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Comment by johndhi | Hacker News Reader

Open placebo studies are super interesting to me. One of the difficulties of pharma is proving efficacy over placebo... because placebo is a very strong factor! I feel like we could, as a medical community, leverage placebo to improve health outcomes much better than we do today. Why not? It seems the only reason not to is some weird Victorian notion about the capital-T Truth.

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If a doctor gives you a placebo, you only get the placebo effect. If a doctor gives you medicine, you get the placebo effect plus whatever extra benefit the medicine provides.

We already are leveraging the placebo effect, unfortunately we are also doing it in a negative way by highlighting side effects.

> the placebo effect plus whatever extra benefit the medicine provides.

Plus, the act of noticing those extra effects can give you another placebo effect on top, e.g. if the medicine has some noticeable effect, the placebo can get stronger, or cause other effects to accompany it.

Of course there is also consciously learning to leverage the effects of the medicine, which is a non-placebo~

For some medications those side effects can be severe though - I think there's some rationale in actually purposefully leveraging the placebo effect without giving the patient a medication that could harm them.

The side effects are also influenced by the placebo effect. Maybe they'd be less problematic, but they'd still exist.

We already have witchdoctors for that. I don't need my medical professionals trying to deceive me.

It's one thing if they tell me that a cup of tea helps some people with migraines, and is another thing if they're selling me sugar pills

Well, to be honest - that's kind of a uniquely American problem. Lots of places in the world don't have free pharmacare but only in America is the cost going to be so incredibly significant that the profit motive is strong enough to encourage charlantry.

I'm speaking from a non-American perspective.

Apparent post is advocating deceit, not for a profit motive but for patient benefit. This is what I disagree with.

I'm not saying anything about the profit motive. I'm saying that doctor should not lie and trick patients.

I mean, this might have been the case when standards of medical practice were so bad that the homeopathic hospital was one of the safest places to be because whilst the medical care there was purely placebo, that was better than a doctor with unwashed hands attempting crude surgery.

But modern treatments are evaluated based on having demonstrable net positive effects above and beyond placebo.

Close. If a doctor gives you a placebo, you can only get the placebo. No guarantee you will get anything, of course. You could also get the negative side effects of the real medicine, without any cure.

I think we already do. When you buy a bottle of decongestant with phenylephrine, you're just buying a bottle of placebo, and this is the most commonly purchased type of decongestant.

Thinking about this ticks me off every time it comes up.

For those unaware, phenylephrine should never have passed FDA trials. It was whisked through almost certainly at the behest of Johnson and Johnson to provide a replacement for the very effective psuedoephedrine, which happened to be a relatively easy methamphetamine precursor.

Then, for J&J to have the gall to market phenylephrine as "Sudafed" was just the cherry on top. I wasn't aware of all that at the time, but the first pill out of a box of new Sudafed was so ineffective compared to the previous pill from the old stuff that I had to look it up.

Wow. I had no idea, I've been taking that for years. It's in every single OTC cold and flu medication with painkillers.

I found this to be a good read/overview:

https://www.science.org/content/blog-post/uselessness-phenyl...

There was a famous study where the patients were told they were receiving a "pill with no medicine in it." It still resulted in measurable improvement.

The short version is that we do use it in some cases where there's a lack of other options. E.g. I can walk into the major pharmacy down the street and buy "earache medicine", which is (almost literally) just water. My insurance won't pay for something like acupuncture right now, but if I were undergoing cancer treatment, suddenly things like that would be partially covered in the name of "pain relief".

This treatment works well for irritable bowel syndrome. Not for everything, of course.

> One of the difficulties of pharma is proving efficacy over placebo

I guess that could be true in a very specific subset of medicine, but I cannot imagine that is true in general. As others are mentioning, the placebo effect already is part of the medicine, except in cases where the patient is medicated while in coma or things like that.

Do you have evidence to support your claim?

I think they mean it in the sense that when developing a new medicine whose degree of efficacy is unknown, you can't just test the medicine and show benefits. You need to test the medicine and separately test a placebo version of the treatment and show that the medicine (+the inherent placebo effect) is more effective than the placebo effect alone.

Ok but then the choice of words is not appropriate. It’s not “difficulty”. It’s just due diligence.

Needing to do the due dilligence is part of the challenge of doing pharma correctly, and thus, its difficulty.

That the work is necessary doesn't make it not part of the challenge.

How are you defining "difficulty" here?

I guess my point is that difficulty is a relative thing. It depends on the task and on the individuals performing it.

Paying people to do the testing properly and, collecting and organizing the results. Making all those schedules. Making sure that the math needs is solid. Founding volunteers. Etc. All of that. It costs a bunch of money.

In the abstract, it could be said that it is a difficult process. I would not would not be able to organize it.

But for the people who are involve in those tests, and that have done that kind of thing hundreds of times, that is not a difficulty. It's routine.

If we are going to define "a difficulty" that way, then anything that a big company does is "a difficulty".

I would absolutely consider many or most of the mandatory tasks of keeping a company, any company, running are the difficulties of having a company, regardless of how difficult any individuals at that company consider those tasks to be.

Yes, successful pharma companies are good at overcoming the challenges involved, some of which you listed. The point is that being able to do so is necessary for that success, and thus, an obstacle.

> some weird Victorian notion about the capital-T Truth.

Only if neither the patient nor insurance are paying for it. Otherwise that's just straight up grift.

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