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Abstract
Special Article
Placebo
and nocebo effects are known to contribute significantly to the
response to symptom control, including analgesia. Clinical trial
methodologies using placebo controls are designed to identify the
magnitude of these effects in the research context. An adequately
powered, randomized, double-blind, placebo-controlled trial of ketamine
in cancer pain has recently been reported, which demonstrated no net
clinical benefit for ketamine over and above that of placebo. Rates of
placebo and nocebo responses were high. The setting of a clinical trial
provides an opportunity to quantify the nonpharmacologic aspects of
patient responses to analgesia, raising important clinical and ethical
issues for practice. The findings of the ketamine study are analyzed in
the context of a methodological discussion of placebo and nocebo
effects, what is known about the biological and psychological bases for
each of these, and their implications for a clinical trial design in the
palliative care setting. Along with reviewing the use of ketamine after
this negative trial, clinicians need to remain aware of the strength
and significance of both placebo and nocebo responses in their own
practices and the biopsychosocial complexity of why and how patients
actually respond to pain management strategies. The results of this
study strongly reinforce the importance of the therapeutic relationship
and the context of care.
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