Placebo :
- Sumit Goel.
PLACEBO is a term used for a pharmacologically and pharmacodynamically inactive substance administered to a patient during the course of therapy when no active drug treatment is indicated. (Placere = to please; Placebo = I shall please)
Placebo effect is any change in symptoms or signs that is not due to the specific physico-chemical effect of the placebo 'agent'.
INDICATIONS OF PLACEBO IN HOMOEOPATHY
* Indisposition and Artificial Chronic Disease
Not every case encountered in medical practice calls for a medicine. A homoeopathic similimum may not be required in cases of indisposition (aphorism 150) and those ill-health due to exposure to avoidable noxious influences, who are in the habit of indulging in injurious liquors or ailments, are addicted to dissipation, who undergo prolonged abstinence from things necessary for support of life, who reside in unhealthy localities, who are deprived of exercise or open air and who ruin their health by overexertion of body or mind (aphorism no.77). The treatment, in such a case may only require the searching out and correcting of the diet, regimen and mode of living of the individual.
Having discovered such a case, the question arises of management of this case. It might seem very simple, merely to tell the patient bluntly that he does not require medicine, but only to mend his life and correct his habits. This view does not take into account, the peculiarities of human nature. Rarely we meet a patient to whom we can give an ideal advice. The average patient who goes to a doctor expects to get medicine. He often resents the assertion that his trouble is due to his own ignorance. To direct the attention to his errors of living and order him to correct them is to apparently put the burden of cure upon him and this is not what he wants. The patient expects the doctor to bear the burden.
Majority of the people seeking medical advice want something tangible to take away to show them, remind them, perhaps even convince them daily that something is being done for them. Placebo, in such cases comes to the rescue of a homoeopathic physician.
Some patients come to the physician at every change of the wind, at every attack of snuffles the baby has, at every little headache or every little pain. If the physician proceeds to change the remedy or prescribe for each one of these little spells of indisposition, one will, in the course of a little while, have such a state of disorder in the individual that one will wonder what is the matter with this patient. The physician had better give the patient no medicine at all, and if the patient is wise and strong and can feel confidence, no medicine is required; but occasionally a dose of constitutional medicine when these little attacks are not on. If not, give them placebo, and let the indisposition pass off of itself. Watch it, however, and it may at the close develop some constitutional manifestations that need to be treated with the suitably selected homoeopathic similimum.
* If you are not sure, give placebo When a physician is called to a new case, a decision is made for medication. The case may be difficult and the physician may be unable to decide offhand what remedy is indicated. Time and opportunity is required to study it up. To make a mistake in the first prescription might be fatal or it might prejudice the case by confusing it, so that a quick and satisfactory cure would be impossible. The confidence of the patient has to be retained as well as a cure has to be effected. Administer the remedy at once if you are sure of it, but not otherwise. If you are not sure, give placebo. In most urgent cases one should not hesitate in referring to the literature and prescribing, even in the presence of the patient!
* The indicated remedy must be given time to act The same course is followed when treatment is begun with single dose. The best remedy in Materia Medica is the indicated remedy, which when administered must be given time to act and its action must not be interfered with by other drugs or influences until it has accomplished its utility. Also too many doses of the best remedy may spoil the case. This is also true of cases where the medicine has to be given at a particular phase of the disease, as in case of intermittent fevers. Hence, administer the second best remedy - placebo.
* A supplement to the indicated remedy Another use of placebo is as a supplement to the indicated remedy. Hahnemann advocated the use of sugar of milk following the giving of a remedy in order to allow the latter to unfold its activity in its entirety. The remedy should be stopped as soon as signs of improvement appear. When improvement begins and one desires to cease medication, simply substitute placebo for the remedy and observe. If patient is improved give placebo, and give this again and again, so long as improvement continues. Even the particulars, unless dependent on a mechanical cause, should disappear. If patient goes back and symptoms remain the same, repeat same remedy and same potency. If it ceases to hold so long, and symptoms return, give same remedy in higher potency. And again, and again followed by placebo, so long as improvement continues, probably for a longer time. If symptoms change, and yet the patient feels better, still give placebo. These may be a return of old symptoms, on the road to cure. Patient may be doing his return journey, especially if they reappear and die away, in the reverse order of their appearing years ago (Hering's law). If the symptoms change, and are not a return of old symptoms, and the patient is not improving, reconsider the case and give the new drug that now fits the altered condition.
