Alternative Medicine and the Placebo Effect

Over the last few weeks I have had a large exposure to peoples’ opinions on various alternative medical remedies—acupuncture, homeopathy, craniosacral therapy, etc. The purpose of this blog is to hopefully clear up the various misrepresentations I have noticed people have of the placebo effect as well as a couple of alternative medical practices.

As far back as I can remember I have been curious about anything I can learn about—especially things foreign to my native culture. Maybe it has something to do with being an immigrant (I’m a Ukrainian-Jew and moved to the USA in 1993) but who knows? During my undergraduate studies, this almost came to be my ruin because I couldn’t commit to a major without worrying that I’d be missing out on learning all the interesting stuff the other majors had to offer. I say this about myself in a testimony to the fact that when I hear of something foreign to conventional thought or practice (or simply to me) and it matches my interests, I inquire. One of my greatest interests is health and so seeing whether alternative remedies work has always been something that interested me. My first experience with alternative medicine was very early on in life when I saw my father, a chronic smoker, receive acupuncture to get rid of his addiction. It didn’t make sense to me as a ten-year-old what sticking needles into the skin had to do with nicotine addiction and after doing my research on acupuncture there is no evidence to support the idea either. In other words, to use a cliché, the jury is still out on that one. As much as I’d love to deal with every alternative medicine practice I’ve come across and my justified skepticism for them, I do not have the time or the attention spam to write coherently on all of them. What follows is mostly on acupuncture and the placebo effect.

DISCLAIMER: The majority of the information regarding acupuncture and the placebo effect that I reference here can be found on The Skeptic Dictionary’s website, Skepdic.com, where links are found directly to research on acupuncture and the placebo effect. None of what has been cited from this source in this blog is for the intentional financial profiting of the author or his affiliates. If anything it is gratitude for the websites great work.

Placebos Scientific control studies in medicine that attempt to determine whether something is a significant causal factor in producing a specific effect often use placebos as a control. In most of these studies, the placebo is defined as an inert substance, and it is compared with an active substance to see if there is any significant difference in outcome in different groups. The typical example would compare a drug in pill form, of known chemical composition, with a pill that looks and is administered like the drug but is actually made of starch or sugar. It is known that placebos can have physiological and psychological effects. So, it is legitimate to assume that if there is a significant difference in outcome between the placebo group and the experimental group that the difference is probably due to the experimental drug in a properly controlled study. However, it cannot be determined from that data alone just how effective the drug is. To know that, it is necessary to determine if there was a placebo effect and, if so, what it was. One method of isolating the placebo effect is to have a third group in the trial that receives neither the experimental drug nor the placebo pill. If the placebo group shows a significant difference in outcome from this third group, it may seem reasonable to assume that the difference is due to the placebo effect. Such trials, however, tell us nothing about the mechanisms of the placebo effect. If they are not carefully designed, we may mistakenly attribute causal effectiveness to both the chemical substance and the placebo. Some or all of the effect could be caused by false impressions of placebo effects such as regression to the mean.

A common misunderstanding regarding placebos is that a placebo must be an inert substance that tricks the patient into thinking he's been given an active substance. This misunderstanding leads to the belief that the placebo effect is "all in the head." That is no truer than that people's physiological responses to what they think is alcohol or a drug are purely psychological. People can be conditioned to have physiological responses to placebos. Furthermore, Martina Amanzio et al. (2001) demonstrated that "at least part of the physiological basis for the placebo effect is opiod in nature" (Bausell 2007: 160). That is, we can be conditioned to release such chemical substances as endorphins, catecholamines, cortisol, and adrenaline. In her book, Women Aren't Supposed to Fly: The Memoirs of a Female Flight Surgeon.

Dr. Harriet Hall tells the story of a man who got a vasectomy without anesthesia because he was mistakenly injected with saline solution rather than lidocaine. She also tells the story of a woman whose severe headaches went away after being injected with saline. The latter swore that only Demerol worked for her, but she had been conditioned to feel relief when she got a shot. Likewise, the vasectomy victim didn't feel excruciating pain because he also was conditioned to get pain relief from certain injections.

Acupuncture vs Sham Acupuncture The Linköping study involved 215 patients with various types of cancer being treated with radiotherapy, which often leads to severe nausea and vomiting. It has been hypothesized that acupuncture can be a significant causal factor in the relief of such nausea. One group was treated with traditional acupuncture. The other group got a sham treatment that involved an identical looking and feeling needle that retracted into a handle on contact with the skin. This method prevents the patients from knowing whether they've actually been stuck with a needle. Both the true and the sham groups believed the treatment had been invasive and effective in reducing nausea: 68 percent of patients who got the acupuncture experienced nausea for an average of 19 days during radiotherapy and 61 percent of the patients who got the sham treatment suffered nausea for an average of 17 days. Vomiting was experienced by 24 percent of the patients getting acupuncture and 28 percent of patients receiving the sham treatment. Fifty-eight of the patients received chemotherapy in combination with radiotherapy. Among them, 82 percent of those in the acupuncture group developed nausea, compared with 80 percent of those treated with the sham needles. Sixty-six percent of patients who got acupuncture and 71 percent who got the sham treatment said they would be highly interested in having acupuncture again if it turned out they needed another course of radiotherapy.

