Placebo Use in Pain Management: A Mechanism-Based Educational Intervention Enhances Placebo Treatment Acceptability.

UNLABELLED: Health care providers use treatments whose effectiveness derives partially or completely from 'nonspecific' factors, frequently referred to as placebo effects. Although the ethics of interventional placebo use continues to be debated, evidence suggests that placebos can produce clinically meaningful analgesic effects. Burgeoning evidence suggest that patients with chronic pain might be open to placebo treatments in certain contexts despite limited knowledge of their well-established psychoneurobiological underpinnings. In this investigation we sought to examine the effects of a brief, mechanism-based placebo analgesia educational intervention on aspects placebo knowledge and acceptability. Participants with chronic musculoskeletal pain completed a web-based survey in which they rated their knowledge of placebo analgesia, assessed placebo acceptability across different medical contexts, and evaluated 6 unique patient-provider treatment scenarios to assess the role of treatment effectiveness and deception on patient-provider attributions. Using a pre-post design, participants were randomized to receive either a placebo educational intervention or an active control education. Results showed that the educational intervention greatly improved perceptions of placebo knowledge, effectiveness, and acceptability, even in deceptive treatment contexts. This was the first study of its kind to show the value of an educational intervention in increasing openness to and knowledge of placebo analgesic interventions among patients with chronic musculoskeletal pain. PERSPECTIVE: In this we article highlight how patients with chronic pain might be open to placebo interventions, particularly adjunct and/or complementary treatments, when provided education on the neurobiological and psychological mechanisms that underlie placebo effects. Study findings highlight ethically acceptable ways to potentially use placebo factors to enhance existing pain treatments and improve patient health outcomes.

Attitudes and motivations of competitive cyclists regarding use of banned and legal performance enhancers.

Drug 'doping' and the use of banned performance enhancing products (PEPs) remains an issue in virtually all competitive sports despite penal consequences and known health risks. The lines distinguishing "fair" and "unfair" performance enhancement have become increasingly blurred. Few studies have explored how attitudes towards legal performance enhancers (drugs/substances, diet, and equipment modifications) may influence motivations to use banned PEPs. In the present study, 68 competitive cyclists completed a survey examining the importance of choosing banned and non-banned PEPs using World Anti-Doping Agency (WADA) and Union Cycliste Internationale (UCI) criteria. Results showed that over 60 percent of cyclists used non-banned PEPs while 8 percent used banned PEPs. Health was overall the most important factor in choosing a PEP while apprehension by a doping agency was least important. Mixed- model ANOVA analyses revealed that motivations to use banned PEPs were complex, as the importance of health, violating the sprit of the sport, performance improvement, and getting caught were differentially influenced by PEP legality (p < 0.001) and whether a cyclist endorsed non-banned PEP use (p < 0.001). The importance of winning, sponsorship, and maintaining competitiveness did not influence non-banned PEP use (p > 0.05). Our findings illustrate the multifactorial nature of PEP use/doping attitudes and highlight the unique role that "legal" performance enhancement may plays in influencing banned and/or unethical sports behaviors. Key PointsUse of performance enhancers is high even among non-professional athletesCyclists overall rated "risk to health" as the most important factor in choosing to use a performance enhancing product.Motivations to use banned performance enhancer are complex and are significantly influenced by whether an athlete utilizes "legal" performance enhancers.

Analgesic placebo treatment perceptions: acceptability, efficacy, and knowledge.

UNLABELLED: Current evidence supports the efficacy of placebo analgesia and illustrates that patients may be open to placebo use despite uncertainty regarding its mechanisms. Debate persists, however, concerning the ethics of placebo treatments. The purpose of the present web-based study was to expand upon the empirical literature on placebo analgesia ethics and acceptability. Participants (n = 100) provided their definition of a placebo and responded to 24 questions addressing placebo analgesia perceived knowledge, acceptability, effectiveness, and likelihood of placebo use among different health care providers. Results support previous research on the effects of placebo on negative mood and health care provider attributions, with findings illustrating that negative consequences of administration were largely mitigated by a beneficial treatment outcome. Results showed that participants conceptualized placebo as predominately inert and were mixed regarding interpretations of placebo effectiveness. Though acceptability ratings were dependent on the context of placebo administration, participants endorsing even moderate placebo acceptability were more open to placebo interventions and reported overall more positive treatment outcomes. Participants believed that placebos were used differentially among health care providers. Additional studies are needed to determine if placebo education can beneficially impact perceptions of placebo analgesia knowledge, acceptability, and treatment effectiveness. PERSPECTIVE: This study presents an examination of analgesic placebo treatment perceived acceptability, efficacy, and knowledge among lay individuals. Our findings highlight the importance of assessing placebo conceptualizations and treatment perceptions in evaluating placebo ethics-a highly relevant finding that informs the clinical use of placebo components in managing pain.

Detecting the emergence of chronic pain in sickle cell disease.