Sometimes quite definite aggravations follow a good homoeopathic prescription when too low a potency is employed, and the physician may think that the case has become worse. All this emphasizes the fact that homoeopathic drugs dare not to be lightly used, and their reaction is to be carefully watched for. During the interim, the patient's natural anxiety in regard to medicine is to be taken care of by judicious resort to a placebo.
In cases of homoeopathic aggravation (Aphorism no. 280), Hahnemann advises - 'In order to be convinced of this, the patient is left without any medicine for eight, ten or fifteen days, meanwhile giving him only some powders of sugar of milk' (aphorism 281).
* Let the case clear itself - to form a faithful picture of the disease " When the disease is of a chronic character, and the patient has been taking medicine upto the time he is seen, the physician may with advantage leave him some days quite without medicine, or in the meantime administer something of an unmedicinal nature and defer to a subsequent period, the more precise scrutiny of the morbid symptoms, in order to be able to grasp in their purity the permanent uncontaminated symptoms of the old affection and to form a faithful picture of the disease. (Aphorism no.91)
At times a patient will present himself, and the physician will be able to get a true image of the sickness by ascertaining all the things that occurred up to a given date. "Upon that date," the patient mat say "I took some medicine, and most of my symptoms, subsided." They lead to another image from which the physician can gather nothing; a scattering has taken place. The symptoms may cover page upon page, and yet no remedy may be clear. None at all; it looks as if a number of provings of drugs had been mixed up all together, intermingling symptoms here and there without any distinctness. No individualization is possible. Administer placebo let the portrait clear.
"Besides this, patients themselves differ so much in their dispositions, that some, especially the so-called hypochondriacs and other persons of great sensitiveness and impatient of suffering, portray their symptoms in too vivid colours and, in order to induce the physician to give them relief, describe their ailments in exaggerated expressions" ('96). It is here that the physician needs to give them something of an unmedicinal nature, observe with freedom from prejudice and trace the accurate portrait of disease.
* Psychotherapy!
The use of placebo is one form and a very powerful form of therapeutic suggestion - psychotherapy. There is evidence that mood or emotional state of a person affects markedly the manifestation of disease, the action of a drug and the process of cure. Experiments and studies have shown that the effect of placebo can mimic the most profound healing responses. The process of homoeopathic interview combined with the expectations of the patient seeking homoeopathic cure may enhance the placebo response itself. Thus, homoeopaths interested in distinguishing the action of homoeopathic remedy from that of placebo response must reasonably begin each case with placebo - " the second best prescription" or maybe the first.
* Homoeopathic drug provings
Placebo is also a very vital member of 'controlled, double blind therapeutic and proving trials!
Influences and bias on the part of provers and the investigator can significantly modify drug responses, interfering with the interpretation of the therapeutic efficacy of a drug. In order to avoid such complications, dummy preparation or substitute drug i.e. placebo is employed, which should be of the same colour and texture as that of the test substance and should be administered in the same way as that of the experimental group.
DISPENSING OF PLACEBO
Placebo is dispensed in the same way as homoeopathic medicines via the same vehicles used for dispensing of medicines.
Vehicles for dispensing of placebo
* Sugar of milk: Care should be taken to enclose an unmedicated globule or a drop of dispensing alcohol.
* Tablets, globules, pillules or pellets: These should be moistened with dispensing alcohol.
* Distilled water, simple syrup.
Dispensing routine
* Instruct and advise the patient as regards the correction of diet and regimen as well as other auxiliary modes of management.
* Confidently prescribe placebo! (without disclosing the identity of the prescription)
A variation in the type of dosage form or even the size of the globules can be effectively used to produce the placebo effect
* They should be bestowed with impressive directions as to the exact number of pills for a dose, the manner of intake and the precise hours of intake!
* Give enough doses to last the interval between two visits as well as instructions when to report back.
* The labeling of the placebo doses should be appropriate and should not reveal the identity of the placebo. The label should carry an identity like 'phytum', rubrum', 'nihilinum', 'lactopen', '( pills', 'S.L., etc. It should also carry potency at random, as patients have a way of investigating their medicine. Any identity for the placebo can be assigned, provided it is not the name of an already existing drug and there is an understanding between the physician and the dispenser as to the nature of the placebo and prescription, to avoid all confusion in the dispensing of the prescription.
SELF ASSESSMENT
* What is placebo? When is placebo indicated? How will you dispense placebo?.
PLACEBO is a term used for a pharmacologically and pharmacodynamically inactive substance administered to a patient during the course of therapy when no active drug treatment is indicated. (Placere = to please; Placebo = I shall please)
Placebo effect is any change in symptoms or signs that is not due to the specific physico-chemical effect of the placebo 'agent'.
