By Dr. Paul Ehrlich
Every so often a study comes along that has the potential to do mischief, not because the scientists involved are in any way irresponsible but because of the way results are reported in a range of media.
One was the study that showed children who grow up on European farms are less prone to asthma than city kids, and another that showed first children are more prone to allergies and asthma than their younger siblings. The way these were spun ranged from the conscientious to the downright misleading and demoralizing. For the first, certain reports made already anxious parents feel that they had doomed their children by raising them in cities instead of the farm, and for the other, it prompted them to wonder what they had done wrong with the eldest child.
Another study showed that pills called leukotriene receptor antagonists (LTRAs) were just as effective in treating asthma as twice-daily doses of inhaled corticosteroids (ICS). Closer examination revealed that ICS is actually much more effective, but for various reasons, including the pain-in-the-neck factor, it is easier for people to keep to a once-daily pill regimen instead of the twice-daily puffing required by Advair or Symbicort, producing results that are good enough on average.
The latest study to prick my thin skin on this general topic is the New England Journal of Medicine article “Active Albuterol or Placebo, Sham Acupuncture, or No Intervention in Asthma” again, not because of the article necessarily but because of the way it gets reported. Some reporters did a good job of analyzing this study, and carefully differentiated the subjective reports of patients on how they were feeling from the fact that only the real medicine made a real difference in the underlying condition. To wit, a sham treatment may make you feel better, but you’re still sick.
But this is how a TV reporter started her story: “Millions of people with asthma worldwide rely on rescue inhalers. But would you be surprised to learn the mind also plays a role in how well they work? It may be a new approach to treating asthma.” With 50% of asthma uncontrolled and 70% of prescriptions un-renewed, I hate the idea of bad reporting convincing patients that taking something phony suggests “a new approach to treating asthma.”
But that was just happy-talk TV reporting. More disturbing is the headline on a medical website: “Asthma Placebo ‘As Effective As Active Drug’ Study Unveils”. The first paragraph cleared things up a good deal: “Asthma and many ailments can be partially just in your head research released this week claims. A new study finds that the power of the placebo effect versus albuterol inhalers left asthma patients thinking that real and fake drugs were doing the same level of good. The results even convinced patients they were breathing much better even if they hadn’t taken a real drug and hadn’t actually improved much.” Still, anyone who stopped reading after the headline would have been misled.
Look, the fact that stress plays a role in triggering asthma attacks is well known, and I suppose this study just confirms it. To wit, taking the placebo takes some of the anxiety out of the patient’s mind and provides feelings of relief. But you have attacks because your lungs are inflamed, and if they are inflamed they are undergoing possibly irreversible damage, called remodeling. This study required that subjects cease to take their controller medication for a time and thus court an attack, which couldn’t be done with severe asthmatics. All these subjects had milder conditions.
There are probably medical situations where the placebo effect ought to be the first recourse—all those antibiotics given for common colds should be replaced by sugar pills, although it might be tricky to charge a co-payment. With asthma, however, we know that “feeling better” is often the problem. Your airways may be remodeling like mad, but you feel well or well enough to neglect taking your controller medication. “Rescue” medication isn’t really asthma treatment anyway, any more than a trip in an ambulance is “health care”. Asthma treatment really means controlling the underlying inflammation so you don’t need to be rescued.
We need new approaches, but this study doesn’t point the way to anything innovative. What we need is a new approach to get more people to follow the old one until some real breakthrough occurs. And in the meantime, don’t try to replicate this study at home! Leave it to the professionals.