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安慰剂的治疗作用:理解研究和临床实践新范式的演变。

Therapeutic Role of Placebo: Evolution of a New Paradigm in Understanding Research and Clinical Practice.

机构信息

Pain Management Center of Paducah, Paducah, KY, and University of Louisville, Louisville, KY.

Department of Anesthesiology and Perioperative Medicine, University of Louisville.

出版信息

Pain Physician. 2017 Jul;20(5):363-386.

Abstract

Research into interventional techniques in managing chronic spinal pain continues to be challenging, mystifying, confusing, and biased. Insight, or lack thereof, into placebo and nocebo phenomena contributes mightily to these difficulties. Unfortunately, placebo-nocebo responses are the subject of numerous controversies and challenges from not only a research perspective, but also clinical perspective. While interventionalists consider the biggest threat to interventional pain management research is inappropriate and outdated interpretation of the data, a greater problem is the misuse of the placebo response in research, with the declaration that all and everything as a placebo effect: with a misinterpretation of the nature of the placebo the, associated conclusions can be inaccurate.Researchers have been aware of placebo and nocebo effects for decades, even though misunderstandings and misgivings continue to be seen in scientific studies. In simplistic terms, placebo and nocebo had been understood to indicate improving or worsening of symptoms that occur during treatment with placebo/nocebo drugs or modalities. However, research has demonstrated that such terminology does not necessarily reflect "true" placebo effect or nocebo response. These effects are based on numerous factors, including natural course of a disease, spontaneous remission, regression to the mean, and a multitude of other conceptual, explanatory, and moral challenges. In modern clinical research, a neutral substance called placebo has been mainly used as a comparison factor rather than being studied itself, while the nocebo response has only been minimally studied.A major misconception involves active placebo, a concept that has been extended beyond the administration of inert substances. The definition of active placebo of an active agent given to a patient, even though the pharmacologic action of the active agent is not known to be beneficial, has been converted to conveniently change many of the treatments which are effective on their own to be defined as placebos, often leading to conclusions that none of the interventions are effective. This review focuses on a multitude of controversies surrounding placebo and nocebo phenomena in research and clinical applications. The discussion includes a focus on unsolved, forgotten, and ignored features of placebo responses in medicine, and provides an appropriate understanding of placebo and nocebo phenomena in interventional pain management. To that effect, this review also describes therapeutic placebos, research with open placebos, and improvements in understanding clinical applications of present interventional pain management research.

摘要

慢性脊柱疼痛管理的介入技术研究仍然具有挑战性、令人费解、令人困惑和有偏见。对安慰剂和反安慰剂现象的洞察或缺乏洞察,极大地促成了这些困难。不幸的是,安慰剂-反安慰剂反应不仅是研究角度,而且是临床角度的众多争议和挑战的主题。虽然介入治疗师认为对介入性疼痛管理研究最大的威胁是对数据的不适当和过时的解释,但更大的问题是在研究中错误地使用安慰剂反应,宣称所有和一切都是安慰剂效应:对安慰剂的性质的误解,相关结论可能不准确。

研究人员几十年来一直意识到安慰剂和反安慰剂效应,尽管在科学研究中仍然存在误解和疑虑。用简单的术语来说,安慰剂和反安慰剂被理解为表明在使用安慰剂/反安慰剂药物或方式治疗期间症状的改善或恶化。然而,研究表明,这种术语并不一定反映“真正”的安慰剂效应或反安慰剂反应。这些效应基于许多因素,包括疾病的自然病程、自发缓解、向平均值回归以及许多其他概念性、解释性和道德性挑战。在现代临床研究中,一种称为安慰剂的中性物质主要用作比较因素,而不是本身进行研究,而反安慰剂反应则仅得到最小程度的研究。

一个主要的误解涉及到主动安慰剂,这一概念已经超出了给予惰性物质的范畴。给患者使用的一种活性药物的主动安慰剂的定义,即使该活性药物的药理作用不知道是有益的,已经被转换为方便地改变许多单独有效的治疗方法,将其定义为安慰剂,通常导致这样的结论,即没有任何干预是有效的。

本综述重点介绍了研究和临床应用中围绕安慰剂和反安慰剂现象的众多争议。讨论包括对医学中安慰剂反应未解决、被遗忘和被忽视的特征的关注,并提供了对介入性疼痛管理中安慰剂和反安慰剂现象的适当理解。为此,本综述还描述了治疗性安慰剂、开放安慰剂的研究以及对当前介入性疼痛管理研究临床应用的理解的提高。

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