Page 4 of 7 FirstFirst ... 23456 ... LastLast
Results 91 to 120 of 199

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

  1. #91
    Join Date
    Sep 2003
    Posts
    12,195
    At our New Year's event a friend told me of his surgery and noted that he was surprised that relatives from other states came in for this event. The doctor never told him just how likely the very swollen organ (kidney, I think) would be cancerous. It was not. Given his post-surgery pain( two ribs were removed), friends and family were surprisingly happy with the outcome. That's when they told him about the cancer likelihood.
    We know time flies, we just can't see its wings.

  2. #92
    Join Date
    Jul 2005
    Posts
    16,002
    Quote Originally Posted by George View Post
    At our New Year's event a friend told me of his surgery and noted that he was surprised that relatives from other states came in for this event. The doctor never told him just how likely the very swollen organ (kidney, I think) would be cancerous. It was not. Given his post-surgery pain( two ribs were removed), friends and family were surprisingly happy with the outcome. That's when they told him about the cancer likelihood.
    Yikes. That's exactly the sort of thing that could result in a disciplinary hearing for the surgeon, in my part of the world.

    Grant Hutchison

  3. #93
    Join Date
    Sep 2003
    Posts
    12,195
    Quote Originally Posted by grant hutchison View Post
    Yikes. That's exactly the sort of thing that could result in a disciplinary hearing for the surgeon, in my part of the world.
    Yep. I thought you would find it interesting. I'm not sure such practice is acceptable here. Perhaps the doctor asked my friend much earlier if he wanted to know or not the risks, and was then given permission to act accordingly, or maybe the wife stepped-in. Given the report he gave me, however, it seems the doctor took liberty with this and, quite possibly, did the "right thing", regardless.

    Would this be more an anti-nocebo or an actual placebo act?
    We know time flies, we just can't see its wings.

  4. #94
    Join Date
    Jul 2005
    Posts
    16,002
    Quote Originally Posted by George View Post
    Yep. I thought you would find it interesting. I'm not sure such practice is acceptable here. Perhaps the doctor asked my friend much earlier if he wanted to know or not the risks, and was then given permission to act accordingly, or maybe the wife stepped-in. Given the report he gave me, however, it seems the doctor took liberty with this and, quite possibly, did the "right thing", regardless.

    Would this be more an anti-nocebo or an actual placebo act?
    As for the wife "stepping in", that wouldn't be an excuse for the doctor concerned, hereabouts. In fact, telling the wife before telling the patient would be considered unethical, of itself.
    It's an effort at avoiding a nocebo effect, falling under the umbrella of "paternalistic medicine", which we really shouldn't be doing as it undermines a basic moral principle of respecting the autonomy of others. And of course it can go hellishly wrong - if your friend had put two and two together from the mass arrival of relatives (I know I would have done), then he'd have ended up going into surgery with increased and unfocussed anxiety, and a justifiable distrust of his surgeon. If he found out after the surgery that he had some short time to live, then he'd probably have had a few important things he wanted to do in the time left to him, and his options would be limited by the fact he was stuck in a bed after major surgery.
    It's all about letting people retain their locus of control.

    Grant Hutchison

  5. #95
    Join Date
    Sep 2003
    Posts
    12,195
    I may be able to get better info on this story via my wife. If so I will share it as it, and this topic, are intriguing.
    We know time flies, we just can't see its wings.

  6. #96
    Join Date
    Apr 2011
    Location
    Norfolk UK and some of me is in Northern France
    Posts
    7,602
    May I share this very recent paper on the interoceptive system which is thought to be the basis of the placebo effect in some research quarters.
    I wrote a layman's interpretation if anyone is interested I can perhaps PM it?


    http://www.biologicalpsychiatrycnni....234-3/fulltext
    sicut vis videre esto
    When we realize that patterns don't exist in the universe, they are a template that we hold to the universe to make sense of it, it all makes a lot more sense.
    Originally Posted by Ken G

