Are pharmacists just shopkeepers?

By Edzard Ernst

We tend to trust pharmacists and are likely to assume that, if they sell this or that product, it must work. This attitude is, however, somewhat naïve and not necessarily correct. Alongside powerful drugs, most pharmacists also sell pure placebos masquerading as medicine – take, for instance, homeopathic preparations or Bach Flower remedies.

Most homeopathic remedies are so highly diluted that they contain not a single molecule of the ingredient printed on the label; in order to contain a single molecule of the declared substance, a “C30” pill [the dilution frequently sold by Boots] would need to have a diameter similar to the distance between the sun and the earth. This makes homeopathy very hard to swallow! About 200 clinical trials are available which tested whether homeopathic remedies have clinical effects beyond placebo. Collectively these data fail to provide good evidence in favour of homeopathy http://www.ncbi.nlm.nih.gov/pubmed/12492603.

Similarly, Bach Flower remedies have no basis in science. Like homeopathic preparations, they contain no active ingredients and, crucially, the clinical evidence is squarely negative http://www.ncbi.nlm.nih.gov/pubmed/20734279. In other words, they are pure and expensive placebos.

Why then are such remedies sold in virtually every pharmacy in the UK and abroad? Are pharmacists content to be shopkeepers, mainly out to make a profit, or are they healthcare professionals who adhere to certain ethical standards? Comments by a spokesman of the leading UK pharmacy chain, Boots, such as “we aim to offer the products we know our customers want”, seem to indicate that, regrettably, the former interests have won the upper hand [Bennett P.Are pharmacists shopkeepers out to make a profit? Pharm J 2010; 22]

But how can this be? Do pharmacists not have codes of ethics to which they are duty-bound? Yes, they do; in fact, even though they vary from country to country, these codes leave little room for manoeuvre instructing pharmacists in no uncertain terms to provide all the relevant information about the products they sell, to tell the truth as well as to act professionally and conscientiously. And such clear orders do not just apply to the sale of conventional drugs. When selling homeopathic or other alternative remedies, a pharmacist’s role is fundamentally the same.

Considering these facts, what choices do pharmacists have, if they elect to - or, if they are employed in chain pharmacies, have to - sell homeopathic or other disproven treatments? They could, of course, inform their customers honestly that these remedies are nothing more than placebos. This would probably deter all but a few from the purchase which hardly seems in the interest of the pharmacists or their employer. Alternatively, pharmacists might keep quiet about the evidence thinking “if the client wants it, she should have it”. This stance is prevalent today but, as it fails to provide the relevant information about the product in question, it clearly violates the pharmacists’ very own ethical code and standards. The only other option would be to stop selling disproven treatments altogether. It is not hard to imagine that this possibility might be unattractive; for some pharmacists, it would just mean earning less money, however, to the many UK pharmacists who are employed by large co-operations, such as Boots, it would mean taking a stand against co-operate policy and perhaps even losing their job in the course of doing so.

What is the solution to this conundrum? I do not pretend to know it, but I feel that pharmacists ought to find it sooner rather than later. As this profession is hoping to take on more responsibility in clinical care, their attitude towards selling disproven remedies should be clarified. Are they shopkeepers or healthcare professionals? Are corporate interests more important than professional ethics? These are not merely questions of professionalism, ethics and honesty but, more importantly, they are questions of patient welfare and public health.

“LITTLE H”

By Edzard Ernst

BIG PHARMA is evil and LITTLE ALT MED is benign, or isn’t it? After researching alternative medicine for roughly two decades, I can produce more than enough examples to demonstrate that the latter assumption is erroneous. Let’s take for example homeopathy, or “LITTLE H”, as we might call it for the purpose of this blog.

The name LITTLE H is not entirely absurd because homeopathy makes, of course, much less money than the pharmaceutical sector; nevertheless, I estimate the annual worldwide sales of homeopathic products to be in the region of 2 or 3 billion pounds. Not bad, considering that there are virtually no costs for drug development or raw materials; remember: homeopathic remedies are so incredibly diluted that they typically contain precisely nothing. So the earnings of LITTLE H are easy and the profits are high.

No wonder then that LITTLE H is trying to safeguard its big income.

