Embracing the Placebo Effect: The Time has Arrived for Rheumatology
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We are privileged to have a stellar group of discussants in this issue of Healio Rheumatology addressing the multiple facets of the placebo effect in the field of rheumatology. For a long time now, the ‘placebo effect’ has represented little more than a troublesome obstacle that clinical investigators — in the course of clinical trials with our growing armamentarium of therapeutics — must overcome to demonstrate that a drug or therapy is truly effective.
Calabrese
We all know that in RA the index that is required to show such superiority is the ACR20, which includes multiple parameters including tender and swollen joints as well as subjective assessments on behalf of both patient and investigator. While our drugs have been demonstrated to be increasingly potent, the placebo response has also grown in strength over the last generation and at times can reach nearly 50%! What a pain (no pun intended) to have to hurdle this untidy clinical response to no therapy besides what they were on.
One theory on this impressive growth of the placebo response is the growing expectations of our patients to the new ‘miracle’ therapies they see in direct-to-consumer advertisements during the evening news where everyone looks much healthier than I am — I addressed the potential negatives of these ads in my editorial in the June 2018 issue of Healio Rheumatology. Interestingly, my informal search of ACR abstracts this year revealed no studies aimed at truly understanding the nature of this formidable phenomenon.
Our discussants, including several prominent placebo response researchers, are teaching us that the ‘placebo effect’ is not merely the response to an inert substance (ie, a sugar pill) but should be viewed as a clinical phenomenon that can be derived by multiple interventions, the most important of which — in my opinion — is the ritual of treatment and the doctor-patient relationship. This concept is directly in line with our work trying to define, strengthen and grow the role of empathy in our clinical encounters.
I know some physicians are bristling at the notion that this is important and that the placebo effect will not stop joint erosions, cure cancer or make patients’ HIV viral load undetectable. On the other hand, the placebo effect — or what I prefer to call ‘relationship-centered healing’ — can be a potent force to improve symptom relief including pain, anxiety and fatigue. These domains just so happen to be the ones that there are hundreds and hundreds of abstracts for at our international meetings. So, what gives?
Just consider a clinical encounter with a fibromyalgia patient where one provider tells the patient: “All your tests are normal, nothing is seriously wrong, and all you have is fibromyalgia. Here is a prescription and go back to your PCP.” Or, alternatively, another provider can explain the diagnosis, assure the patient that their symptoms are quite real and not “psychosomatic” or their own fault and convince them that behavioral approaches of exercise, sleep hygiene, healthy eating and some form of stress modification are biologically relevant, and all have evidence of variable effectiveness. Which one may better cultivate the placebo effect or generate relationship-centered healing?
Although I am simplifying this far too much, I think you get the idea. If you do, then shouldn’t we ask why we aren’t studying the heck out of this phenomenon to grow it in our practice and teach our trainees. I will tell you that I am all in and eager to contribute to this emerging area of research within the domain of rheumatology.
I hope you enjoy the roundtable, and by all means, let me hear your take on this through Twitter at @LCalabreseDO or email me at calabrl@ccf.org.
- For more information:
- Leonard H. Calabrese, DO, is the Chief Medical Editor, Healio Rheumatology, and Professor of Medicine, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, and RJ Fasenmyer Chair of Clinical Immunology at the Cleveland Clinic.
Disclosures: Calabrese reports consulting relationships with AbbVie, Centecor Biopharmaceutical, Crescendo Bioscience, GlaxoSmithKline, Horizon Pharma, Janssen Pharmaceuticals, Pfizer, Regeneron Pharmaceuticals and UCB.
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