Table 2

Suggested potential clinical applications of procedures to elicit placebo effects in non-malignant pain, subject to further research

ProcedureSuggested clinical applications
Patient’s beliefs and characteristics
1.Select patients based on treatment historyStop prescribing interventions of a type that a patient has previously not responded to (eg, tablets); instead, prescribe a different, new type of treatment (eg, psychological therapy).
2.Create positive expectancyTell the patient the intervention is likely to be effective.
Elicit patients’ treatment and illness beliefs and expectations and dispel any misconceptions.
Empower patients to self-care.
3.Reduce negative expectancyLimit emphasis on major potential side effects and describe how uncommon they are.
Hide cessation of analgesia administration (eg, as in Benedetti et al 73), after obtaining advanced consent and ensuring patients are aware they can request additional analgesia if needed.
4.Convey a positive therapeutic message through informed consent proceduresProvide written and/or verbal information that conveys a positive therapeutic message about treatment.
Provide clear rationale for treatment.
Provide patient testimonials and supporting literature/media.
5.Harness sociocultural contextElicit patients’ culturally embedded treatment and illness beliefs, preferences and expectations, dispelling any potentially harmful misconceptions.
Involve significant others in care.
Practitioner’s beliefs and characteristics
6.Practitioner expectancyOnly prescribe a treatment to patients when the practitioner expects it will be effective; communicate that expectation to patients.
7.Practitioner’s personal characteristicsHonour patient preferences for particular practitioners.
Use indicators of expertise/high status in offices, in correspondence and when referring to other practitioners.
Ensure the patient is seen by a practitioner whose views/values are congruent with the patient’s views/values.
Healthcare setting
8.Active recruitmentActively seek out patients and invite them to attend clinic regarding a particular intervention (as opposed to waiting for patients to present).
9.Active retentionPersonally contact patients if they miss an appointment.
Use incentives to encourage patients to keep appointments.
10.Follow-upRoutinely invite patients to book a follow-up appointment after an intervention has finished and prior to repeat prescription.
Encourage the patient to take responsibility for and self-manage their condition following an intervention.
11.Follow a standardised protocolUse patient-friendly treatment protocols and share with patients where they fit in that protocol.
12.Ethical oversightEnsure that patients understand that their treatment protocol is sanctioned by a higher authority, for example, National Institute for Health and Care Excellence.
13.Participating in researchInform patients that all outcomes and practitioner performance is audited and can contribute to improved knowledge and treatment for future patients.
14.Symptom monitoringAsk patients to monitor their symptoms regularly, for example using email, phone apps, web-based systems, paper forms.
Assess treatment outcome.
Give patients feedback on symptom improvements following monitoring.
15.Enhanced environmentEnsure that the environment is professional, pleasant and peaceful.
Employ friendly and helpful support staff.
Treatment characteristics
16.Sham intervention—medicationOpenly prescribe sham medication.
With advanced prior consent, prescribe sham medication.
17.Sham interventions—physicalOpenly prescribe sham physical treatments.
With advanced prior consent, prescribe sham physical treatments.
18.Sham interventions—attention onlyIncrease frequency and duration of consultations.
19.Ineffective substancesPrescribe substances that are likely not to cause harm but not clearly indicated or substances unlikely to be effective, for example, simple linctus.
20.Use side effectsTell patients about side effects associated with positive clinical outcome.
21.Matched treatmentsDesign appearance of prescribed substance (eg, colour, packaging, taste) to match known effective treatments.
22.Maximised treatment proceduresWithin safety limits prescribe higher dose/higher frequency/larger pill.
Use different colour treatments.
Instigate ritualistic procedures patients can perform when taking medicines.
Maximise adherence to treatment through education, easy follow-up appointments, easy repeat prescription arrangements, and so on.
23.ConditioningPrescribe highest tolerated dose first, then titrate downwards.
With consent, begin with active intervention, pair with a seemingly identical placebo then substitute for placebo alone (eg, as in Sandler and Bodfish56).
Patient–practitioner interaction
24. The process of informed consent Actively seek patient consent.
Provide treatment options and encourage the patient to choose from these options if they so desire.
25.Detailed historyTake a detailed medical and psychosocial history/update.
Ensure the patient feels listened to, for example, through non-verbal communication and/or capturing information.
Ask questions about the meaning of symptoms.
26.Diagnosis/testsProvide a definitive/confident diagnosis.
Examine the patient fully.
27.CareAllow patient adequate time to tell their story and listen to them.
Validate the patient’s concerns.
Use non-verbal techniques to convey empathy, compassion, warmth.
Use touch judiciously.
28.Patient-centred communicationIndividualise consultation style according to a patient’s preference for example, collaborative versus authoritative.
Engage in collaborative decision-making with the patient.
Develop shared treatment goals that you and the patient agree on.
29.Extra attentionGive extra attention to or show more interest in a patient by seeing them more frequently, having longer consultations or visiting at home.
Do not rush the patient.
30.Continuity of careEnsure patient is cared for by the same practitioner.
Read records before consultation.
  • Suggestions for clinical applications pending research into effectiveness and ethical acceptability in clinical settings.