CONTEXT: Sickle cell disease (SCD) is an inherited hematological disease marked by intense pain. Early in life the pain is episodic, but it becomes increasingly chronic in many cases. Little is known about this emergence of a chronic pain state. OBJECTIVES: The goal of this study was to determine whether adult SCD patients whose pain is still largely episodic show early signs of the disturbed pain processing (hyperalgesia and increased temporal summation) and cognition (hypervigilance and catastrophizing) that are characteristic of a chronic pain state. METHODS: SCD patients (n=22) and healthy controls (n=52) received noxious pressure stimulation for up to three minutes and periodically reported pain intensity and unpleasantness on 0-10 scales, allowing the rate of pain increase (temporal summation) to be determined. Pain intensity discrimination also was measured, and attitudes toward pain were assessed. RESULTS: There were no overall differences in pain ratings or temporal summation between patient and control groups. However, patients' experimental pain ratings tended to increase with age and those reporting a history of very painful episodes showed particularly rapid temporal summation of pain unpleasantness. Patients were significantly impaired at discriminating intensities of noxious stimulation. Patients were more hypervigilant than controls, but catastrophizing was elevated only during pain episodes. CONCLUSION: Most SCD patients whose pain remits entirely between episodes are not in a chronic pain state, but some--those who are older and have a history of highly painful episodes--appear to be transitioning into it. These early signs of disturbed processing may aid clinicians seeking to forestall disease progression.

Factors affecting placebo acceptability: deception, outcome, and disease severity.

UNLABELLED: A burgeoning body of evidence supports the efficacy and elucidates the mechanisms of placebo analgesia. Debate persists, however, concerning their ethical use, with many of the present arguments being philosophically based. The present web-based study empirically investigated the acceptability of an analgesic placebo treatment. Participants (103) responded to vignettes depicting patients receiving a placebo analgesic. We experimentally manipulated: 1) placebo treatment instructions (level of deception); 2) treatment outcome; and 3) patients' pain severity. Participants rated vignettes on outcome measures of deception, physician-patient relationship, and patient mood. Participants then characterized a range of placebo acceptability through ratings of deceptiveness, effectiveness, and negative consequences. Results showed that placebos described as "medication shown to be a powerful analgesic in some people" were equally deceptive as those described as "standard drug treatment." Ratings of patient mood and physician approval were determined as much by treatment instruction as by treatment outcome and an analgesic response mitigated the negative consequences of deceptive administration. Participants tolerated moderate effectiveness and considerable negative consequences in an acceptable placebo, although results suggest lay individuals may not have a sophisticated conceptualization of placebo effectiveness. Studies altering individuals' understanding of placebo effectiveness and mechanisms are needed to identify additional factors determining placebo acceptability. PERSPECTIVE: This study represents an empirical examination of analgesic placebo acceptability among lay individuals. This article is the first to systematically manipulate deception, treatment outcome, and disease severity to determine how these factors interact to differentially determine placebo acceptability-a highly relevant finding that informs the clinical use of placebo.

Effects of high intensity training by heart rate or power in recreational cyclists.

Technological advances in interval training for cyclists have led to the development of both heart rate (HR) monitors and powermeters (PM). Despite the growing popularity of PM use, the superiority of PM-based training has not been established. The aim of the present study was to investigate the relative effectiveness of HR-based versus PM-based interval training on 20 km time trial (20km TT), lactate threshold (LT) power, and peak aerobic capacity (VO2max) in recreational cyclists. Participants (n =20; M age=33.9, SD =13) completed a baseline 20km TT to establish their VO2max and LT and were then randomly assigned to either HR-determined or PM-determined training sessions. Over a period of up to 5 weeks participants completed 7.2 (± 1.1) interval training sessions at their specific LT for their respective interval training method. Repeated measures analyses of variances (ANOVAs) showed that both HR-based and PM-based training groups significantly improved their LT power (F(1,16) = 28., p < 0.01, eta(2) = 0.63) and 20km TT time (F(1,16) = 4.92, p = 0.04, eta(2) = 0.24) at posttest, showing a 17 watt increase (9.8%) and a near 3-and-a-half minute improvement (7.8%) in 20km TT completion time. There were no significant group (HR vs. PM) x time (baseline vs. posttest) interactions for 20km TT completion time, LT power, or VO2max ratings. Our results coincide with the literature supporting the effectiveness of interval training for endurance athletes. Furthermore, our findings indicate that there is no empirical evidence for the superiority of any single type of device in the implementation of interval training. This study indicates that there are no noticeable advantages to using PM to increase performance in the average recreational cyclist, suggesting that low cost HR monitor are equally capable as training devices. Key pointsInterval training improves performance for recreational cyclists as measure by changes in lactate threshold watts and 20km time trial timeNo evidence of superiority of either heart monitor training and power meter trainingLow cost heart rate monitors are equally capable as training devices.