Here's a dilemma for you...

You are a physician who is treating a patient suffering from chronic pain. The patient has been on morphine but is still experiencing difficult pain. You can increase the dose but high doses of morphine introduce side effects that may not be tolerable, including constipation, respiratory depression, headaches and nausea. What should you do?

Well, a recent survey (Tilburt, et al, 2008) of 334 active internists and 345 rheumatologists in the U.S. found that doctors currently make considerable use of placebos. Here's a highlight of some of their findings:

1. 58% said they would be very or moderately likely to give a dextrose pill to a patient with fibromyalgia if trials had shown placebos to be superior to no treatment.
2. 62% believed that recommending such treatments was ethically permissible or even obligatory.
3. 55% reported recommending at least one placebo treatment over the past year. These include so-called "active" placebos, such as over-the counter analgesics (41%), vitamins (38%), antibiotics (13%), and sedatives (13%). Only 2% recommended entirely inactive placebos ("sugar pills").

And how did these physicians describe the placebo treatments they recommended to their patients?

1. 68% of those who recommend placebo treatments said they typically describe them as "a medicine not typically used for your condition but might benefit you."
2. 18% described placebo treatments as a "medicine"
3. 5% actually revealed the treatment as "a placebo".

So, at least in this sample of physicians, most would prescribe a "sugar pill" for patients with chronic pain if there was evidence of their efficacy over no treatment. In other words, most physicians regard the therapeutic impact of placebos to be legitimate. "If they work, at least for some patients, why not?" seems to be the thinking.

The other interesting finding from this study is the use of "active" placebos -- innocuous treatments such as vitamins and over-the-counter analgesics. I think this is interesting because it somewhat sidesteps the deception issue that tends to stand as a barrier to the clinical exploitation of the placebo effect. Doctors can honestly say that these treatments help many people to feel better.

In sum, it appears that most docs believe that recommending placebo treatments to be ethically permissible but there is a definite preference for "active" placebos in which there is some degree (even if small) chance of a beneficial pharmacological effect, or at least promote a sense in the patient that the doctor is taking care of the patient and also of being able to take some control of one's condition.

So as the debate seems to rage on about whether to use placebos in clinical practice, it appears that they are very much alive and well and at work in a remarkable number of doctors' offices!

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Tilburt et al. (2008). Prescribing "placebo treatments": results of national survey of US internists and rheumatologists. BMJ 2008;337:a1938.