Now as I have said so many times before, the placebo effect is not about a sugar pill, it’s about the cultural meaning of a treatment, and our expectations: we know from research that two sugar pills are more effective than one, that a salt water injection is better for pain than a sugar pill, that colour and packaging have a beneficial effect, and so on. Interestingly, there has even been a trial on patients with arm pain specifically comparing a placebo pill against a placebo ritual involving a sham medical device, modelled on acupuncture, which found that the elaborate ritual was more effective than the simple sugar pill. “Placebo” is not a unitary phenomenon, there is not “one type of placebo”.
But the most important background information missing from the news reports wasn’t about the details of the study: it was about back pain. Because back pain isnt like epilepsy or tuberculosis. Most of the big risk factors for a niggle turning into chronic longstanding back pain are personal, psychological, and social: things like depression, job dissatisfaction, unavailability of light duty on return to work, and so on.
And the evidence on treatments tells an even more interesting psychosocial story: sure, anti-inflammatory drugs are better than placebo. But more than that, bed rest is actively harmful, specific exercises can be too, and proper trial data shows that simply giving advice to “stay active” speeds recovery, reduces chronic disability, and reduces time off work.
We don’t like stories and solutions like that for our health problems. There are huge industries telling you that your tiredness is due to some “chromium deficiency” (buy the pill); your cloudy headed foggy feeling can be fixed with vitamin pills, pills, and more pills. It is a brave doctor who dares to bring up psychosocial issues for any complaint when a patient has been consistently told it is biomedical by every newspaper, every magazine, and every quack in town.
Friday, October 05, 2007
the medicalization of back pain
Here. An excerpt: