When Placebo Is Not Placebo

    Often when traditional technologies fail to work it’s not uncommon for a new treatment to be dismissed as “it’s the placebo effect”, if it helps the patient.  This is so very common with the chronic pain patient and could possibly be the worse use of the term “placebo” in medicine and regulatory parlance.

     Here’s some background on the path the chronic pain patient takes.

    The pain could be of “unknown etiology” or it could be a disease process such as fibromyalgia, RSD, Carpal Tunnel Syndrome, or the common secondary diagnosis of sciatica.   The issue though is crystal clear.  The symptom has become the diagnosis simply because the patient’s problem can not be corrected and the pain is not eliminated.

    Prior to the diagnosis evolving to “chronic pain” the patient exhibits her/himself as a patient that has come for medical attention due to pain.  The initial exam generally consists of a preliminary diagnosis being made and then a treatment protocol is designed for that patient.  In most cases such as protruding disc, degenerative disc disease, Tic Doloreux as examples there is a physical cause of the pain and if that is discovered via lab tests, radiology, observation etc. then the cause of the pain is discovered and treated.  The pain goes away because the causative factor is discovered and treated, or the cause is determined and the patient is educated that it could be a viral causation and, time, is the healer with treatment only for the symptomatic pain until the virus is gone or the condition is untreatable.

     In most situations it will be something simple to eradicate the problem such as antibiotics, anti-inflammatories, aspirin, ibuprofen, rest, hot/cold modalities, or physical therapy.  The pain symptom goes away and the medical team no longer sees the patient since there is no problem.  Cause has been treated and pain is no longer present.  Patient is “well”.

     However, there are a certain percentage of the above patients that the treatment protocol did not work.  Those patients did everything they were told to do yet the pain persists and they continue to visit the doctor complaining the pain is not getting better and may actually be getting worse.  If the doctor is a primary care physician it is now the patient is referred out to some other specialty such as neurology, rheumatology, orthopedics, neurosurgery, chiropractic or some one else.  New tests begin, review of old tests continues and the treating medical specialist knows, or should know, the traditional remedies did not work.  An important point to remember is when the patient has reached this point in the treatment of “pain” the success rate at this point for these patients is 0 %.  It is no longer valid to state that “80% of these patients get better with bed rest and aspirin”.  These patients did not.

       If the patient continues to experience pain any previous diagnosis may be ruled out and a new diagnosis emerges.   The new “diagnosis” is “chronic pain” possibly “due to”, or “of unknown etiology”.  It is this point in time that the medical profession and other alternative practitioners admit the reason the patient is experiencing pain is “unknown or untreatable”.  

     This is where the use of the term “placebo” is lost or misused.  At this point in time the previous statements about how patients that have been treated successfully blur the reality that the chronic patient has been down the traditional path, unsuccessfully, so now the patient population is vastly different than the patients who were treated successfully.  It is no longer valid to reference treatments following this stage to be shown as being “placebo”.   It is better for our understanding to advance the concept those treatments now that work may be due to our misunderstandings, rather than the fall back phrase “placebo”.   Anything that stops the pain is a treatment methodology that is new and has a positive outcome when all previous treatments failed. 

       It’s so common for positive treatment outcomes to be written off as “placebo”, even if only a sugar pill, but the goal of all people who choose to help other people is to achieve the goals of helping by stopping the condition.   With chronic pain patients the condition is “continuing, recurrent pain”.

      Are there quacks?  Yes.  Are there shysters? Yes.  Are there those who proclaim to treat, accept money for doing so, yet don’t.   Yes. 

    It’s better to try to understand and to not defer to prejudicial statements when by attempting to understand and clarify correctly would better serve the chronic pain patient.