Complementary Alternative Medicine 2 Flashcards
Identify the main theories of the placebo effect.
Endogenous opiates ("both placebo pain effects and other psychologically moderated pain effects involve them")
-"Naloxone seems to be able to antagonist placebo analgesia"
Conditioning
“People who experience the placebo effect have become classically conditioned to expect relief when they take medication. The stimulus is the medicine (or what’s perceived to be medicine) and the response is relief from their symptoms”
Expectancy
(“When people already know what the result of taking a pill is supposed to be, they might unconsciously change their reaction to bring about that result, or simply report that result as the outcome even if it wasn’t”)
e.g. wine and placebo
Motivation
– A more compliant patient?
Identify ways in which blinding can occur when investigating the efficacy of acupuncture.
Sham acupuncture locations
– Variation anyway, could hit meridians ‘by chance’
– Practitioner blinding?
Sham acupuncture needles
– Practitioner blinding?
– Patient blinding?
Identify orthodox explanations for an efficacy of acupuncture.
– Gate control theory of pain
– Opioid release
– Placebo effect
Why do people use CAM ?
- Health promotion (e.g. general wellbeing)
- Believe will be more effective than conventional treatment
- Exhausted conventional options
- Conventional options associated with side effects / risks
- No conventional therapy available
- Conventional approach emotionally / spiritually bereft
- Feeling more in control
Define medical pluralism, giving an example.
Adoption of more than one medical system (beliefs/behaviours/treatments)
For example, think about complexity of interactions in migrants • Trust in doctors/systems back home • UK system may be confusing • Pragmatism • Speed of access
To what extent are CAMs effective ?
Some may be effective
– Herbal remedies could contain active ingredients
Some CAM therapies clearly have no plausible scientific explanation or inherent efficacy
Many factors can make a treatment appear effective
– Disease-associated
– Patient-focussed
– CAM-based
Identify natural impediments to making valid inferences.
- Placebo effect
- Natural history of disease
- Regression to the mean
- Causal inferences
- Reluctance to admit when wrong – i.e. cognitive dissonance
- Simple optimism (internal locus of control)
- Respect for authority
Identify ethical issues around CAM.
Does it work?
– It it’s nothing more than a placebo, is that a bad thing?
– Do we need to know how a treatment works?
Is it safe?
– Regulation of practitioners / substances
– Direct vs indirect harm
How to balance patient choice against the first duty of a doctor?
How to balance patient choice against the first duty of a doctor, in the context of CAMs?
– Make the care of your patients your first concern
– Patient autonomy
– Informed choice
Identify questions which need to be asked when considering the question of whether CAM provision or research should be funded form public funds.
Should it be researched?
– Worthwhile finding active ingredient in herbal meds?
– As worthwhile researching homeopathy?
A fair allocation of money?
– Or a diversion of funds from science-based therapies?
A fair exploration of choice?
– Or weakening commitment to the scientific method?
– Undermining or enhancing public trust?
True or False: Massage often part of chiropractic assessment.
TRUE
Identify a treatment which could be used to compare with chiropractic to determine the efficacy of the latter.
Physiotherapy
Define placebo, nocebo effect, and placebo effect.
PLACEBO- Any therapeutic procedure which has an effect on a patient, symptom, syndrome or disease, but which is objectively without specific activity for the condition being treated
PLACEBO EFFECT- psychological or psychophysiological effect produced by placebos.
NOCEBO EFFECT- when patients respond adversely to a placebo intervention
Give examples of different types of placebos, and the range of factors that may influence the “placebo effect”.
EXAMPLES
Patients with Irritable Bowel Syndrome were exposed to painful stimuli (a rectal distension balloon) under local anaesthetic or a placebo. They split the trial into two arms, with half of the patients in each group receiving the placebo, the other hald the local anaesthetic. They were then either told you “may receive an active or placebo agent” or that “the agent you have been given is known to significantly reduce pain in some patients”. Those who were given the more positive statement reported less pain, whether they received the anaesthetic or the placebo.
FACTORS WHICH MAY INFLUENCE THE PLACEBO EFFECT
-Hawthorne effect ‘(the alteration of behaviour by the subjects of a study due to their awareness of being observed’)
“-Empathetic patient/doctor interaction can also add to the placebo effect
-Natural history of the disease “
Outline 3 reasons to support the use of placebos in clinical practice.
“1) It may have an evidence base: Published evidence applies to a patient only if that patient has similar characteristics to
patients in the study population. Even if this is the case, their response can rarely be accurately predicted. This is one of the problems with evidence based medicine: often its application to the individual is under less than ideal conditions.
However, where a study shows a response of the placebo in comparison with the
baseline then that is precisely what the study shows. It is possible to state with confidence that, were the conditions of treatment to be
replicated as in the study, the patient would have a statistical likelihood of responding
to the placebo, just as we can say that it is statistically likely that the patients would
respond to the active intervention. There is
thus a response whose cause is debatable but genuine. On strictly scientific grounds no
deception would be involved in referring to this response as an evidence base.
2) Cost-effective
3) Offers the best
option for respecting patients’ autonomy (as long as some conditions are respected)”
