever in placebos of any kind. Would you clarify your thinking please?
    Last edited by Eclogite; 2017-Dec-23 at 04:11 PM. Reason: typo

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    Quote Originally Posted by UntrainedObserver View Post
    Irrelevant.
    A metric ton of crap covered by a thin veil of gold is still crap. And guess what ? If your magic system of choice works no better than placebo in each and every case, we're talking about crap.
    But, as I pointed out above, placebo works very well indeed, to the huge benefit of many people every day, in the setting of mainstream medicine and effective drugs.
    One of the reasons homeopathy works as well as it does is because it follows a model of care that generates trust - long detailed consultations with calm unhurried practitioners. It produces a level of placebo effect that most mainstream practitioners can't hope to equal in the pressurized environment of modern healthcare. It's just as well our drugs are pharmacologically active, because our ability to use the undoubted benefits of the placebo effect are being steadily degraded by a system that has forgotten the nature and value of good doctor/patient interactions.

    Grant Hutchison

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    Quote Originally Posted by Eclogite View Post
    I'm not sure, despite the invective, what your argument is. It is clear that you believe that homeopathic theory has zero validity. I agree. I understand that has been well established by the evidence of many well constructed experiments. However, I also understand that there is some evidence that the use of homeopathy, in some instances, can provide a beneficial placebo effect. The only way I can make sense of your remarks is to imagine that you see no value whatsoever in placebos of any kind. Would you clarify your thinking please?
    I see no value whatsoever in pseudoscience and magic thinking of any kind: in this particular case, homeopathy (and no, I do not believe it has zero validity: it has zero validity).
    Placebos work, I know: it's still not clear how, but they work.
    The fact that, in some cases, magic water instills a placebo effect is by pure chance and nothing else: this thin veil of gold does not change the fact that it rests on a metric ton of homeopathic crap.
    Correlation does not imply causation, as we know...
    Eppur si muove....

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    Over here in Switzerland, they use the term "homeopathy" also to cover herb-based medicine and not just the classical meaning (diluted until not an atom remains...). Confusing... because some natural herbal medicines are quite good.

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    Quote Originally Posted by UntrainedObserver View Post
    I see no value whatsoever in pseudoscience and magic thinking of any kind: in this particular case, homeopathy (and no, I do not believe it has zero validity: it has zero validity).
    Placebos work, I know: it's still not clear how, but they work...
    Actually, we do know in some detail how the placebo effect works, down to the specific neurotransmitters and pathways involved.

    Grant Hutchison

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    Quote Originally Posted by gzhpcu View Post
    Over here in Switzerland, they use the term "homeopathy" also to cover herb-based medicine and not just the classical meaning (diluted until not an atom remains...). Confusing... because some natural herbal medicines are quite good.
    One problem with effective herbal medicines is that you have no idea of the dose you're getting, because the plants and preparation methods are extremely variable.
    The other problem with effective herbal medicines is that they have side-effects and interactions just like regular drugs, but many people who use them think they're somehow "pure" and harmless. I once saw someone almost bleed to death during surgery because of the garlic preparation he'd been taking, which he hadn't mentioned to anyone because he didn't think it was relevant.

    Grant Hutchison

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    Quote Originally Posted by UntrainedObserver View Post
    I see no value whatsoever in pseudoscience and magic thinking of any kind: in this particular case, homeopathy (and no, I do not believe it has zero validity: it has zero validity).
    Placebos work, I know: it's still not clear how, but they work.
    The fact that, in some cases, magic water instills a placebo effect is by pure chance and nothing else: this thin veil of gold does not change the fact that it rests on a metric ton of homeopathic crap.
    Correlation does not imply causation, as we know...
    You do have to be careful not to throw the baby out with homeopathic bath water, however.
    Repeatedly saying "crap" distracts us from the fact that homeopathy has a measurable effect (albeit not by the mechanism proposed by its practitioners). If we can understand that effect and how it is maximized, then we can use it. Though it no doubt sticks in the craw of self-described "sceptics", many doctors could actually learn something about how to generate a therapeutic doctor/patient relationship if they sat in on a homeopathic consultation.

    Grant Hutchison

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    Quote Originally Posted by grant hutchison View Post
    One problem with effective herbal medicines is that you have no idea of the dose you're getting, because the plants and preparation methods are extremely variable.
    The other problem with effective herbal medicines is that they have side-effects and interactions just like regular drugs, but many people who use them think they're somehow "pure" and harmless. I once saw someone almost bleed to death during surgery because of the garlic preparation he'd been taking, which he hadn't mentioned to anyone because he didn't think it was relevant.

    Grant Hutchison
    Oh dear. I eat a lot of garlic. I'd better make sure I always mention it.

