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Counterfeit Placebos

Last week it was reported that police in Bangladesh had made a major bust at a factory that was producing counterfeit homeopathic drugs. The counterfeiters were attaching the labels of other drug producers to the remedies they were producing in their own factory. Dhaka's Daily Star reported the bust with the rather ironic headline "Fake Medicine Factory Busted".

Of course, even homeopathic remedies need to be guaranteed safe if they are sold in stores, and counterfeiters are not bound by the same safety controls as other more reputable sources. There are also 'intellectual property' issues concerning the use of other company's labels and trademarks. So I am not here to tell you that this drug bust was unnecessary or ridiculous. In fact I want to challenge The Star's implicit suggestion that homeopathic remedies are by their nature counterfeit therapies.

I should acknowledge right away that homeopathic medicines don't do anything beneficial in any kind of pharmacological or somatic sense. In homeopathic theory, dilution is not considered to reduce the effectiveness of a treatment. This is why you can sell a preparation of homeopathic chamomile even when the chamomile is so dilute that there is not even a single molecule of chamomile left in the preparation. In other words, homepathic medicines work (when they work) through the placebo effect.

So how is it that some trials have found that these medicines work better than placebo? The answer, put simply, is that some placebos are better than others. The distilled water and sugar pills that are used as placebos in clinical trials make particularly bad placebos. To explain why, it helps to look at another kind of 'fake' medicine.

In 2008, Kirsch et. al. published a paper which showed, fairly convincingly in my view, that the entire  multi-billion-dollar industry in antidepressants is involved in the sale of placebos. There are two reasons this discovery has gone largely unheralded in the ethics literature and the popular media. First, Kirsch titled the paper "Initial Severity and Antidepressant Benefits: A Meta-Analysis of Data Submitted to the Food and Drug Administration", which doesn't exactly roll off the tongue. And second, antidepressants — despite being placebos—work extremely well. 60% of people see a significant reduction in depression when they take a course of these drugs, significantly better than the number who improve after taking an inert sugar pill placebo.

How can it be that antidepressants are simultaneously placebo-based and significantly better than placebo? I won't rehearse Kirsch's findings here, but part of the answer lies in the fact that antidepressants — unlike sugar pills — make really excellent placebos. The placebo response depends on an unconscious association between drug-taking and medical benefits, so the best placebos are those that best mimic active therapies, warts and all. If a placebo gives you insomnia, nausea or headache (as prozac can) or if it tastes bad (as a not-too-dilute infusion of chamomile might) then you will associate it strongly with active medications you have taken in the past, like pseudoephedrine, which causes insomnia and tastes bad.

The problem with homeopathic remedies is not that they are no better than placebos. Placebos can be wonderful and powerful drugs, and when they are used to treat the felt symptoms of a disease (such as pain or depression) rather than the underlying biological processes behind it, there is nothing fake or counterfeit about them. The problem with most homeopathic remedies is that they are often just too weak and bland to make decent placebos.

As well as making sure that the factories manufacturing them are producing safe, non-toxic remedies, we should make sure that their homeopathic products taste bad and produce mild, reversible, unpleasant side-effects. A slightly sickening, slightly revolting placebo would not be a counterfeit medicine at all.


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4 Comment on this post

  1. I’ve read, although I have no sources to back the claim up, that placebos are also more effective when they take the form of large brightly coloured pills rather than small, easily-swallowed ones, and possibly also that more expensive placebos work better too. This would correlate with your suggestions above.

  2. Chapter 5 of Ben Goldacre’s ‘Bad Science’ will help you out there Daniel. Yellow is best for treating depression, green for anxiety, and pink for improving concentration. In addition, 4 pills are apparently better than 2. The references to the relevant studies are in the back of the book. he also notes how the pharmaceutical industry have cottoned onto the colour thing and seem to colour their drugs accordingly.

  3. Even if some placebos are more effective than others for the reasons given, isn’t it still the case that a placebo is necessarily in some case “fake” because it relies on deceipt? More importantly, if the benefit is the result of believing something that isn’t true, is there not a risk that the costs might outweigh the benefit because of the inherent unhealthiness of harbouring false beliefs?

    To be clear: I am not suggesting that we rush to ban placebos, or for that matter hat we should rush to convince people that they should stop taking their homeopathic remedies. But I think we should be cautious in recommending them, even the particularly nasty-tasting, nauseating ones. Better, surely, to instil in ourselves and others the ability to nurture beliefs that are neither true nor false but positive and self-fulfilling. And then perhaps we can even do without the bad taste.

  4. One of the main problems with homeopathic medicine is that it is very often used to treat the “biological processes” “underlying” (or “behind”) serious diseases and serious health problems. To be sure, although I have not bothered to look for relevant statistics, the homeopathic industries explicitly purport to treat precisely the biological processes underlying serious diseases/health problems as opposed to mere symptoms. Besides the problem of not appropriately controlling for different kinds of different placebo effects, virtually all (if not all) of the studies demonstrating the effectiveness of homeopathic treatments for the biological processes underlying serious diseases/health problems appear in pseudo-medical journals produced by the homeopathic industries. (In addition, virtually all, if not all, attempts to reproduce the results of those studies – with appropriate trial controls and statistical analyses – in mainstream medical labs/hospitals and published in mainstream medical journals fail – fail to reproduce the results of those studies.) Anyone who both does not benefit from the homeopathic industry and who has counterexamples to any of these claims, please correct me.)

    My narrow mind does not see any good reason to promote, or speak positively, of placebos as appropriate treatments for anything, including the mere symptoms of diseases (mostly for concerns involving reliability and inappropriate substitutes for more effective treatments, for instance). The effectiveness of using placebos to treat symptoms of trivial health problems seems to depend on patient ignorance and/or self-deception. To be sure, in order to preserve such placebo effectiveness, it seems necessary to promote and preserve patient ignorance and self-deception (as opposed to patient information, understanding, and education about the subtle details of placebo effectiveness, alternative treatment options and how they work, etc.).

    Appropriate remarks about depression of course depend on the contextual details of the depression. For instance, placebos cannot treat well, or cannot treat well for long, depression caused by character/personality traits/disorders that cause patterns of behavior which repeatedly lead individuals into the kinds of situations or relationship dynamics that tend to correlate with depression.

    Perhaps there is no danger in using placebos to treat mild symptoms of trivial health problems. The main problem with homeopathy is both that it aims to treat the biological processes underlying serious diseases/health problems and that expert practitioners of homeopathy do not restrict their treatments to mild symptoms of trivial health problems. These contingent but persistent and longstanding features of homeopathy lead me to hold the sorts of views expressed in this comment.

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