  7. #97
    Join Date
    Oct 2005
    Posts
    26,097
    It seems to me there are two very different types of "placebo" effects that are so different they really deserve their own terms. We can loosely define the placebo effect as the effect that taking a medicine (real or fake) has on our attitude about our illness, and how that attitude then affects our health, prior to any physiological therapeutic effect the medicine may or may not have that is independent of our attitude about it. But our attitude can affect our outcomes in two very different ways-- it can affect our perception of our state of health and how we live based on that perception, and it can affect measurable outcomes that do not involve our perceptions. This line gets blurred when the "measurements" of the outcomes cannot be made independent from our perception, such as when we ask people to rate their pain or when we ask how much sleep they are getting or how depressed or anxious they feel. But with the size of a tumor, for example, there is no such blurring. So isn't the placebo effect a different thing when you have outcomes in which perception is directly involved, and outcomes where it isn't? When people talk about "mind over body," they generally mean that second type of effect, but are we doing enough to separate the two types when separation is possible? And how large are the signals of the two types, when separation is possible? (The need for the separation of perception from objective outcomes is the reason for the need for double-blind testing to control for the placebo effect, but double-blind testing cannot be used to separate the two types of placebo effect-- something new would be needed there. Outcome assessment would need to be classified as either perception-dependent or perception-independent.)
    Last edited by Ken G; 2018-Jan-06 at 03:09 PM.

  8. #98
    Join Date
    Jul 2005
    Posts
    16,002
    If we take the old motto "pain is what the patient reports", then we can imagine all sorts of social pressures or mood changes that might make a placebo pain killer work, independent of the neural activity in the pain pathways themselves.
    But what we're finding from functional imaging is that placebo pain relief is associated with activity in descending pathways that modulate pain transmission at a spinal level - it's not (just) about how we accommodate our pain at a conscious level.
    In terms of pain research, this is only just kicking off (shortly before I retired, someone presented the first scan showing placebo-induced activity at a segmental level in the spinal cord - she joked that those three bright pixels had cost her three years of her life). So we've yet to tease out the contributions of descending inhibition, attentional components that determine whether pain signals arriving at the cortex are incorporated into the workspace of consciousness, and the patient's attitude to the pain signals that do arrive in consciousness.
    But we do have data from asthma, in which measured airway resistance tracks the patient's perception of benefit, and data showing immune modulation of which the patient couldn't be aware.

    So it's an area researchers are actively interested in, for sure.

    Grant Hutchison

  9. #99
    Join Date
    Jul 2006
    Posts
    11,986
    Tripler Army Hospital in Hawaii is doing work sort of in the opposite direction.

    They routinely do procedures with no analgesics whatsoever that would be expected at other facilities.

    Finally got vindicated too. I was relating what happened to me back in '81 at Tripler in a quiet waiting room at the San Francisco VA at Fort Miley.

    I had a hand that had been broken for three days get set without pain relief, while the guy on the table next to me was having a fractured femur reduced the same way.

    They actually said out loud "You're going to faint anyway." The guy with the broken femur did. His eyes went round, he blanched, and then fainted with his eyes open.

    I didn't faint, and only groaned loudly once, when he first started manipulating the fracture. When he finally finished I was wondering why my other hand was sticky and looked I saw that I had driven my fingernails through the skin of my palm until they drew blood.

    As I finished, this young doctor walked by and stated quite authoritatively;

    "That doesn't happen!"

    When two others in the room stood up and said they were both Army and the same thing happened to them at Tripler. One guy was in uniform with his arm in a sling. Broke both forearm bones. Set at Tripler, without anesthesia. So they're still doing it!

    The young doctor actually backed away from us, like he thought he was the victim of some sort of scam.

    If you still know anybody "in the business" Dr. Grant, have them look at Tripler Hospital. I am really curious as to why this goes on there.

    I did have a more unpleasant experience than that in the ER, but that would be off topic.
    Time wasted having fun is not time wasted - Lennon
    (John, not the other one.)