The strategy to promote homeopathic trade seems clever. The often stated fact that homeopathic products are biologically implausible and do not work beyond placebo is currently countered by the notion that the Swiss government has just released a report which demonstrates the effectiveness of homeopathy. The evidence is, in fact, so strong and reliable, it is claimed, that the Swiss government made homeopathy refundable. If you go online, you find such claims so often that you might eventually even believe them e.g. those made by Dana Ullman.

Yet the truth is quite different: the Swiss government’s decision to include homeopathy for a short trial period was forced by a referendum and not by evidence. What is more, the report in question has just been disclosed in the SWISS MEDICAL WEEKLY as a “case of research misconduct” .

But that has nothing to do with LITTLE H, I hear you think. Perhaps, but what would you say, if several German manufacturers of homeopathic preparations have been paying a journalist around £40 000 annually to systematically blacken the name of those who dare to question that homeopathy is more than an elaborate placebo-therapy?

As I am one of the key targets of this systematic attempt of character assassination – my name appears multiple times on almost every blog on the website in question - I have known about this story for some time.

At First I felt that this sort of thing must be ignored; if I went after everyone who published untruths or insults about me, I would be doing nothing else. And anyway, who cares about some freak throwing dirt around? That, at least, was the advice of virtually all my friends; the worst, they thought, would be to give these strange people publicity by acknowledging their existence.

However when, in a single blog-post by the homeopathy-sponsored mud-slinger, we counted no less than 31 insulting untruths, or grossly misleading statements about me and my research I changed my mind. As I had contact with the DEUTSCHE HOMOEOPATHISCHE UNION (DHU), Germany’s largest manufacturer of homeopathic preparations and one of the firms that was financing the defaming-bonanza, I formulated a polite email alerting my contact to this bizarre situation and pointed out that this sort of thing might not be in the best interest of their public image.

The response confirmed that the DHU were paying the character assassin for running the blog but that he had total editorial freedom over its contents. Therefore the DHU were in no position, they alleged, to interfere. Nevertheless, they seemed concerned about libellous statements, and a meeting was arranged to resolve the issue; consequently I decided it would be only fair to abstain from going public until we had discussed the matter in person.

Meanwhile, a German investigative journalist got wind of all this [no, I did not tip him off] and published the whole sleazy story with all the depressing details in a German daily paper. As a result, another firm sponsoring the character assassin, WELEDA, discontinued their financial support of the mud-slinger. Intriguingly, my meeting with DHU was then called off - I was informed that this was for reasons unrelated to these latter developments…

So what sort of untruths does this LITTLE H-sponsored character assassin tell about me?

As the material is in German, I better tell my readers who might not master this language. Essentially, he repeats ad nauseam that I am a very bad scientist, that my results cannot be trusted, that I have lied about my past as well as about my qualifications, that I ”deliberately and dishonourably mislead my readers and the public”, that my “fan-club” are “atheistic fundamentalists”, that I “enjoy a very bad reputation within the scientific community”, that I react to criticism by conducting ad hominem attacks, that I am never prepared to engage in a constructive dialogue, and that all of this is politically motivated.

If BIG PHARMA would be found out tomorrow to do such a thing to an academic scientist who is critical about the value of this or that drug, the world media would be all over the culprit; all hell would break lose – and rightly so, in my view. But this is not BIG PHARMA, it is only LITTLE H - and homeopathy is benign.

Isn’t it just!

The problem with homeopathy for babies

By Matt Kaiser

I never thought I’d end up writing about homeopathy for babies, but some things just take you by surprise.

For those that are unaware, a homeopathic preparation starts by taking a substance, usually one that would cause an ailment, and dilute it down to such a degree that none of the original substance remains. The belief is that water retains a ‘memory’ of the agent, which can then be used to treat the ailment. The more diluted the preparation, the more effective the supposed remedy is. To give an idea of the level of dilution of most standard homeopathic preparations, the Merseyside Skeptics made ‘homeopathic vodka’ and tested it on a few willing volunteers.

The arguments against homeopathy have been made effectively elsewhere, so I won’t re-tread those well-articulated paths too heavily, but will sum it up briefly. To support homeopathy, proponents usually 'cherry-pick' flimsy, uncorroborated evidence to try and prove efficacy, suggest that a placebo effect is still a positive effect (and so what’s the problem?), or simply argue that everyone has an unhindered choice to decide what treatments they use. The primary problem for me (for it’s a problem among many) is that patients replace or delay conventional treatment in favour of alternative treatment, often at a serious detriment to their health. This is exacerbated by the decision to make homeopathic treatments available on the NHS - justified by the Government with the patient choice argument - and by major pharmacies that lends legitimacy to the practice in many people’s minds. The Science and Technology Committee, however, conclude unequivocally that it’s not valid.