    My friend says her sister is getting into homeopathy and he feels the need to stage an intervention. I reassured him that at least it will only take up an infinitissimal amount of time.

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    Quote Originally Posted by Glom View Post
    Oh dear. I eat a lot of garlic. I'd better make sure I always mention it.
    Difficult to get into dangerous territory with normal dietary use - it's the concentrated preparations sold by herbalists that cause the problems.
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    There is the "Pill Popping Effect": even if a patient knows that the pill is a placebo, he still feels better!

    The mere act of popping a pill makes him feel better.

    That the patient feels better is surely the main thing, although some doctors would say that the patient's numbers are more important than how he actually feels!
    Last edited by wd40; 2017-Dec-23 at 09:50 PM.

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    I wonder if Homeopathists practice what they preach.
    I should be able to give them Placebo Money: it works just like real money, as long as they think it's real money.

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    Quote Originally Posted by UntrainedObserver View Post
    I see no value whatsoever in pseudoscience and magic thinking of any kind: in this particular case, homeopathy (and no, I do not believe it has zero validity: it has zero validity).
    Placebos work, I know: it's still not clear how, but they work.
    The fact that, in some cases, magic water instills a placebo effect is by pure chance and nothing else: this thin veil of gold does not change the fact that it rests on a metric ton of homeopathic crap.
    Correlation does not imply causation, as we know...
    The highlighted statement reflects a rather peculiar attitude. There is nothing chance about it. We know that the expectation of the patient as to the outcome of a treatment has an impact upon that outcome. That is why, in some instances, a homeopathic treatment leads to improvement in a patients condition. No chance is involved. That does not alter, in any way, the observation that homeopathy itself does not work.
    Last edited by Eclogite; 2017-Dec-24 at 10:09 AM. Reason: typo

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    Quote Originally Posted by wd40 View Post
    There is the "Pill Popping Effect": even if a patient knows that the pill is a placebo, he still feels better!

    The mere act of popping a pill makes him feel better.

    That the patient feels better is surely the main thing, although some doctors would say that the patient's numbers are more important than how he actually feels!
    Well there is some ambiguity about anything we pop in our mouths. Whatever the pill box says on the label, there is no way to really know what is in the pill. For example, there could have been a mix-up at the factory and there could be some weird chemicals in the pill, so in some ways you can believe what you want when you swallow anything.
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    Thread moved from OTB to S&T
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    It seems that some of the posters are conflating, or at least confusing, homeopathy with placebo. As Grant says, the placebo effect is at least somewhat understood, and it doesn't matter whether or not the actual substance being administered is doing anything directly to the body as to how or if it "works". That's the point of it being considered a placebo effect. What it does show is that how medicine is administered is at least as important as what, which is something medicine ("mainstream") really needs to take a look at that many homeopaths already do well.

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    Quote Originally Posted by UntrainedObserver View Post
    Irrelevant.
    A metric ton of crap covered by a thin veil of gold is still crap. And guess what ? If your magic system of choice works no better than placebo in each and every case, we're talking about crap.
    Nonsense, placebo effect is evidence based. Depression, inflammation, pain, all affected.
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    Originally Posted by Ken G

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    Perhaps there is a larger issue here as well, alluded to in Grant's comments, which is: what is the importance of the patient's own attitude about their condition? This question gave birth to the concept of "holistic" medicine, the idea of treating the "whole" patient rather than just the disease. Some doctors seem to act like it is the disease that is the patient, others are quite clear that their patient is a human being with an important role to play in their own recovery. I've seen this with cancer doctors quite clearly, and with infertility doctors. Some seem to say, "we have a problem that involves a person and a condition, and we are treating the combination of the person and the condition," while others only treat the condition. A classic example of the latter is the make-believe TV doctor "House," who never treated any people except insofar as he needed to trick them into not lying about their medical histories-- he always found the miracle treatment that would cure the condition despite the patient. Although I enjoyed the drama and humor of "House," perhaps there is indeed a significant error in treating medicine this way.

    There is another issue as well, which is the necessity of "protocols" when it comes to scientific assessment of efficacy. In principle, it would be nice to allow every individual case to be treated on its own individual merits. Doctors who seem to be tailoring a treatment to an individual are likely to benefit from an improved placebo effect than doctors who are quite clear that their patients are members of a class of people all receiving precisely the same treatment for statistical purposes. Yet if doctors make their patients feel like individuals who are being cared for on a case-by-case basis, then how can the groups be classified to achieve the necessary statistics? So it is a significant problem, when the desirable placebo effect actually makes medical efficacy more difficult to assess.