  10. #100
    Join Date
    Oct 2005
    Posts
    26,097
    Quote Originally Posted by grant hutchison View Post
    But what we're finding from functional imaging is that placebo pain relief is associated with activity in descending pathways that modulate pain transmission at a spinal level - it's not (just) about how we accommodate our pain at a conscious level.
    So indeed there is a mixture between that which improves the patient's outlook, and that which demonstrates physiological feedback. So then the question is, how to quantify that mixture? Is it 50-50 or what? And how does it differ for different conditions? I presume that it took time for this kind of research to even be accepted and not ruin one's career. Understanding how it works could help it be manipulated ethically, to get the best of both worlds. Surrendering the placebo field to the alternative folks is giving them too much power to mismanage the ethics, which cost people like Steve Jobs their life. Couldn't there have been a way to give him both proven cures, while serving his need to seek out the special, the unique? It's a challenge-- did medicine fail Jobs by not seeing the whole picture, or was it just his own obstinance that was to blame?

  11. #101
    Join Date
    Jul 2005
    Posts
    16,002
    Quote Originally Posted by Ken G View Post
    I presume that it took time for this kind of research to even be accepted and not ruin one's career.
    I'm not aware of that ever having been a problem. Indeed, there's more of a danger of the opposite happening - in the past, doctors understood the value of the doctor-patient relationship very well, and were keen to investigate and understand it; today, market forces are driving a model of "efficient delivery", which means the patient turns up, gets some pills or some surgery, and goes away again. Research that challenges that model of "care" is seen as actively subversive, in some quarters.

    Then again, Sir Robert Hutchison was expressing similar sentiments before I was born, so maybe there's hope yet:
    From inability to let well alone; from too much zeal for the new and contempt for what is old; from putting knowledge before wisdom, science before art, and cleverness before common sense; from treating patients as cases; and from making the cure of the disease more grievous than the endurance of the same, Good Lord, deliver us.
    Grant Hutchison
    Last edited by grant hutchison; 2018-Jan-07 at 04:03 PM. Reason: Second para

  12. #102
    Join Date
    Oct 2005
    Posts
    26,097
    Quote Originally Posted by grant hutchison View Post
    Then again, Sir Robert Hutchison was expressing similar sentiments before I was born, so maybe there's hope yet:
    Your namesake from a century ago? A great wit indeed.

  13. #103
    Join Date
    Apr 2011
    Location
    Norfolk UK and some of me is in Northern France
    Posts
    7,602
    I am reading the book "placebo" at the mo and one interesting study cited was the rats dosed with a drug supposed to cause some effect but actually reduced their immune system. There was a parallel sweet tasting offering and the test was of Pavlovian conditioning. When they discovered the rats were dying because their immune systems shut down, they changed the experiment and found the conditioned rats continued to die when given the sweet syrup but unconditioned rats were OK. The point about both conditioning and placebo is that interoception explains both. But the subtle thing in humans is how we come to trust for example doctors or white coats so most of us expect to get better and we do even in false surgery and similar trials. Attitude must be from the same interoception idea, ie that happy optimistic people tend to live longer.. Expectation bias might not have so many "neutral" connotations as placebo which has too much taint of doing nothing. Placebo is a major use of communal belief systems to achieve positive healing.
    sicut vis videre esto
    When we realize that patterns don't exist in the universe, they are a template that we hold to the universe to make sense of it, it all makes a lot more sense.
    Originally Posted by Ken G

  14. #104
    Join Date
    Oct 2005
    Posts
    26,097
    I must have missed something-- are you saying rats can experience a placebo effect? Surely it must be the experimenters' placebo effect, I presume via poor data handling.

  15. #105
    Join Date
    Dec 2006
    Posts
    2,125
    Quote Originally Posted by Ken G View Post
    I must have missed something-- are you saying rats can experience a placebo effect? Surely it must be the experimenters' placebo effect, I presume via poor data handling.
    Is the implication that the Pavlov reaction - of a dog being taught to salivate at the sound of a bell - is an example of a placebo effect?

