Pandemic Placebo

Pat Wellenbach/AP

The buzz drummed up around hydroxychloroquine by our President as a treatment for Covid19 doesn’t surprise me. Honestly, a lot of politics is snake oil and he’s proven to be really good at selling it to some of us.

But it’s a great opportunity to consider what pills we are willing to swallow. I find hydroxychloroquine quite bitter. Maybe you don’t.

Lots of what we do in this modern medical industrial complex is mysterious, but don’t think for a minute its more complicated than human nature. Placebos tell us something about human nature, so it would be wise to understand them if we can. It might tell us something about ourselves, and about the prescriber.

Kind of like Idaho Democrats, placebos have a bad name they don’t deserve. Why disparage something that really has an effect? I guess it depends on the effect you want. It turns out, our bias effects our outcome. What you believe about your treatment influences the effect the treatment has on you.

They frequently do work; placebos I mean, not politicians.

When a placebo is given to a patient it can have an effect on the measured outcome; the “placebo effect”.  Placebos make headaches better, lower blood pressure, improve pain, ease anxiety and improve performance, the list is long. Believe it or not, they can have side effects too. They can cause nausea, ringing in the ears, all number of unpleasant things. Don’t forget that these effects, desired or not, are as real as we perceive them to be. Even the color of the pill can have an effect. We are such marvelous mysterious creatures.

For a drug to be FDA approved it has to show an effect greater than a placebo. That requires a lot of hard, expensive work. The patient has to be blind to whether the drug is a placebo or “real” and further, the treatment team needs to be blinded to the nature of the treatment also. The faith that patients place in their treatment, and the faith that providers have, has an effect. The standard for an effective drug is that it must clear the placebo hurdle of faith. That’s a high bar. Isn’t it refreshing to know our faith is so powerful?

The effect of hydroxychloroquine on the Covid19 illness has not been held to these standards. One very small report without blinded patients or providers reported some benefits; two larger ones showed no effect. Trying a novel treatment in the face of a novel virus in the midst of uncertainty is not irresponsible. Honestly reporting it for others to consider and test is responsible. Testing the treatment against a placebo would be responsible. Such testing might provide some evidence. But such testing takes time, effort and discipline. Do we lack such resources now? Should we be buying snake oil?

I remember my pharmacology lectures in medical school. The pharmacist professor wore a long white coat as he stood on the stage addressing the large theater of students. He spent a whole hour, after beta blockers and before tricyclic antidepressants, talking about the placebo effect. He emphasized how real the placebo effect was, how powerful it was, and how foolish we would be to minimize it. He encouraged us to tell patients the treatment would work. “Use this effect for your patients benefit.” At the time I felt he was leading us down the road to be snake oil salesmen. But it’s really not as simple as that. I think he was encouraging us to choose a treatment we had faith in, and impart that faith to our patients. The foundation for that faith should come from tested evidence. It’s a sad fact that many medical treatments have no such evidence, yet they are prescribed daily.

Maybe that was why I was such a lousy Idaho politician. I couldn’t sell blue pills when red ones were in demand.

About ddxdx

A Family physician, former county coroner and former Idaho State Senator
This entry was posted in Uncategorized. Bookmark the permalink.