Many doctors say they offer OTC meds or other placebos

Doctors know there's little clinical value in prescribing medications that won't work. But that doesn't keep patients from asking for them.

Mitchell Kahn, MD, knows this struggle. The Bellingham, Wash., internist prefers to talk patients through their problems and offer therapeutic reassurance. But the reality is that days are long, time is short and sometimes, he said, patient demands just wear you down.

Dr. Kahn is not alone. Patients who demand antibiotics for the common cold or ask their doctors to recommend vitamins are found frequently in physician exam rooms. They present doctors with an ethical dilemma: When all else fails, is it OK to harness the power of the placebo effect, and what should patients be told?

According to a British Medical Journal study, more than half of American physicians regularly recommend treatments aimed primarily at achieving a placebo effect.

Only 5% described these treatments to patients using the term "placebo," despite American Medical Association ethical policy that says "the use of a placebo without the patient's knowledge may undermine trust, compromise the patient-physician relationship, and result in medical harm to the patient."

AMA policy, adopted in 2006, says: "A placebo is a substance provided to a patient that the physician believes has no specific pharmacological effect upon the condition being treated."

In the BMJ study, researchers surveyed 679 U.S. internists and rheumatologists about their attitudes and clinical practices regarding placebo treatments. The surveys at first did not use the term "placebo," instead asking physicians whether, within the last year, they had "used a treatment whose benefits derive from positive patient expectations and not from the physiological mechanism of the treatment itself."

"You try to get at very controversial things in multiple different ways where you reduce the emotional charge of the answer and get to the actual facts," said study co-author Ezekiel J. Emanuel, MD, PhD, chair of the National Institutes of Health Dept. of Bioethics. "If I went up to a doctor and said, 'How often do you prescribe placebos?' They'll say, 'Never!' "

Forty-five percent of physicians said they had not used any placebo treatment in the last year. Only 5% of doctors said they used inactive substances such as sugar pills. More common recommendations were for over-the-counter analgesics and vitamins.

Nearly seven in 10 physicians surveyed said they described the recommendations to patients as "a medicine not typically used for your condition but [that] might benefit you."

The BMJ article, published Oct. 23, confirms earlier studies. A January Journal of General Internal Medicine study found that 45% of 231 surveyed Chicago academic physicians used placebo treatments, and only 4% described the recommendations to patients using the term placebo.

Farr A. Curlin, MD, co-author of the BMJ study, said the results reflect what he sees in clinical practice.

"In the context of uncertainty about whether any particular treatment will be helpful, it's not uncommon for doctors to encourage patients to try something that's not very high risk, that the patient has some hope in, and that the doctor believes may give the patient some of the placebo response," said Dr. Curlin, assistant professor of medicine at University of Chicago Pritzker School of Medicine.

Some say study misses mark

Many physicians responded online after the BMJ article was published, objecting to how the authors defined placebo treatments.

The study authors are "including many medications that may be traditionally used by physicians but that don't have a strong evidence base for their effectiveness," said Thomas Morgan, MD, assistant professor of pediatrics at the Vanderbilt University School of Medicine in Tennessee, in an AMNews interview. "I'd cite the example of over-the-counter cough and cold medicines as lacking rigorous proof that they're effective, yet some patients swear by them and want them prescribed to them."

Howard Brody, MD, PhD, said such responses are a "rationalization" of deceiving patients. Dr. Brody is a medical ethicist, retired family physician and author of The Placebo Response: How You Can Release the Body's Inner Pharmacy for Better Health.

Doctors have the power to achieve a placebo effect by advising, comforting and reassuring patients, he said.

"The bad news is that because physicians are just so darn rushed in so many medical contexts, we don't have time to do the hard work of creating solid doctor-patient relationships, and we are tempted to use shortcuts that are deceptive," Dr. Brody said. "The harm is low level, but ultimately it's not where we want to be."

AMA Secretary Ardis D. Hoven, MD, said in a statement: "The patient-physician relationship is rooted in trust. A physician should only use placebos with a patient's knowledge and consent; otherwise, that trust is eroded."