  16. #106
    Join Date
    Jul 2005
    Posts
    16,002
    I can't vouch for the rat experiment, but you can get some interesting placebo effects by conditioning in humans. The conditioning involves giving repeated doses of a real drug, and then a placebo that looks the same. What's interesting is that if you condition with an opioid analgesic, you get placebo analgesia that's reversed by an opioid antagonist drug, but if you condition with a nonsteroidal anti-inflammatory (which isn't an opioid) you get placebo analgesia that's not, or only partially, reversed with an opioid antagonist.

    Benedetti also gives a whole list of immune and endocrine responses that can be conditioned - you can damp down graft rejection using placebo, if you've first conditioned with an immune suppressant, for instance.

    Grant Hutchison
    Last edited by grant hutchison; 2018-Jan-09 at 02:14 AM. Reason: Second para

  17. #107
    Join Date
    Jul 2006
    Posts
    11,986
    Quote Originally Posted by Robert Tulip View Post
    Is the implication that the Pavlov reaction - of a dog being taught to salivate at the sound of a bell - is an example of a placebo effect?
    No, that is an example of conditioning.

    The dogs heard a bell rung just before being fed for X amount of feedings.

    Later, the same dogs would salivate at the sound of a bell, even if food wasn't present.
    Time wasted having fun is not time wasted - Lennon
    (John, not the other one.)

  18. #108
    Join Date
    Jul 2006
    Posts
    11,986
    Scientists call it conditioning.

    I call it remembering what happened yesterday.
    Time wasted having fun is not time wasted - Lennon
    (John, not the other one.)

  19. #109
    Join Date
    Apr 2011
    Location
    Norfolk UK and some of me is in Northern France
    Posts
    7,602
    I think the point is that both conditioning and placebo (and nocebo) can be seen as examples of the interoception model which is experiential predictive modelling. The prediction is to reduce surprise, which assists homeostasis. Conditioning involves triggers which lead to predictions, salivating in the dogs, and placebo shows for example the immune system winding up or down in response the clues. These effects are unconscious but amply illustrate the way the brain models the internals and then predicts changes to maintain homeostasis. So rats and dogs have been shown to exhibit the same modelling.
    sicut vis videre esto
    When we realize that patterns don't exist in the universe, they are a template that we hold to the universe to make sense of it, it all makes a lot more sense.
    Originally Posted by Ken G

  20. #110
    Join Date
    Jul 2005
    Posts
    16,002
    Generally, conditioning is considered to be one way to induce a placebo effect, the other being expectation. Conditioning requires initial exposure to the real drug, whereas expectation does not.

    Grant Hutchison

  21. #111
    Join Date
    Oct 2005
    Posts
    26,097
    Quote Originally Posted by grant hutchison View Post
    I can't vouch for the rat experiment, but you can get some interesting placebo effects by conditioning in humans. The conditioning involves giving repeated doses of a real drug, and then a placebo that looks the same.
    That sounds like a normal placebo effect in the sense that the patient is conditioned to expect a certain response, and expectations can lead to a placebo effect.
    What's interesting is that if you condition with an opioid analgesic, you get placebo analgesia that's reversed by an opioid antagonist drug, but if you condition with a nonsteroidal anti-inflammatory (which isn't an opioid) you get placebo analgesia that's not, or only partially, reversed with an opioid antagonist.
    That does not sound like a normal placebo effect, or indeed even something that is possible! Presumably you are saying this is true even if the patient doesn't know an opioid from a hole in the wall, so how could their placebo effect be reversed by a real drug that is having no physiological effect and also does not alter their expectations? Or, are you saying the patient is told "this is an opioid antagonist so should reverse your opioid analgesic," in which case it wouldn't matter if it was an actual opioid antagonist or not, it would only matter what they were told to expect.
    Benedetti also gives a whole list of immune and endocrine responses that can be conditioned - you can damp down graft rejection using placebo, if you've first conditioned with an immune suppressant, for instance.
    That's back to the normal placebo response, where expectations are being conditioned by actual physiological responses. Remarkable that expectations could affect something like graft rejection though. I wonder if patients get better results if they don't even know a graft has occurred, say in young children for whom there is not the same ethical constraints.

