Mike Adams discovers the placebo effect. Hilarity ensues.

ResearchBlogging.orgIt’s Friday. That means I’m in the mood for something more amusing. In the past, I used to use Fridays to have some fun with some particularly outrageous bit of woo, such as quantum homeopathy or DNA activation. Lately, I haven’t done Your Friday Dose of Woo nearly as often as I used to, but that doesn’t mean that I don’t appreciate good woo when I see it. However, some bits of craziness just aren’t suitable for YFDoW not so much because they aren’t crazy enough but because of the deadly seriousness of the intent or because they lack that light-hearted bit of looniness that characterizes the very best woo. Either that, or they’re just as loony, but they are primarily based on an utter misunderstanding of science that, because it is so utter and willful, might end up being just as amusing as any installment of YFDoW but somehow leaves a bad taste in the mouth, which is why I don’t included the YFDoW tag on it.

Which brings us to Mike Adams.

Mike Adams, a.k.a. the “Health Ranger.” Adams veers wildly between hilarious and despicable in his nearly daily excretions on his website NaturalNews.com. He’s so hilariously off base whenever he tries to discuss science and medicine seriously that he never fails to give me a chuckle at his antics. Truly, there is no human being I can think of who is better at demonstrating the power of ignorance to entertain and inspire by provoking mockery. At least, he would, if it weren’t for the potential harm that comes from people actually listening and paying attention to his rants against science, science-based medicine, and anything that seems to him to have anything to do with those evil “pharmaceutical” medicines. Just such a rant appeared earlier this week entitled Nearly all drug trials scientifically invalid due to influence of the mind; Big Pharma science dissolves into wishful thinking.

Oh, looky. Mikey has discovered the placebo effect! And he hasn’t figured out that nearly all of the quackery he promotes only appears to work because of placebo effects! Indeed, he makes this clear from the very first paragraph:

A new study in Science Translational Medicine has cast doubt over the scientific validity of nearly all randomized, double-blind placebo controlled studies involving pharmaceuticals used on human beings. It turns out that many pharmaceuticals only work because people expect them to, not because they have any “real” chemical effect on the body. As you’ll see here, when test subjects were told that they were not receiving painkiller medications — even though they were — the medication proved to be completely worthless.

Here’s the study to which Adams refers.

Reading that paragraph exploded yet another one of my irony meters, of course. Not that I expect that Adams will ever reimburse me for their loss, or anything like that. The truly hilarious part about this paragraph is that Adams seems blissfully oblivious (or is being willfully ignorant) about how the vast majority of “alternative” therapies that he endorses only appear to “work” because of placebo mechanisms. (See? I can use bold text as well!) True, there are often also regression to the mean, confirmation bias, and confusing correlation with causation, but the main driving force for most “alternative” medicine therapies remains placebo effects. Think homeopathy, which is water. Think reiki, which is faith healing substituting Eastern mysticism for Christian beliefs. Think “therapeutic touch,” which does not involve touching and is not detectably therapeutic in any way.

Of course, scientists performing clinical trials already do their best to try to account for placebo and nonspecific effects. Why else do you think that in recent years physicians studying, for example, acupuncture have gone to such lengths to develop retractible needles and various other devices designed to hide from both the patient and practitioner whether or not the needles have actually penetrated the skin or designed studies such that acupuncture needles were placed in the “wrong” places in control groups? And, guess what? The results of those studies have been resoundingly negative, with acupuncture performing no better than placebo or “sham” acupuncture. This is but one example.

Before I look at the rest of Mike Adams’ rant, what was this study, and what did it really show? After all, usually Adams’ description of a what a study shows and what the actual study shows are related only by coincidence. Either that, or Adams is very good at ignoring the nuance and qualifications, misrepresenting a study as somehow condemning all of medicine, which is what he does right here when he states:

As pointed out by George Lewith, a professor of health research at the University of Southampton, these findings call into question the scientific validity of many randomized clinical trials. He said, “It completely blows cold randomized clinical trials, which don’t take into account expectation.”

Actually, I tried, but couldn’t find this quote from George Lewith in the BBC article reporting this study, which makes me wonder whether it was removed from the article. Perhaps this is an example of nefarious pharma-whores swooping in and complaining, as Majikthise did when she complained about the reporting on this article. Of course, these sorts of stories about this study are usually at best clueless or lazy reporting. Adams goes far beyond that into twisting the story and study into his ideological pretzel. Indeed, the hypothesis that expectancy effects can influence the level analgesia achieved by pain medications is nothing new; it’s been known for decades at least. Yet Adams treats this study as though it’s a bolt out of the blue, without context or nuance. I know, I know, it’s Mike Adams. What else would we expect? What makes this study interesting are the study design and the state-of-the-art brain imaging that allowed scientists to hone in on the areas of the brain responsible for expectancy effects. The investigators summarize it this way in the introduction:

Placebo analgesia represents the best-studied placebo response (4) and is mediated by an activation of the opioid-dependent endogenous pain modulatory system (5-7). Nocebo effects, including nocebo hyperalgesia, are less well investigated but have also been associated with an interference with the endogenous opioid system (8). The effects of positive or negative expectation of the effectiveness of the treatment may therefore be mediated by the same biological systems through which drugs exert their treatment effects.