INDICATIONS OF PLACEBO IN HOMOEOPATHY
* Indisposition and Artificial Chronic Disease
Not every case encountered in medical practice calls for a medicine. A homoeopathic similimum may not be required in cases of indisposition (aphorism 150) and those ill-health due to exposure to avoidable noxious influences, who are in the habit of indulging in injurious liquors or ailments, are addicted to dissipation, who undergo prolonged abstinence from things necessary for support of life, who reside in unhealthy localities, who are deprived of exercise or open air and who ruin their health by overexertion of body or mind (aphorism no.77). The treatment, in such a case may only require the searching out and correcting of the diet, regimen and mode of living of the individual.
Having discovered such a case, the question arises of management of this case. It might seem very simple, merely to tell the patient bluntly that he does not require medicine, but only to mend his life and correct his habits. This view does not take into account, the peculiarities of human nature. Rarely we meet a patient to whom we can give an ideal advice. The average patient who goes to a doctor expects to get medicine. He often resents the assertion that his trouble is due to his own ignorance. To direct the attention to his errors of living and order him to correct them is to apparently put the burden of cure upon him and this is not what he wants. The patient expects the doctor to bear the burden.
Majority of the people seeking medical advice want something tangible to take away to show them, remind them, perhaps even convince them daily that something is being done for them. Placebo, in such cases comes to the rescue of a homoeopathic physician.
Some patients come to the physician at every change of the wind, at every attack of snuffles the baby has, at every little headache or every little pain. If the physician proceeds to change the remedy or prescribe for each one of these little spells of indisposition, one will, in the course of a little while, have such a state of disorder in the individual that one will wonder what is the matter with this patient. The physician had better give the patient no medicine at all, and if the patient is wise and strong and can feel confidence, no medicine is required; but occasionally a dose of constitutional medicine when these little attacks are not on. If not, give them placebo, and let the indisposition pass off of itself. Watch it, however, and it may at the close develop some constitutional manifestations that need to be treated with the suitably selected homoeopathic similimum.
* If you are not sure, give placebo When a physician is called to a new case, a decision is made for medication. The case may be difficult and the physician may be unable to decide offhand what remedy is indicated. Time and opportunity is required to study it up. To make a mistake in the first prescription might be fatal or it might prejudice the case by confusing it, so that a quick and satisfactory cure would be impossible. The confidence of the patient has to be retained as well as a cure has to be effected. Administer the remedy at once if you are sure of it, but not otherwise. If you are not sure, give placebo. In most urgent cases one should not hesitate in referring to the literature and prescribing, even in the presence of the patient!
* The indicated remedy must be given time to act The same course is followed when treatment is begun with single dose. The best remedy in Materia Medica is the indicated remedy, which when administered must be given time to act and its action must not be interfered with by other drugs or influences until it has accomplished its utility. Also too many doses of the best remedy may spoil the case. This is also true of cases where the medicine has to be given at a particular phase of the disease, as in case of intermittent fevers. Hence, administer the second best remedy - placebo.
* A supplement to the indicated remedy Another use of placebo is as a supplement to the indicated remedy. Hahnemann advocated the use of sugar of milk following the giving of a remedy in order to allow the latter to unfold its activity in its entirety. The remedy should be stopped as soon as signs of improvement appear. When improvement begins and one desires to cease medication, simply substitute placebo for the remedy and observe. If patient is improved give placebo, and give this again and again, so long as improvement continues. Even the particulars, unless dependent on a mechanical cause, should disappear. If patient goes back and symptoms remain the same, repeat same remedy and same potency. If it ceases to hold so long, and symptoms return, give same remedy in higher potency. And again, and again followed by placebo, so long as improvement continues, probably for a longer time. If symptoms change, and yet the patient feels better, still give placebo. These may be a return of old symptoms, on the road to cure. Patient may be doing his return journey, especially if they reappear and die away, in the reverse order of their appearing years ago (Hering's law). If the symptoms change, and are not a return of old symptoms, and the patient is not improving, reconsider the case and give the new drug that now fits the altered condition.
Sometimes quite definite aggravations follow a good homoeopathic prescription when too low a potency is employed, and the physician may think that the case has become worse. All this emphasizes the fact that homoeopathic drugs dare not to be lightly used, and their reaction is to be carefully watched for. During the interim, the patient's natural anxiety in regard to medicine is to be taken care of by judicious resort to a placebo.
