Amir, PharmD Profile picture
May 17, 2021 โ€ข 16 tweets โ€ข 7 min read โ€ข Read on X
1/ Forget COVID for a sec! Come read about ๐ŸŒŸ๐˜ฑ๐˜ญ๐˜ข๐˜ค๐˜ฆ๐˜ฃ๐˜ฐ๐˜ด๐ŸŒŸ instead.

Is placebo effect as powerful as some suggest?
Not really.
But it's surprisingly consistent, & that has important implications in medicine.

I dug up an old student presentation on them.
Letโ€™s dive in๐Ÿงต Quote from Emile Coue "...
2/ The term was 1st used in medicine in the 1800s: Treatment "adapted more to please than to benefit".

Even then, the importance of suggestion/placebos/bedside manner/whatever you call it was known to be tremendously important.
3/ A famous early Placebo-controlled trial (i.e. comparing the "treatment" to an identical sham) used wooden rods in place of Perkins Tractors, which were metal rods made of supposedly "special alloys".
It showed they were no more effective in managing the advertised disorders Front cover of early study ...
4/ But the idea of a placebo control is much older. The Catholic Church for example used "fake" holy objects in people claiming to be possessed.

If your subject reacted to fake holy objects, you could thankfully remove demons from the differential. ๐Ÿ˜ˆ Painting of Saint Francis B...
5/ In the 20th century, Pharmacist & Psychologist ร‰mile Couรฉ heavily promoted placebos & "autosuggestion". He'd famously talk up how good his pills were to his patients to boost their effect.

And indeed, placebos were used in everyday medicine until later in the 20th century. Photo of Emile Coue
6/ Placebos eventually fell out of favour once there were more discussions of how unethical it was to lie to patients.

Placebo controlled trials became a gold standard in research in the 1960s.

And the 70's-90's boasted some of the wildest studies ABOUT placebos ever.
7/ BLACKWELL (1972)

Take some med students.
Give em blue or red capsules.
Tell em it's either a sedative or stimulant.
It's all placebos (hehehehe)

End:
- 2x likely to report being LESS alert if they got blue.
- 3x as likely to have "severe" effects if they got 2 caps vs 1. Chart summarizing student r...
8/ COOPER & BRANTHWAITE (1981)

Women given placebo or Aspirin in either fancy or plain packaging.
Told to take as needed for headaches and record response.

END:
- Expected distribution, but fancy placebos were closer to unbranded ASA in response rate than to bland placebos. Chart summarizing patient r...
9/ MONTGOMERY & KIRSCH (1996)
Make fake "topical anesthetic"
Make scientific finger torture device
Sign college kids up to test them

END:
- Placebo consistently reduced intensity, unpleasantness, and dimension of painful stimuli to a SMALL but STATISTICALL SIGNIFICANT degree. Photos of finger pressure d...
10/ CRAEN & MOERMAN (1999)
Now it gets weird.

Meta-analysis of 79 trials of *endoscopy-confirmed* GI ulcers from โ€™77 to โ€™94
Compared twice daily vs 4 times daily placebos

END:
4x daily placebo 6-8% more likely to lead to resolution at 4wks (statistically significant). First page of study
11/ And more recently?

2013 - Actual vs sham surgery for degenerative meniscal tear.
Sham: Rolled into OR, knocked out, legs moved around, covered in bandages.
Used LKSS scoring scale for benefit.

END:
- Surgery: 21.7 point improvement
- Sham: 23 point improvement First page of study
12/ โ€œWhat else you got?โ€

- Acupuncture's effect determined by pt's expectations
- Salin inj > capsules > tablets in placebo effect.
- Opposite of placebo effect: nocebo, or negative rxn to inert Rx. often caused by anxiety

I could go on.
13/ โ€œThis is interesting, but is it useful?โ€

I think so!

Lesson 1) The ritual of medicine is important. Not just in the intervention, but feeling safe, heard, and supported has consistent benefit.

Ted Kaptchuk has written and talked a lot about this.

tedmed.com/talks/show?id=โ€ฆ
14/ Lesson 2) Placebo effects can be manipulated, and we need to pay attention to how placebo-controlled trials actually blind their participants.

Also makes comparison tricky. Did you know placebos in antidepressant trials have become more effective?

Walsh et al (2002) Chart by Walsh et al showin...
15/ Lots of theories about that^ phenomenon. I think it's because we simply understand depression better. Many older trials were short by today's standards. We have a greater understanding that depression is a long game, and it'll vary over time. Newer trials were longer too.
16/ See below the sources used for the presentation/this tweetorial. Apologies for it being an img. If you have any issues finding a source let me know and I'll try to pull it up.

#TwitteRx #MedTwitter #psychtwitter #Placebo #scicomm ImageImageImage

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More from @TheAmirImani

Dec 28, 2022
This is your periodic, completely random recommendation to not let a chiropractor touch your neck.
Bonus comment: (Actual) medicine is a balance of risks and benefits.