So what’s this got to do with babies?

Well, we’re fairly sure that my little boy’s teething at the moment. This can be a pretty painful process and we would, of course, like to reduce his discomfort as much as possible. So it was with this in mind that my wife bought some teething granules, on the recommendation of some her friends who swore by this particular brand.

Now imagine my surprise when I whipped out the box, in anticipation of riding to my son’s rescue and alleviate his pain, only to discover that these were homeopathic teething granules. First, the surprise that these even exist; and second, the puzzlement that my wife, knowing my somewhat sceptical nature towards ‘alternative’ medicine, had actually bought them for our son. On the second point, she assured me that she didn’t realise they were homeopathic - this fact is revealed only on the back of the packet - and that she was going only on the testimonials of her friends (common ‘evidence’ homeopaths produce). So I’ll give her the benefit of the doubt on that score.

But the first point, that homeopathic pain relief exists for babies, has been troubling me since. The preparation is a 6C dilution of ‘Chamomilla’ (or chamomile). This means that it has been diluted 10-12, or to 0.000000000001 of the original substance. In the ‘homeopathic vodka’ preparation, this would have been reached by the 6th cup of water. So a pretty extreme dilution. Leaving aside the homeopathic tenet that the diluted agent should cause the symptoms of the ailment ('like with like' theory) and, as far as I know, chamomile doesn’t cause teething-like pain, there’s scant evidence I could find of this substance’s pain relief qualities (as advertised) nor of its often assumed general calming properties (also this). Nevertheless, at a 10-12 dilution, it seems extraordinary that there would be enough active molecules to have any effect, and we know that water cannot retain a ‘memory’ of a solute.

As soon I saw that this was a homeopathic treatment, I convinced my wife that we needed to buy a proper teething pain relief. We bought some teething gel, with some well-tested analgesic and antiseptic compounds in it to treat the gums directly, as well as some general pain relieving medicines. And this, to me, demonstrates the crux of the issue: if we’d persisted with the homeopathic treatment, then we would have delayed using the more reliable teething gel and could have caused our son a few nights of needlessly heightened pain.

My wife, bearing in mind the gushing anecdotes about the efficacy of this treatment, suggested we could use them alongside the proven analgesics, thereby nullifying my argument about delaying proper treatment. There’s no harm in it and if the homeopathic granules did work, then that’d be a bonus! After all, our first priority is to provide some respite for our child.

But this still made me uncomfortable for a number of reasons. First, as a subscriber to evidence-based decision-making, I was fundamentally uncomfortable with adding credence to this type of healthcare. I did not want to be part of the community that perpetuates this approach - the pain may have been alleviated independently of the homeopathic treatment but our friends could still have given us a ‘told-you-so’ nod.

In a wider context, I believe it to be utterly wrong that companies sell and profit from pseudoscientific approaches, given the concerns with these remedies outlined here and elsewhere. Any backing we gave it, either by buying more or telling our friends to give it a go, would fuel this industry and lend weight to its wide availability in pharmacies and through publicly funded health services. It would have cost us more money too, and this additional financial burden may force others to choose between effective and ineffective remedies - something that could be avoided by only making effective treatments available.

Lastly, all of the previous points relate to giving legitimacy to an unfounded treatment for teething pain, but homeopaths and their supporters often make erroneous generalisations about the efficacy of homeopathy. Proponents use their selected ‘evidence’ for homeopathic treatment of one condition to argue, ‘hey, homeopathy works!’, and so seamlessly advocate all manner of dilutions to treat every ailment going. This is as ludicrous as suggesting that just because one drug can successfully treat one type of viral infection, ‘hey, drugs work!’, and so we can use all manner of drugs for all types of infections, without showing individual therapies work.

This last point is particularly dangerous when it comes to treating extremely serious and potentially fatal diseases, such as malaria, HIV/AIDS and cancer. Any credibility people see in homeopathic treatment for one disorder may spill over to influence their decision in treating another disorder, with potentially dire consequences.

I may be getting ahead of myself, but I think I’ll get off this bandwagon while I can.

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This post is a re-working of a version originally posted at The Skeptical Dad.