In praise of placebos

Often the best medicine is simply having someone care

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The art of medicine consists of amusing the patient while nature cures the disease. — Voltaire (1694-1778)

One might assume that 250 years of medical advances have made Voltaire’s witticism irrelevant. However, even today some illnesses are helped as much by the passage of time and by caring support as by expensive medical treatment. Thus, one unexplored but potentially fruitful way to cut health care costs without negatively impacting patient outcomes could be the wider use of placebos.

In the April 1 edition of Spine, I reviewed four decades of research on the centuries-old technique of lower back pain care by spinal manipulation. With analytics based on 56 studies, I established that (1) non-surgical lower back pain usually improves irrespective of treatment and (2) the likelihood of spinal manipulation being effective nearly matched a random pattern.

Those studies that considered treatment versus non-treatment favored treatment about half the time. Where all treatments, non-treatment and spinal manipulation were compared, spinal manipulation was the best outcome one-third of the time.

In other words, the frequency of treatment success was what you could expect from rolling dice. Overall, treatment was responsible for just one-third of improvement in chronic pain patients and a paltry 3 percent among patients with acute pain. Time and the body’s natural recovery process did the rest.

This finding solves the mystery of why so many approaches to healing, from surgery to acupuncture to shamanism, claim success. For some ailments, they all “work” because most of their patients would have gotten better anyhow!

This discovery raises some interesting questions. For example, how much public subsidy should we provide, in the form of health insurance coverage and student loans for training programs, to treatments that appear to barely, if at all, outperform placebo effects? Second, could improved research methods detect placebo effects better and faster, enabling us to direct patient care at much lower cost and without harmful side effects?

Given the many uncertainties and inconsistencies that plague even the best medical research, the evidence part of “evidence-based medicine” can be in the eye of the stakeholder.

Chiropractors claim ample evidence to support treatment, and they have enough patients who believe in them to keep them in business for decades to come. Many will interpret my findings as showing not that spinal manipulation is ineffective, but that some practitioners do it better than others. (And all of them would say that they are among the ones who do it well.)

We could illustrate the same dynamic with many forms of alternative medicine. Skeptics abound, scientific evidence is inconclusive, yet millions of practitioners and patients swear by it.

On the other hand, advocates of alternative medicine remind us of similar fault lines in our society’s predominant allopathic medicine. For instance, Jack Wennberg’s classic work on “practice pattern variation” demonstrates that your likelihood of getting back surgery depends more on your doctor’s zip code than your medical need.

So let us turn to another interpretation of the Spine article, one that might find chiropractors and alternative-medicine proponents siding with us: There is too much unnecessary, expensive, invasive medicine.

Identical physical symptoms may be prone to multiple interpretations, each with its associated expertise and treatment. Compare the following: “I have a bad back,” “I slipped a disc,” “I pulled a muscle,” “I have a subluxation,” “I have impeded spleen qi,” and “I need more homeopathic quantum entanglement.”

All these assertions reflect a fantastic diversity of health beliefs. The professionals who offer these diagnoses provide explanations and hope-filled invitations. In accepting one of them, the patient enters a therapeutic alliance with credible advice, monitoring and encouragement. Just committing to treatment might be the real treatment.

In alternative treatments, patients are told that “it will take time to regain your health.” Granted sufficient cultural authority, chiropractors and other alternative medicine practitioners could dissuade patients from risky and painful medical tests, dependence on addictive drugs and needless surgeries.

This makes what chiropractors do secondary to what they prevent. True natural healing may involve distracting patients with a good story and avoiding medical interference. Spinal manipulation at least gives patients time, reassurance and permission to recover — without a costly back surgery that often has no greater probability of success than time and encouragement. (Of course, alternative medicine can become the new dependence — and the new form of bloated expenditure — as “regaining health” creeps into ongoing treatment for “maintaining health.”)

The greater theme here is that so much of our health and well-being lies in our connection with others. My study found that people receiving care — even if it was sham therapy in a control group — showed greater improvement over those stuck on a waiting list.

The logical conclusion is that we are more resilient and more likely to recover if we have a plausible explanation of why we hurt and when the pain might end, and if we know that someone cares. How many other conditions might also require just patience, community and time to heal?

J. Michael Menke of the University of Arizona is head of psychology and a health-decision analyst at the International Medical University in Malaysia. He is also a former chiropractor.

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