If your intervention has no proven benefits, then any risk is unacceptable.
If you're wondering how common the injury like dissection & stroke is, the answer is we don't know because there's no proper reporting system or attempt to gauge incidence. They'd rather pretend this doesn't happen.

ED/neuro/vascular docs can tell you differently.
Read 7 tweets
Mar 5, 2022
โญ Transplant immune suppression failure from St John's Wart

โญ Kidney stones from high dose vitamin C

โญ Blunted response to platinum-based chemo due to antioxidant supplement

โญ๏ธ Hypercalcemia and falls from high dose Vit D
โญ Diarrhea from magnesium supplements

โญ Chronic insomnia from a supplement secretly containing banned stimulants

โญ Liver failure requiring transplant from a contaminated herbal product

โญ Antibiotic AND thyroid supplement failure from crazy iron use
โญ Stomach bleed from new turmeric supplements while on an anticoagulant (had been warned about this)

โญ Liver injury from secretly taking their own pills in addition to hospital meds at the same time.

โญ๏ธ Fainting from "vitality supplement" "contaminated" with Viagra.
Read 5 tweets
Apr 5, 2021
1/ The message is consistent: Variants are causing more severe infection in younger people.

Youโ€™ve seen the stories of 30-40 year olds in the ICU, on heart/lung machines, and dying.

So from a rehab hospital, let me tell you about some of the survivors. ๐Ÿงต
2/ We see #COVID19 survivors of all ages. Early 30s to late 90s.
- Severe cases often have some lung injury.
- Many develop heart issues or have existing ones worsen.
- Going from โ€œfrequent hikesโ€ to โ€œneed to catch my breath halfway up a flight of stairsโ€ is a common complaint.
3/ - Some developed nerve injury, especially if they needed long ICU care.
- Same with kidney injury.
- Oh ya, and LOTS of clots. Usually have to continue blood thinners here. 1/5 ppl hospitalized with COVID develop clots.
Read 10 tweets
Feb 14, 2021
1/ Plenty of people like @deonandan and @DeNovo_Fatima have made great points on the #VitD buzz. Here's my 2 cents.

Title:
๐‘Šโ„Ž๐‘ฆ ๐‘Ž๐‘Ÿ๐‘’ ๐‘š๐‘œ๐‘ ๐‘ก ๐‘ ๐‘๐‘–๐‘’๐‘›๐‘ก๐‘–๐‘ ๐‘ก๐‘ /๐‘‘๐‘œ๐‘๐‘ก๐‘œ๐‘Ÿ๐‘  ๐‘ ๐‘ข๐‘โ„Ž ๐‘๐‘ข๐‘ง๐‘ง๐‘˜๐‘–๐‘™๐‘™๐‘  ๐‘Ž๐‘๐‘œ๐‘ข๐‘ก ๐‘‰๐‘–๐‘ก ๐ท ๐‘Ÿ๐‘–๐‘”โ„Ž๐‘ก ๐‘›๐‘œ๐‘ค?

Man I suck at titles.
๐Ÿงต
2/ Let's start with 2 summaries. All sources at the end.

๐—ง๐—Ÿ;๐——๐—ฅ #๐Ÿญ - For most people, it's safe to take anywhere from 200 to 4000iu of Vit D/day.

We just don't want ppl to think these pills are an alternative to social distancing,๐Ÿ˜ท, or medical help if you're sick. E.g. โฌ‡๏ธ
3/ ๐—ง๐—Ÿ;๐——๐—ฅ #๐Ÿฎ - There's a TON of uncertainty w/ #VitaminD.

๐‘จ) Weโ€™re not totally sure what Vit D level people need

๐‘ฉ) Weโ€™re not sure if levels behave like a phase reactant

๐‘ช) We're not great at measuring levels

๐‘ซ) Weโ€™re not sure how much supplements help
Read 23 tweets
Jan 1, 2021
When pts ask me why I'm skeptical of #supplements by default, I give examples to highlight the lack of regulation+data. I wrote some here.

Title: โ€œSome reasons I'm cautious with supplements and would rather you get the nutrients in your diet"

Rolls off the tongue, I know.๐Ÿงต
1) The largest trials of antioxidant ๐Ÿ’Šshowed they donโ€™t โฌ‡๏ธrisk of cardiovasc events, diabetes, cancer, or cognitive decline.
Some showed โฌ†๏ธhemorrhagic stroke and prostate cancer, but itโ€™s inconsistent.

pubmed.ncbi.nlm.nih.gov/17698683/

pubmed.ncbi.nlm.nih.gov/19066368/

ncbi.nlm.nih.gov/pmc/articles/Pโ€ฆ
2) Vitamin C pills failed to โฌ‡๏ธ the risk of getting a cold in trials of the general population. Starting it AFTER you get a cold doesnโ€™t seem to help.
But if you take it regularly and get a cold, it might be 8% shorter ๐ŸŽ‰

cochranelibrary.com/cdsr/doi/10.10โ€ฆ

Kids might be another story tho
Read 8 tweets

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