There was an interesting piece in Medscape yesterday, about chronic pain and placebo ‘treatments’, which raised some intriguing questions from my bioethics perspective. Although focused primarily on osteoarthritis, this likely applies to at least a few other chronic pain conditions as well. It’s quite a lengthy article, so I’ll provide a bit of a summary here:
One of the ongoing challenges for clinicians and researchers trying to improve symptoms is that not all people who meet the Kellgren and Lawrence definition of osteoarthritis have symptoms, and not all who have clinical symptoms of osteoarthritis meet the Kellgren and Lawrence definition.
This complicates both research into and treatment of osteoarthritis.
It suggests that there are a number of factors contributing to the experience of pain in osteoarthritis that have little or nothing to do with the currently understood disease pathophysiology — the contextual and nonspecific effects.
And that makes it challenging to tease out what are genuine treatment effects associated with an intervention from what are placebo effects.”
In other words, the severity of the symptoms doesn’t necessarily translate to the severity of the disease. A patient with moderate disease may experience severe pain, while another with highly developed disease may be out walking and cycling every day with minimal experience of pain. There’s also the fact that many patients report continuing pain after knee replacement surgery, when the expected cause of their pain has been repaired or completely removed.
As an example, “around 10% of people who receive a total knee replacement report dissatisfaction with the procedure, mostly due to ongoing pain and stiffness. But with a knee replacement, the underlying pathology — supposedly the cause of their symptoms — has been surgically removed, said pain specialist Apkar Apkarian, PhD, director of the Center for Translational Pain Research at Northwestern University in Chicago.”
What does all this mean, in terms of treating osteoarthritis – and potentially some other chronic pain conditions?
Apkarian argues that osteoarthritis research has focused on the joint for far too long and should instead be taking a closer look at the brain to understand why some feel pain and others don’t, which could then shed light on what role the placebo effect plays in response to treatment in this disease.
“The brain circuitry, brain emotional circuitry, brain learning circuitry, all of those are massively, causally engaged in chronic pain, and we need to become serious and start targeting them”.
The article then goes into a detailed analysis of some research into the use of placebos for osteoarthritis pain, and the surprising results that these ‘treatment’ were effective even in cases when patients had been told in advance that the placebo was an inactive substance. In some cases, it may be that there was a beneficial effect of talking about their pain with a healthcare professional while feeling supported, while in others it might be simply having someone listen to them. Unfortunately, these possibilities weren’t accounted for or captured in the research presented.
Which brings us to the placebo effect in osteoarthritis and why so many individuals with the disease report sometimes significant benefits from placebo treatments that are designed specifically not to work.”
This is an important question, of course, but another perhaps more pressing question occurred to me while reading the following paragraph on tennis elbow and the frequent reflex of surgeons to offer surgery for a condition that is likely to resolve on its own given sufficient time:
Unfortunately, persistent tennis elbow symptoms are often used as justification for surgical intervention. “Surgeons commonly say, if you’re not better by a certain time, then you need surgery, and that’s nonsense because the natural history is that you’ll still get better irrespective of how long you’ve had symptoms,” Buchbinder said. “By 1 year, 90% are better anyway, so the chances that [surgery] is going to beat that are pretty tiny.”
At this point, have you guessed what some of my intriguing bioethics questions are? With so many risks involved in surgery, why are these surgical interventions being offered at all, if research shows that issues like persistent tennis elbow will resolve with non-invasive treatment? Are these procedures being used as income-generation tools by surgeons and/or surgical centres – not only in the U.S. but also in other countries with a fee-for-service based approach to surgeon remuneration?
And in terms of informed consent to surgery, are patients being advised that the surgery may not reduce their pain as much as placebo? Or that their experience of pain might not improve with surgery, or alternatively that it could well resolve within a year without surgery? Are the risks of surgery versus a wait-and-see approach fully explained?
Most of all, I suppose, I’m left wondering – from a bioethics perspective as well as from my viewpoint as a Patient Partner in pain research and with pain research organizations – where is the oversight at a systemic or societal level in terms of ensuring that patients undergoing these surgeries specifically to resolve chronic pain are fully informed of other approaches to pain management. I’d never have thought, before trying it myself, that learning to paint with watercolours could have such a huge impact on my own pain experience with Complex Regional Pain Syndrome (CRPS). Yet creating an art practice has had an almost incredible impact on my pain, my well-being, and my quality of life – for pain as well as for my Mild Cognitive Impairment. (For more on this, follow #ArtDespitePain on social media, or visit my art website at www.SandraWoods.art.)
As for anyone suddenly thinking that healthcare systems could save money by instituting placebo ‘treatment’ across the board for chronic pain conditions, bear in mind that “Apkarian’s research suggests that in general about half of patients respond to placebo, and half don’t” – with no way at present of knowing which patients fall into which groups. Not only that, but his statement may apply on to the particular pain conditions he has been studying; the same placebo effects may not be seen across other diseases or conditions.
What do you think about all this? Feel free to comment over on my social media, as I’ve had to disable the Comments feature here due to the high level of spam from Russian bots and hackers; it all became too much to deal with, because of my Mild Cognitive Impairment from one of my 2 different rare diseases.
Reference:
Bianca Nogrady. Osteoarthritis Has a Placebo Problem, and It’s Challenging Both Research and Clinical Practice. Medscape Medical News; a division of WebMD LLC. ePub 18 Jun 2025:
https://www.medscape.com/viewarticle/osteoarthritis-has-placebo-problem-and-its-challenging-both-2025a1000g87