  22. #112
    Join Date
    Oct 2005
    Posts
    26,097
    Quote Originally Posted by grant hutchison View Post
    Generally, conditioning is considered to be one way to induce a placebo effect, the other being expectation. Conditioning requires initial exposure to the real drug, whereas expectation does not.
    But presumably the conditioning does affect expectations, unless the patient is not aware they are receiving a treatment.

  23. #113
    Join Date
    Jul 2005
    Posts
    16,002
    Quote Originally Posted by Ken G View Post
    That does not sound like a normal placebo effect, or indeed even something that is possible!
    The original paper is here
    We investigated the mechanisms underlying the activation of endogenous opioids in placebo analgesia by using the model of human experimental ischemic arm pain. Different types of placebo analgesic responses were evoked by means of cognitive expectation cues, drug conditioning, or a combination of both. Drug conditioning was performed by means of either the opioid agonist morphine hydrochloride or the nonopioid ketorolac tromethamine. Expectation cues produced placebo responses that were completely blocked by the opioid antagonist naloxone. Expectation cues together with morphine conditioning produced placebo responses that were completely antagonized by naloxone. Morphine conditioning alone (without expectation cues) induced a naloxone-reversible placebo effect. By contrast, ketorolac conditioning together with expectation cues elicited a placebo effect that was blocked by naloxone only partially. Ketorolac conditioning alone produced placebo responses that were naloxone-insensitive. Therefore, we evoked different types of placebo responses that were either naloxone-reversible or partially naloxone-reversible or, otherwise, naloxone-insensitive, depending on the procedure used to evoke the placebo response. These findings show that cognitive factors and conditioning are balanced in different ways in placebo analgesia, and this balance is crucial for the activation of opioid or nonopioid systems. Expectation triggers endogenous opioids, whereas conditioning activates specific subsystems. In fact, if conditioning is performed with opioids, placebo analgesia is mediated via opioid receptors, if conditioning is performed with nonopioid drugs, other nonopioid mechanisms result to be involved.
    You can tease out the effects of conditioning and expectation in an experimental setting, because you can choose what information you give your experimental subjects about the drugs they are receiving. You can also compare like with like, by exposing the subjects to a "standard model" of pain - in this case asking them to exercise their arm with a tourniquet in place, until they are unable to continue because of ischaemic muscle pain.
    My copy of the original paper has gone astray when I cleared my office. I'll see if I can turn it up.

    Quote Originally Posted by Ken G View Post
    That's back to the normal placebo response, where expectations are being conditioned by actual physiological responses. Remarkable that expectations could affect something like graft rejection though. I wonder if patients get better results if they don't even know a graft has occurred, say in young children for whom there is not the same ethical constraints.
    Well, the conditioned placebo response shows, across a number of parameters, the same spectrum of immune modulation, at a biochemical level, as the original anti-rejection drug. It's a remarkable result, and although we can hand-wave how the connection between central nervous system and immune system "must" be mediated, we're a long way from understanding how things like that can happen.

    Grant Hutchison

  24. #114
    Join Date
    Oct 2005
    Posts
    26,097
    Quote Originally Posted by grant hutchison View Post
    Well, the conditioned placebo response shows, across a number of parameters, the same spectrum of immune modulation, at a biochemical level, as the original anti-rejection drug. It's a remarkable result, and although we can hand-wave how the connection between central nervous system and immune system "must" be mediated, we're a long way from understanding how things like that can happen.
    I see, it is almost as if the body "learns" to trigger the same biochemical response that the medicine itself produces. One wonders how deep this goes-- does this mean any time I am receiving a drug that needs to build up in my system over time, part of the reason the drug becomes therapeutic is that my body notices it is having some desired effect and produces some kind of biochemical cooperation to increase the response, even to the point of being able, to some degree, to replace the treatment when it is not present? If so, one wonders what role the brain knowing about what is happening plays-- it would seem like a type of placebo that is not about what the patient thinks.