However, placebo and nocebo experiments have been performed with biologically inert compounds, the use of which in daily clinical practice is constrained by ethical and legal limitations (9). Knowledge regarding the effect of psychological factors on the efficacy of active pharmacological treatments is surprisingly sparse. Furthermore, there is scant information about the neural mechanisms by which the effects of expectations interact with the pharmacological effects of biologically active drugs. However, behavioral observations from studies that compared the open and hidden application of drugs or explicitly modulated the expectancy regarding a given drug by verbal instruction show that psychological treatment effects can influence drug efficacy (10-17).

In the experimental design, the investigators studied the effect of positive and negative expectations on the efficacy of an analgesic (the u-opiod antagonist remifentanil) at a standardized infusion rate related to the patient’s weight, age, and gender. Twenty-two patients were hooked up to an IV and monitored by an anesthesiologist, so that they were blinded to whether they were receiving opiate or saline solution. They were then subjected to heat to a level that causes pain and told to rate their pain on a scale of 1 to 100. The initial mean pain rating among the subjects was 66 (baseline). Subjects were then administered remifentanil without being told that they were receiving it (no expectancy), after which the mean pain score declined to 55. Next, they were told they were being given a painkiller (positive expectancy), and the score declined further, to 39. Finally, without changing the dose, subjects were told that the opiate was being turned off and that they should expect that their pain would return (negative expectancy). Their mean scores then returned to 64, which is a level that was statistically indistinguishable from no drug at all. The results are summarized in the graph below:

i-35f45151cf50d04ae60c3bfed3dee38f-expectation1.jpg

While the patients were undergoing these procedures, their brain activity was measured using functional MRI, which revealed that the observed placebo and nocebo effects were reflected by changes in activation of core areas of the cerebral pain network, including the insula, bsal ganglia, contralateral thymus, and brainstem, including the periaqueductal gray. The authors conclude:

Our results suggest that a consideration of the contribution of negative experience and expectancy to analgesic efficacy is necessary, but the conclusions may also apply to any pharmacological treatment, particularly in chronic disease. A new and systematic appreciation of the role of individual differences (genetic, psychological, and neurological) among humans is ushering in the exciting possibility of personalized medicine. Understanding and controlling the psychological context in which medicines are delivered will be an important part of making this move from the general to the personal successful.

Basically, this study demonstrates that expectancy effects can be more powerful than we had previously thought. In this one artificial situation, such effects were capable of boosting analgesia significantly or completely wiping out the apparent effect of the analgesia. These results, if confirmed (and, remember, this is a very artificial situation using only one drug and one painful stimulus), they do suggest that more care might well be needed to take into account the power of expectancy effects. What this study does not mean is what Adams says:

This leads to the fascinating conclusion that in today’s medical system, many drugs may only work when patients expect them to because it is the patient’s mind creating the physiological effects, not the drug itself.

No, not exactly. Adams has taken one trial of one drug and one physiological effect (pain) and generalized it to all pharmaceuticals, which is, of course, utterly ridiculous. Let’s just put it this way. There’s no good evidence that expectancy, either positive or negative, will determine whether a chemotherapy agent eliminates your cancer. Of course, when you live in a world of fantasy, like Mike Adams, that leads to some true howlers. For example, he states that the only way to design a “truly scientific” clinical trial is to completely eliminate expectancy effects this way:

The answer to that is simpler than you think: In humans, you must eliminate the trial subjects from learning of any expectation of the drug’s effects. In other words, you can’t sign patients up for a “blood pressure drug trial” because right there you’ve set the expectation that the drug will lower blood pressure.

You essentially have to sign people up for a trial of a “mystery drug” with no expectation of any effects whatsoever. That way, the mind of the study participants is no longer a variable in the outcome of the drug trial. From there, all the various physiological effects of the patients must be tracked. With the patients’ minds now out of the picture, you can get an honest assessment of the genuine chemical action of the drug itself.

