Many nurse prescribers work in the community, and all community nurses will be used to conventional drug treatments and probably, the offering of lifestyle advice as well. However, there may be many patients in their caseloads who are receiving placebo pills as part of their treatment, of course, without their awareness.
There is controversy surrounding placebo prescription and, in 2017, NHS England recommended that GPs stop prescribing homeopathy owing to a lack of robust evidence to support its use (NHS England, 2017). This was followed by a decision in 2018 by The Royal London Hospital for Integrated Medicine to stop providing homeopathic therapies funded by the NHS (Pattenden, 2018). Evidence demonstrates, however, that placebos are effective (Locher et al, 2017), particularly for treating conditions such as osteoarthritis where other ‘best-practice’ treatments such as nonsteroidal anti-inflammatory drugs (NSAIDs) are associated with harmful side effects (Howick et al, 2013).
How common is placebo prescription?
Interestingly, a UK study conducted in 2013 found that 97% of 783 surveyed GPs have prescribed a placebo to patients at some point in their careers, and that prescription of placebos, such as sugar pills or other treatment with no established efficacy, is widespread (Howick et al, 2013; Roberts, 2013). Three-quarters of the doctors surveyed prescribed such treatments on a daily or weekly basis (Roberts, 2013).
Despite the understandable controversy surrounding the ‘deception’ of patients regarding their treatment, Howick et al (2013) pointed out that prescribers are taking this course of action to help patients, rather than to deceive them. The Royal College of General Practitioners acknowledged that there is a place for placebos in medicine, noting that they can help people and are perfectly acceptable to use as long as they do not cause harm and are not expensive (Roberts, 2013). Howver, the study by Roberts (2013) emphasised that prescribers should be aware of sham treatments that could cause side effects or issues such as resistance to drugs.
An example
An example of a condition that may be effectively treated by placebo in combination with exercise is osteoarthritis. It is not only one of the most common chronic conditions, but also the most common type of arthritis (Centers for Disease Control and Prevention, 2018). Osteoarthritis can affect any joint in the body, especially those that bear the most weight, and it currently affects more than 8 million people in the UK (Imm, 2017).
There are many treatments recommended for use in people with osteoarthritis. However, new findings published in the Journal of the American Medical Association suggested that all but one of these drugs is no more effective than a placebo (Gregori et al, 2018). The authors noted that while osteoarthritis is a progressive long-term condition, the trials carried out to test treatments are short-term ones, resulting in unclear recommendations for patients (Gregori et al, 2018).
Gregori et al (2018) carried out a systematic review and meta-analysis of 31 pain interventions for knee osteoarthritis across 47 randomised controlled trials (RCTs) including 22 037 patients, most of whom were aged between 55 and 70 years. The trials ranged from 1–4 years with at least 12 months of follow-up and. Worryingly, only glucosamine sulphate demonstrated significant pain improvement compared with the placebo (Gregori et al, 2018; Clinical Pharmacist, 2019). Improvements in joint space narrowing were also observed for glucosamine sulphate, as well as for chondroitin sulphate and strontium ranelate (Gregori et al, 2018). However, the efficacy of the remainder of drugs studied is uncertain, and the authors concluded that larger RCTs are needed to resolve this (Gregori et al, 2018).
In fact, while paracetamol, NSAIDs, opioids, steroid injections and even platelet-rich plasma (PRP) treatments are all recommended options for osteoarthritis, alongside supportive treatments (for example, transcutaneous electric nerve stimulation, hot/cold packs and manual therapy), lifestyle changes such as exercise and weight loss are actually recommended first and foremost, as is the case with most long-term conditions (NHS, 2016).
Conclusion
Non-medical prescribers such as nurses may wish to consider their own use of placebo prescription, and whether and where it may fit into their prescribing toolkit. This should be reflected on alongside social prescribing in today's climate of increasingly holistic prescribing, in order to prevent overprescribing or the medicalisation of patients and avoid harmful or unknown side effects.
All long-term conditions are known to have a significant negative impact on a person's quality of life, and there is a need to learn how to most effectively treat affected individuals and improve outcomes. It is worth paying heed to new and ongoing research that demonstrates which recommended treatments are the most effective, as well as to determine whether there is some value in prescribing placebo pills in some instances, which may help the person to feel reassured without the added side effects of other treatments.