The discussion isn't solely about asthma sufferers; it extends to everyone. We often fall prey to illusions when evaluating the effectiveness of treatments based on our personal experiences.

Misunderstandings about placebos are widespread, affecting both professionals and the general public. They aren’t magical cures; rather, they do not induce measurable changes in the body. A true placebo does not evoke physiological alterations.

But what is a placebo? It's an intervention that, when accompanied by positive expectations and social support, leads individuals to believe in its efficacy over time.

For instance, many adults take an aspirin for headaches, often believing it alleviates their pain. However, the dosage is typically insufficient for pain relief, and the headache would likely improve regardless of the aspirin. A randomized clinical trial (RCT) would confirm this.

The problem lies in the fact that individuals don't usually conduct their own RCTs; they rely on their subjective impressions before and after a treatment.

Rituals, such as taking a pill, can mislead individuals into believing that a change has occurred in their bodies. Authority figures or social media can amplify susceptibility to the placebo effect.

Cultural beliefs also play a role in what is perceived as effective. For instance, cannabidiol (CBD) is a point of contention, with some advocating for its benefits despite skepticism.

In co-ops or stores frequented by New Age enthusiasts, one might find more placebos than clinically validated treatments available.

Many believe acupuncture effectively alleviates pain, yet they can also be swayed by sham treatments, where needles are inserted in non-therapeutic locations.

While numerous individuals assert that acupuncture has significantly helped them, it's conceivable that receiving sham treatments from a well-meaning but uninformed practitioner would yield similar subjective results.

Similarly, users of the Headspace app report profound changes in their mental states. When given fake instructions, their self-reports remain indistinguishable from those who received standard guidance from the app.

I'll reassess my stance on Headspace if compelling evidence of its efficacy surfaces.

Claims about the extraordinary power of placebos often stem from reliance on subjective self-reports without objective validation.

With pain and mood, we usually lack objective metrics, despite their realness. We only measure pain's interference with daily life.

So, what's the downside of using placebos for pain and mood management?

Primarily, placebo effects are fleeting, and individuals may spend vast sums on them.

In wellness-oriented grocery stores, you might encounter more placebos than effective treatments. Distinguishing between proven medications and placebos can be challenging. Don't rely on co-op staff for insights—they'll likely share personal anecdotes favoring placebos, often citing impressive changes in pets after using CBD.

Overreliance on placebos can delay individuals from pursuing more effective therapies.

The U.S. Food and Drug Administration permits some pills to be marketed as antidepressants based on clinical trials showing that diagnosed individuals generally improve more with these drugs than those receiving inert pills with similar support.

Establishing a pill as an antidepressant requires an RCT, and there are far more failed candidates than successful ones in this domain.

One intriguing study involved participants with well-controlled asthma who consented to an experiment that could include non-proven treatments. Researchers needed subjects with conditions where both objective and subjective assessments were possible.

The study juxtaposed a recognized treatment with sham acupuncture and fake inhalants against effective albuterol.

This groundbreaking study was generously made available through the prestigious New England Journal of Medicine. You can access it via the link below.

Wechsler ME, Kelley JM, Boyd IO, Dutile S, Marigowda G, Kirsch I, Israel E, Kaptchuk TJ. Active albuterol or placebo, sham acupuncture, or no intervention in asthma. New England Journal of Medicine. 2011 Jul 14;365(2):119–26.

This double-blind pilot study screened 79 individuals, with 46 meeting the criteria for mild-to-moderate asthma. After consenting, they were randomly assigned to one of four interventions.

The study compared an inhaled albuterol bronchodilator against three control conditions: a placebo inhaler, sham acupuncture, and no intervention.

Albuterol is recognized for alleviating breathing issues in asthma patients.

The following figure illustrates subjective outcomes from two self-reported measures regarding perceived improvements in asthma symptoms and treatment credibility.

The bar graph reveals compelling evidence that both placebo treatments yielded subjective improvements in breathing comparable to those observed with albuterol. All interventions outperformed the no-intervention group.

Patients reported significant relief with albuterol (50% improvement), and similarly with the placebo inhaler (45%) and sham acupuncture (46%). In contrast, the no-intervention group reported only a 21% improvement.

The difference in subjective effects between the active albuterol inhaler and the placebo inhaler wasn't statistically significant (P=0.12), with a small effect size (d=0.21).

Thus, both the proven treatment and the placebo inhaler had similar subjective outcomes.

However, the placebo effects demonstrated significant differences compared to no intervention (d=1.07 for placebo inhaler and d=1.11 for sham acupuncture, both with P<0.001).

Participants were indeed misled in this study. Without any intervention, their subjective reports remained unchanged. When subjected to fake procedures, they perceived improvements akin to those experienced with effective medication.

The perceived credibility of the treatments was high, with many patients believing they received actual treatment (73% for albuterol, 66% for placebo inhaler, and 85% for sham acupuncture).

The two double-blind conditions showed no significant differences, but sham acupuncture was deemed more credible than the inhaler conditions (P<0.05).

Sham acupuncture appeared more compelling, likely due to the added ritual and perceived experimental nature of the treatment.

To date, placebos remain potent, with patients often mistaking sham acupuncture for real or placebo inhalers.

Figure 3 presents objective physiological responses—improvement in forced expiratory volume (FEV1) measured through spirometry. Data for each intervention (albuterol, placebo inhaler, sham acupuncture, and no intervention) is displayed across three visits.

The average percentage improvement in FEV1 was 20.1±1.6% with albuterol, compared to 7.5±1.0% with placebo inhaler, 7.3±0.8% with sham acupuncture, and 7.1±0.8% with no intervention.

No significant differences emerged among the three inactive interventions, which did not yield the improvement observed with active albuterol.

The difference in efficacy between the albuterol inhaler and placebo inhaler was significant (P<0.001) and substantial (d=1.48).

In contrast, no significant differences were found among the placebo interventions and the no-intervention control (P=0.65 for placebo inhaler vs. no intervention; P=0.75 for sham acupuncture vs. no intervention).

The authors concluded:

“In this repeated-measures pilot study assessing active-drug and placebo effects in asthma patients, both placebo types exhibited no objective bronchodilator effects beyond the improvement observed with no intervention. However, the subjective improvements in asthma symptoms with both inhaled placebo and sham acupuncture significantly surpassed those of the no-intervention control, aligning with active drug results.”

I consider myself a skeptical advocate for evidence. I dislike being misled and recognize my cognitive biases, especially when I assume I know a lot. Occasionally, I need a reminder that I can be confidently mistaken.

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