He then goes on to note that it is “fascinating” that no drug trials are performed this way. Never mind that, even if Adams weren’t a stark, raving loon about this study and were completely correct in his claim that the way to overcome placebo effects would be to eliminate any mention of what a drug is supposed to do in the patient education literature for the trial, such a trial as the one Adams describes would be completely unethical. The reason would be because informed consent would not be possible in such a trial. Besides, there are ways to control for placebo and expectancy effects that have been used for decades. Indeed, doing so in more rigorous clinical trials of CAM interventions is exactly what has led to the conclusion that the vast majority of such interventions only appear to “work” because of placebo and expectancy effects. What this study does is to raise the bar; it tells us that, for measures with a major subjective component at least, such as pain, anxiety, depression, etc., we need to be more careful than perhaps we have been in designing clinical trials to take into account expectancy effects. That’s all. It’s science building on previous results and refining what we know about expectancy. It’s also an unreplicated study. Remember the “decline effect”? It wouldn’t surprise me in the least if future studies designed like this one found that expectancy effects were not as large as to be able to eliminate the analgesic effect of a powerful opiate. At the very least, what I would expect in future studies is that the magnitude of these expectancy effects will likely vary depending upon the symptom measured and the specific drug used. Not that any of that stops Mike Adams from doing what Mike Adams does and dismissing all clinical trials based on a small, provocative study of 22 subjects! It’s a friggin’ pilot study, and Adams is ready to declare all of clinical science invalid based just on this!

But that’s not all. This is, after all, Mike Adams. Simply invalidating all clincial trials of pharmaceuticals based on an intriguing pilot study is not enough for him. Oh, no. He has to proclaim science as having rejected the “mind”:

That is why the pharmaceutical industry is trying to deny the existence of the mind. It’s why medical journals are reluctant to publish studies that invoke the power of the mind, and it’s why medical schools refuse to teach medical students about mind-body medicine.

The placebo effect — perhaps the single most powerful tool for healing — is utterly discarded as worthless by the entire medical profession!

The mind is so powerful that it can render drugs obsolete. When doctors truly understand and are able to harness the power of the mind, they won’t need routine pharmaceuticals. They will only need to empower patients with the factually correct belief that they have the power to heal within them, and chemical drugs have only been symbolic metaphorical chemicals that allowed the mind to believe healing was taking place.

This is a cultural issue, of course. The culture of our modern world is one of reductionism. Western science refutes the power of the mind and denies individuals the power to heal. Healing must come from external intervention, we are taught: through chemicals, radiation or surgery.

In a parallel world, with the exact same biology, consciousness and environment, another race of human-like creatures might have chosen a different path — the path of patient empowerment where doctors are mere guides who teach patients how to heal themselves. Healing is a personal art, done from the inside out, not through dangerous chemical interventions. All that is necessary for this parallel world to become a reality is a shift in the beliefs of the people. When society accepts as real the power of the mind, it suddenly becomes believable to the weak-minded masses who always look to figures of authority to tell them what’s real.

But the deeper truth of the matter is that what’s real is what you make real. Your mind, all by itself, can alter your physiology, neutralize toxic drugs, halt pain and probably even achieve other seemingly miraculous feats such as re-growing lost limbs. What’s necessary to get there isn’t technology but rather belief in the ability of the mind to shape the outcome of the body.

“What’s real is what you make real”? Geez. What is this but The Secret, the New Age belief that you can have anything you want if you just want it badly enough, that you draw what you want to you? In other words, wishing makes it so! Although there is a grain of truth to such beliefs (wanting something and taking positive steps to pursue it are far more likely to lead to obtaining it than not wanting it and not taking steps to pursue it), at its core Adams’ Secret-like wishing is a profoundly childish belief based on fantasy and desire rather than science. What’s even more mockery-worthy is that Adams seems to think that the power of the mind could even regrow lost limbs! Good luck with that, Mike. One pictures Adams, having lost a limb in a traumatic accident, staring at the stump and wishing fervently for his limb to grow back. A pathetic image, but no more pathetic than Adams’ apparent belief that he could do that if only those horrible reductionistic scientists would see things his way and start studying his woo.

Moreover, it’s a massive straw man to claim that scientists “deny” the existence of the mind? WTF? Science does not deny the existence of the mind. Rather, modern neuroscience is consistent with the hypothesis that what we call “consciousness” or the “mind” is nothing more than the product of the brain. In other words, there is no magical, mystical “mind” that is separate from the nervous system. That’s all. Adams is simply asserting a mind-body duality that science has failed to confirm, and, again, he’s doing it on the basis of a study that is not only a small pilot study but that actually implicates a neurological mechanism for placebo and expectancy effects.

When I see a screed like this one, I have to wonder whether Adams truly believes what he is saying. Given his Internet empire built on snake oil, I often think that he must know that what he’s saying is complete nonsense and that he says it anyway out of utter contempt for his readers and followers. On the other hand, he asserts such nonsense with extreme confidence and with such vehemence, such that at times I think he really does believe it. Only Adams knows for sure which is the case, and he might well be deluding himself. Whatever the case, no misrepresentation of science appears to be too egregious for him.

REFERENCE:

Bingel, U., Wanigasekera, V., Wiech, K., Ni Mhuircheartaigh, R., Lee, M., Ploner, M., & Tracey, I. (2011). The Effect of Treatment Expectation on Drug Efficacy: Imaging the Analgesic Benefit of the Opioid Remifentanil Science Translational Medicine, 3 (70), 70-70 DOI: 10.1126/scitranslmed.3001244