  25. #115
    Join Date
    Jul 2005
    Posts
    16,002
    Quote Originally Posted by Ken G View Post
    If so, one wonders what role the brain knowing about what is happening plays-- it would seem like a type of placebo that is not about what the patient thinks.
    Yes, it's why we think of conditioning and expectation as two different routes to a placebo effect, which may or may not work simultaneously.

    Here's how the conditioning experiments are set up:
    Use a standard model of pain in volunteers - tourniquet ischaemia time is common, in which volunteers carry out a standard arm exercise with a tourniquet in place until they find the pain unacceptable. Tests are usually done at daily intervals.

    1) Test them without analgesia
    2) Condition them by repeating the exercise with an analgesic on board, for two or more sessions
    3) Repeat with a placebo, or with an opioid antagonist, without informing the test subject
    4) Test again without analgesia, to check for any kind of baseline change due training or loss of engagement

    You can ring the changes on this experimental design by administering placebo in phase 1) and 4), revealing or concealing the nature of drug switches, and so on. By working your way through that sort of experimental design in different ways, you can tease out the contributions of conditioning and expectation. The fact we have antagonists to a number of neurotransmitters involved in placebo responses means we can test which pathways are at work without resorting to neuroimaging.

    Grant Hutchison

  26. #116
    Join Date
    Oct 2005
    Posts
    26,097
    Remarkable.

  27. #117
    Join Date
    Sep 2003
    Posts
    12,195
    I wonder how much of the placebo affect can be attributed to muscle relaxation? When I get a headache, I pause and relax every muscle above my nose, usually with complete benefit. These aren't migraines or anything too strong, admittedly. I also relax muscles in my face, especially around the eyes, to help me fall asleep.
    We know time flies, we just can't see its wings.

  28. #118
    Join Date
    Jul 2005
    Posts
    16,002
    A stand-up comic is doing a show called "Laughter Is The Best Placebo" locally.

    At first I thought this showed great insight, but reading the rest of the advertisement suggests that the show is all about his angst and relationship difficulties.

    Grant Hutchison

  29. #119
    Join Date
    Apr 2011
    Location
    Norfolk UK and some of me is in Northern France
    Posts
    7,602
    I am involved in research where it is important to test against a control and the criticism "this is just placebo" has been raised. There are drugs which have been tested against placebo, (I will try to avoid naming them at this point) and our results are better than the drugs so you would think we would be able to counter the criticism. But it is that word "just" that gets me. There have been life and death anecdotes where placebo/ nocebo were involved. It's not a small effect. Homeopathy as mentioned by the OP may be one of the best placebos and I hope we can test against that and win because even if we are accused of being "just" a placebo, we could still be better than the best! I hope we get past this "just placebo" attitude and start to harness the mechanism.
    sicut vis videre esto
    When we realize that patterns don't exist in the universe, they are a template that we hold to the universe to make sense of it, it all makes a lot more sense.
    Originally Posted by Ken G

  30. #120
    Join Date
    Apr 2011
    Location
    Norfolk UK and some of me is in Northern France
    Posts
    7,602
    Quote Originally Posted by grant hutchison View Post
    A stand-up comic is doing a show called "Laughter Is The Best Placebo" locally.

    At first I thought this showed great insight, but reading the rest of the advertisement suggests that the show is all about his angst and relationship difficulties.

    Grant Hutchison
    I believe there was Japanese research recently that monitored immune response to watching funny films versus documentaries and the funny films were positively better.
    sicut vis videre esto
    When we realize that patterns don't exist in the universe, they are a template that we hold to the universe to make sense of it, it all makes a lot more sense.
    Originally Posted by Ken G

Posting Permissions

  • You may not post new threads
  • You may not post replies
  • You may not post attachments
  • You may not edit your posts
  •