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Australian Journal of Pharmacy : July 2005
ucation Allergic reactions may demand antihistamine treatment and local applications of hydrocortisone.’19 The effect of colour A systematic review of many studies found that the colour of pharmaceuticals affect the perceived action of a drug and seem to influence the effectiveness of a drug. Also, a relationship exists between the colouring of drugs that affect the CNS and the indi- cations for which they are used. Some trends suggesting that green and blue may have more sedative effects and red and orange may have more stimulant effects have been found.20, 21 Placebo and ethics and legality? The power of the placebo effect has led to an ethical dilemma. We should not deceive other people, but we should relieve the pain and suffering of our patients. Should health professionals use deception to benefit one’s patients? Is it unethical for a pre- scriber to knowingly prescribe a placebo without informing the patient? If informing the patient reduces the effectiveness of the placebo, is some sort of deception warranted in order to benefit the patient? Some professionals think it is justified to use a placebo in those types of cases where a strong placebo effect has been shown and where distress is an aggravating factor. Others think it is always wrong to deceive the patient and that informed consent requires that the patient be told that a treatment is a placebo treatment. If this were the case the conduct of clinical trials would be in jeopardy. If the placebo effect is an illusion, Scenario M ADELEINE Angoisse has a long-standing history of chronic daily headaches. She previously had been treated by numerous doctors and had tried a number of medications; all caused non-specific side effects and resulted in her continually changing therapy. She also has a history of anxiety and depression. She is aged 35, single and quite thin. She weighs 55kg and is 172 cm tall (BMI = 18.6 kg/m2 that her anti-anxiety tablets are not working and her depression is certainly not good. She says to you as she hands you a prescription for Panadeine Forte 2 prn: ‘I knew I shouldn’t have let that chemist change my tablets last time. They don’t work. They might be cheaper, but they are different and the colours are not right and they make me feel sick. I feel nauseous, I get palpitations, I’m constantly sweating, and I am having breathing difficulties as well as diarrhoea. Nothing works for me, I always get things wrong.’ ). She also complains Current medications • Panadeine Forte tablets (paracetamol 500mg/codeine 30mg) 2 prn. • Alepam (oxazepam) tablets 5mg tds (changed from Murelax two weeks ago). • Axit (mirtazepine) tablets 30mg 1 daily (changed from Avanza two weeks ago). The brief clinical history provided by Ms Angoisse raises the strong possibility that her nonspecific side effects represented are due to the nocebo effect, exacerbated by her anxiety state. Most practitioners (health professionals) have encountered patients who seem to have an adverse response to almost every medication prescribed. In such situations, both practitioner and patient come to expect an adverse outcome. This may be exacerabeted by an anxious patient reading the Consumer Medicines Information (CMI) leaflet. Typically, the side effects that occur are not commonly THE AUSTRALIAN JOURNAL OF PHARMACY VOL.86 JULY 2005 ? 573 then another ethical dilemma arises: should placebos be given if it is known that deception does not really reduce pain or aid in the cure of anything? Recent work has addressed the question of the placebo in clin- ical practice. The authors argue, first, that the placebo can be an effective treatment, second, it is demonstrated that its use does not always entail deception and, finally, they produce guidelines according to which the placebo may be used for clinical purposes. They suggest that in select cases, use of the placebo may even be morally imperative.22 Table One summarises key points that could be considered when reviewing a patient’s medication and response or non- response. Table One: Response or non-response to therapy • Response to drug therapy may be influenced by biased expectations and enhanced suggestions • Placebos are effective in 50–60 per cent of people with certain conditions • Placebo effect may be a measurement of mind over behaviour which can validly show objective health changes • The nocebo effect where harmful effects occur may be related to beliefs, attitudes and cultural factors • Colour, size, brand, and shape of tablets may influence response