In cases of homoeopathic aggravation (Aphorism no. 280), Hahnemann advises - 'In order to be convinced of this, the patient is left without any medicine for eight, ten or fifteen days, meanwhile giving him only some powders of sugar of milk' (aphorism 281).
* Let the case clear itself - to form a faithful picture of the disease " When the disease is of a chronic character, and the patient has been taking medicine upto the time he is seen, the physician may with advantage leave him some days quite without medicine, or in the meantime administer something of an unmedicinal nature and defer to a subsequent period, the more precise scrutiny of the morbid symptoms, in order to be able to grasp in their purity the permanent uncontaminated symptoms of the old affection and to form a faithful picture of the disease. (Aphorism no.91)
At times a patient will present himself, and the physician will be able to get a true image of the sickness by ascertaining all the things that occurred up to a given date. "Upon that date," the patient mat say "I took some medicine, and most of my symptoms, subsided." They lead to another image from which the physician can gather nothing; a scattering has taken place. The symptoms may cover page upon page, and yet no remedy may be clear. None at all; it looks as if a number of provings of drugs had been mixed up all together, intermingling symptoms here and there without any distinctness. No individualization is possible. Administer placebo let the portrait clear.
"Besides this, patients themselves differ so much in their dispositions, that some, especially the so-called hypochondriacs and other persons of great sensitiveness and impatient of suffering, portray their symptoms in too vivid colours and, in order to induce the physician to give them relief, describe their ailments in exaggerated expressions" ('96). It is here that the physician needs to give them something of an unmedicinal nature, observe with freedom from prejudice and trace the accurate portrait of disease.
* Psychotherapy!
The use of placebo is one form and a very powerful form of therapeutic suggestion - psychotherapy. There is evidence that mood or emotional state of a person affects markedly the manifestation of disease, the action of a drug and the process of cure. Experiments and studies have shown that the effect of placebo can mimic the most profound healing responses. The process of homoeopathic interview combined with the expectations of the patient seeking homoeopathic cure may enhance the placebo response itself. Thus, homoeopaths interested in distinguishing the action of homoeopathic remedy from that of placebo response must reasonably begin each case with placebo - " the second best prescription" or maybe the first.
* Homoeopathic drug provings
Placebo is also a very vital member of 'controlled, double blind therapeutic and proving trials!
Influences and bias on the part of provers and the investigator can significantly modify drug responses, interfering with the interpretation of the therapeutic efficacy of a drug. In order to avoid such complications, dummy preparation or substitute drug i.e. placebo is employed, which should be of the same colour and texture as that of the test substance and should be administered in the same way as that of the experimental group.
DISPENSING OF PLACEBO
Placebo is dispensed in the same way as homoeopathic medicines via the same vehicles used for dispensing of medicines.
Vehicles for dispensing of placebo
* Sugar of milk: Care should be taken to enclose an unmedicated globule or a drop of dispensing alcohol.
* Tablets, globules, pillules or pellets: These should be moistened with dispensing alcohol.
* Distilled water, simple syrup.
Dispensing routine
* Instruct and advise the patient as regards the correction of diet and regimen as well as other auxiliary modes of management.
* Confidently prescribe placebo! (without disclosing the identity of the prescription)
A variation in the type of dosage form or even the size of the globules can be effectively used to produce the placebo effect
* They should be bestowed with impressive directions as to the exact number of pills for a dose, the manner of intake and the precise hours of intake!
* Give enough doses to last the interval between two visits as well as instructions when to report back.
* The labeling of the placebo doses should be appropriate and should not reveal the identity of the placebo. The label should carry an identity like 'phytum', rubrum', 'nihilinum', 'lactopen', '( pills', 'S.L., etc. It should also carry potency at random, as patients have a way of investigating their medicine. Any identity for the placebo can be assigned, provided it is not the name of an already existing drug and there is an understanding between the physician and the dispenser as to the nature of the placebo and prescription, to avoid all confusion in the dispensing of the prescription.
SELF ASSESSMENT
* What is placebo? When is placebo indicated? How will you dispense placebo?.
You have no right to disclose professional secrets, one patient read your blog and accused me with rude behavior though he is recovering from his disease under my treatment, please delete this blog
ReplyDeleteDr. Do you agree that you are dispensing placebo? My dilutions labeled as 6x, 6c, 12c. ? Won't you explained to the patient, who asked you the doubt? Difficult to practice homeopathy without knowledge of how to dispense daily doses? and explain the same to patient when questioned against.
ReplyDelete