Drugmakers Are Desperate to Find Out.. I became a web friend of Wired writer Steve Silberman because of the uncanny parallelism in our interests, and I usually post blinks to his thoughtful and important pieces. Here, he describes the difficulty drug manufacturers are having in distinguishing the efficacy of medications they are testing from that of the placebos to which they are compared. Perhaps surprisingly, the rates of placebo response seem to be growing, so that the claims for pharmacological effectiveness of their products are harder and harder to make. Big Pharma desperately wants to know why, both to succeed again in establishing the efficacy of the products they are developing and to capitalize on the placebo effect if they can find a way to bring it to market itself.
As Silberman describes, comparison with placebo has long been the gold standard in evaluation of drug efficacy. This has largely made the placebo effect a troublesome enemy of allopathic medicine. This is a weakness of those with a concrete, limited conception of how healing works. In fact, our understanding should be stood on its head. Instead of being a nuisance, the placebo effect may be the basis of most therapeutic effects, both in particular of the ‘magic pills’ we physicians give our patients and, more generally, of the healing relationship per se. I have long found it pitiful that most physicians do not see that much of what they are doing is mobilizing their patients’ intrinsic healing responses through enlisting them in a shared belief system. Of course, those healing responses have a physiological basis themselves. It is only the incredibly naive, for the past thirty or fifty years at least, who still must distinguish ‘mind’ from ‘body’ as if they are separate.
The placebo response may be getting stronger, if indeed it is, because it is more and more difficult to find subjects who are not in the grip of the Big Pharma Big Lie, in this era of TV advertising for prescription drugs and of physicians in the pockets of the manufacturers of the medications they prescribe.
The other reason it may be harder to distinguish pharmacological from palcebo effects is that drug development in the last decade or more has been largely a story of trying to squeeze larger and larger profits out of smaller and smaller distinctions in drug efficacy. There have been relatively few ‘breakthrough’ discoveries in pharmacology that have not been swamped by a rush of competing products consisting of slightly altered molecules claiming to be improvements but in reality serving only to establish or extend patent rights.
This is especially true in my own field of psychiatry. While there are certainly in some cases differences in individual patients’ responses to different medicines in the same class (say, for example, serotonin-reuptake-inhibiting antidepressants or dopamine-blocking antipsychotics). Prescribers, pitifully, trot out one after another drug in the same or similar class when a patient does not do well with an initial choice of medication, subjecting the patient to a futile and prolonged cycle of sequential expectation and disappointment. Even patients who are doing well on a medicatioon are often switched to far more expensive newer analogues which hit the market claiming to be improvements. And these claims are largely written by the ad copyists and marketing specialists rather than the scientists, who by and large cannot demonstrate advantages of their products in head-to-head comparisons with older, tried-and-true gold standard medications.
Finally, although I am not talking merely about the mental health domain when I argue for a broadened conception of how healing works, it is surely true that neurobiological and mental disorders have been one of the last frontiers in pharmaceutical development, and (along with a shift of emphasis to chronic diseases from the acute diseases with which medicine has had its greatest successes) a major focus in drug development in the last two decades or so. The placebo effect is probably at its strongest in the realm of behavioral disorders.