    Of course, there is also a significant error in "holistic" treatments, which is that they are invariably not scientific, by which I mean they make no effort to document success or failure such that treatments could be judged and improved in a scientific way. Somehow treating the "whole patient" has become synonymous with an excuse to avoid systematic assessments. When how the patient "seems to feel" is viewed as more important than quantitative benchmarks, why bother to assess at all, except informally and anecdotally? That "informal" aspect cuts deeply into holistic treatments, indeed I would claim that some pracititioners realize it makes no difference at all if the patient receives "homeopathic remedies" that cost a lot more than just water, instead of literally just giving them water. Further, I suspect that no homeopathic remedy actually does any of the things claimed for homeopathic solutions. The breakthrough in making money as a homeopath is the recognition that you can simply use a container that once held some amount of some substance, and that qualifies as any amount of dilution you like. Since the more diluted the better, it doesn't take a genius to reach the obvious conclusion that any contact with the claimed substance is already unnecessary, and I'd bet that most homeopathic remedies don't have any relation at all to the substances they cite, so should cost no more than water-- but do. So they are fundamentally dishonest, from the start. So there's the issue Grant brought out-- the almost automatic association between pure placebos and dishonesty, charlatanism, and greed. Yet practitioners of holistic medicine are rarely greedy people, they are often very caring individuals with a high moral purpose and little financial motivation. Some doctors may go into medicine because it's the most money they can make, while holistic practitioners generally seem to do it out of a desire to help others without going through the necessary formal training to be doctors.

    Given all this, and the scientific results Grant described, the solution seems clear: a kind of marriage of the best of what scientific assessment can produce, along with the benefits of care-giving that stresses the patient's attitude about their own condition and not just the condition itself. I've seen doctors who understand that, so we simply need to make sure that those kinds of doctors are the ones in demand, and not the "House"-like doctors (though spoiler alert: House always finds the cure in the last five minutes!).
    Last edited by Ken G; 2017-Dec-24 at 03:09 PM.

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    Quote Originally Posted by Eclogite View Post
    The highlighted statement reflects a rather peculiar attitude. There is nothing chance about it. We know that the expectation of the patient as to the outcome of a treatment has an impact upon that outcome. That is why, in some instances, a homeopathic treatment leads to improvement in a patients condition. No chance is involved. That does not alter, in any way, the observation that homeopathy itself does not work.
    The us surgeon general said homeopathy was the best placebo he came across. There is a story there even though the dilution is beyond Avagadros number, it's a story and the homeopath is a credible person who listens and uses rules. People believe and thus it works. Don't knock it too much. Separating out the belief from the aliphatic effect is hard too, and individuals react differently. Why is that? Different physiology or different beliefs?
    sicut vis videre esto
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    Quote Originally Posted by profloater View Post
    ... the aliphatic effect ...
    Allopathic?

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    Don't forget that being exposed to certain things gets the bodies own systems activated, more than making up for the poison. That means that some poisons in small quantities are healthy. The dose makes the poison. Thus the saying, what doesn't kill you makes you stronger. That being said, homeopathy is weird. Never got involved in it. That being said, the statistics of making something better are very complicated.
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    It's this placebo effect that is keeping me from going whole-in on Daith piercings for my migraines. Since it is said to be based on accupressure, I think the 3 or so people I am following (one, a close family member) are having a persistent placebo effect from theirs, which has resulted in a reduction of migraines from 20-25 per month to 1 or 2. But "knowing" it's placebo should or shouldn't affect how they "perform" for me?

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    Migraine is strongly placebo-responsive (something like 30 or 40% of people in the placebo limb of migraine drug trials experience improvement).
    Invasive placebos (like saline injections) are more effective than oral drug placebos.
    So I wouldn't be surprised if something as invasive as a daith piercing had a strong placebo effect on migraine.
    It seems to be one of those word-of-mouth movements, with little clinical research to support it, though the Cochrane collaboration has recently supported the usefulness of acupuncture for migraine - and I've certainly seen acupuncturists use locations close to the crus of the helix (the location of a daith piercing), though there's huge debate both inside and outside the acupuncture community about the validity (or even the concept) of particular sites.
    Perhaps some acupuncture to the region would let you test the effect without actually running the risk associated with the piercing itself (or just plain ending up with a pointless hole in your ear)?

    As to whether a placebo works if you know it's a placebo, that depends on your expectation of the placebo.

    Grant Hutchison

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    I know at least one placebo that works on me.

    I have an allergy to pets that brings on asthma. If I forget my puffer, I will be in distress all night.
    If I have the puffer, and I use it, my asthma fades rapidly - mostly out-of-sight, out-of-mind.

    Here's the kicker: the puffer is empty, and has been empty for years.

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    Asthma, again, a good placebo responder, with objectively measurable changes in airway reactivity resulting from placebo administration.

    At what point did you work out your puffer was empty? Had you already had some good placebo responses before you realized?

    Grant Hutchison

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