Experience Medical anecdotes regarding the effectiveness of a treatment fall into several categories. This is true whether we are talking about alternative medicine or whether we are talking about science-based conventional medicine. Some of the stories are unquestionably true and probably justify the conclusion that the treatment was effective. For example, the pain in your wrist is so severe that you can't grip the brake on your bicycle. You go to your acupuncturist, your chiropractor, or your physician for treatment. You leave the medical office feeling great and ride your bike home with no problem gripping and squeezing the brake lever. I hope it will become clear below why a thoughtful healer should wonder when such a patient leaves the office whether the success was due to the needles unblocking chi, the touching and massaging, the comforting and hopeful words, the injection, the spontaneous or natural resolution of the problem, or one of a host of other factors that might actually be the most significant causal agent in that particular healing process.

Some stories are unquestionably true, but they probably do not justify the conclusion that the treatment was effective. For example, we know that many people seek relief for their pain from a physician, chiropractor, or acupuncturist only when the pain becomes severe. We also know that many types of pain follow cycles: periods of relative freedom from pain are followed by periods of gradual increase in severity; and periods of severe pain are followed by gradual reduction in pain. The natural regression of pain and other disorders often leads both medical practitioners and patients to erroneously conclude that the treatment was effective when in fact the patient would have improved even if he or she hadn't sought any treatment. In short, most pains and illnesses go away on their own, but some of them go away shortly after seeking treatment and this leads us to think erroneously that there is a causal connection between the treatment and the relief. We know for a fact, for example, that many patients who are given antibiotics by their physicians erroneously attribute their recovery from a viral infection to the medicine. The patients really feel relief. They really show physiological changes. They really get better. Yet, we know that none of this has anything to do with the antibiotic because antibiotics don't act on viruses; they act only on bacteria.

Skepticism regarding the actual cause of recovery is clearly justified in some instances. But is skepticism regarding the cause of the recovery unwarranted in those cases where the patient has clearly benefited from the treatment? In other words, is it possible to be wrong about the cause of recovery in cases where we are clearly justified in attributing the recovery to acupuncture, homeopathy, chiropractic, or scientific medicine? Yes, it is, and we know this from various studies involving such things as conditioning.

Scientific studies that have shown how conditioning affects our response to medical treatment, conditioning can involve much more than obvious factors like getting an injection, taking a pill, or being touched where it hurts. Conditioning can involve the theater of the medical setting and medical rituals, including the medical uniforms worn, medical jargon spoken, and medical gadgetry used. These conditions affect the patient's expectation of relief by the treatment, as does the manner of the healer. Patient expectation, it turns out, plays a significant role in the effectiveness of many kinds of treatment. In short, classical conditioning is "hypothesized to be the primary triggering mechanism for the placebo effect…which must be learned before it can manifest itself" (Bausell 2007: 131).

Whether a given effective treatment is due to conditioning and the placebo effect cannot be determined by asking either the patient or the healer, unless they are aware of scientific studies that have demonstrated whether the effectiveness is due to conditioning or the placebo effect. A physician who prescribes antibiotics for a bacterial infection does so with knowledge that there are many scientific studies that demonstrate the effectiveness of antibiotics. The physician also has knowledge that bacterial infections cannot be treated effectively with placebos. Likewise, there are no placebo chemotherapies or birth control pills. As long as there is sufficient knowledge to justify the treatment as a necessary condition for healing, the healer is warranted in concluding that successful treatment is due in large part to the treatment and not to a placebo effect. It is becoming more and more evident, however, that most successful medical treatments involve "placebo factors," i.e., factors other than a drug, a surgery, or the like. It may seem absurd to some people to even consider the possibility that millions of satisfied customers around the world could be responding to conditioning and placebo effects when they receive medical treatment, whether it be acupuncture or some science-based conventional therapy. As pointed out earlier in the homeopathy discussion, however, no individual experience, no matter how dramatic, can provide us with enough information to know how much of the success was due to conditioning and placebo effects, and how much was due to some other mechanism such as the unblocking of chi along pathways called meridians, or the balancing of yin and yang, which are often offered as explanations of how acupuncture works. The only way to determine whether acupuncture works by some other mechanism besides conditioning and placebo effects is to do randomized, double-blind, controlled studies. If that is not possible, then scientific studies must be devised that rule out, as far as possible, conditioning and placebo effects as the main factors in the effectiveness of acupuncture.

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