23/12/2015 Pharmacies, Professionalism and Homeopathy | Science-Based Pharmacy

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Pharmacies, Professionalismand Homeopathy

JULY 26, 2015JULY 26, 2015 / SCOTT

(https://sciencebasedpharmacy.files.wordpress.com/2015/07/img_83702.jpg)Can you spot the sugar pills among the medicine?

Retail pharmacies have a sugar pill problem. Homeopathic “remedies”look like conventional medicine when they’re stocked on pharmacyshelves, like the photo above. But unlike conventional medicine,homeopathic products don’t contain any “medicine” at all. They areeffectively and sometimes literally sugar pills – placebos. Notsurprisingly, there is convincing evidence to show that homeopathy isuseless as a medical treatment, and fundamentally incompatible with ascientific understanding of medicine, biochemistry and even physics.Questions have been raised worldwide about the ethics of pharmacistsand pharmacies selling homeopathy to consumers who may not realizewhat they’re buying. This practice, which appears to be growing, is

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attracting sharp criticism from other health professions. So why dopharmacies sell them? And will the pharmacy profession change?

Homeopathy is not herbalism

To understand why homeopathy has no place in a pharmacy, it’sessential to understand how homeopathy differs from other forms ofcomplementary and alternative medicine (CAM). Homeopathy is oftenmisunderstood as a natural remedy, akin to a type of herbalism. Themarketing and labeling of these “remedies” encourages this perception,often describing homeopathy as a “gentle” and “natural” system ofhealing, and putting cryptic terms like “30C” beside long Latin names ofwhat appears to be the active ingredients. In reality, there is littlelikelihood that a homeopathic remedy contains even a single molecule ofany listed ingredient. So while there may be hundreds of homeopathicremedies in a pharmacy, they are chemically indistinguishable, usuallycontaining just sugar and water. The result is a growing assortment ofplacebos on store shelves, alongside medicines and even supplementsthat actually contain active ingredients. Homeopathy was “invented” in1796 by Samuel Hahnemann, a German physician. He described thepractice as guided by two key principles, which he called “laws”:

1. The “Law” of Similars – Hahnemann believed substances thatproduce specific symptoms in healthy people will cure those samesymptoms in an ill person. Sometimes referred to as “like cures like”,the law of similars is simply a form of magical thinking. Homeopathic“remedies” can be made with natural ingredients like salt or onions,but also substances like shipwrecks, light bulbs, the Berlin Wall andeven vacuum cleaner dust or moonlight(http://naturalhealthanswers.co.uk/madefrom.php). Wheninfectious material is used, the remedy is called a “nosode” andhomeopaths believe that these products can cure or preventinfections(https://www.sciencebasedmedicine.org/homeopaths-threaten-public-health-selling-sugar-pills-as-vaccine-alternatives/). Deciding which substances will cure whichsymptoms is determined by a process called a “proving” which isentirely without any scientific basis(http://rationalwiki.org/wiki/Proving_%28homeopathy%29).(Here are homeopath provings for the Berlin Wall remedy(http://www.interhomeopathy.org/berlin_wall) and alsosunlight reflected off the planet Saturn(http://www.interhomeopathy.org/trituration_proving_of_the_light_of_saturn),as examples of a typical “proving”).

2. The “Law” of Infinitesimals – Hahnemann believed that theeffectiveness of a remedy increases the more that remedy was diluted.He advocated a series of sequential dilutions with shaking(succussion) after each dilution, believing that the water would“remember” its contact with the original substance. According toHahnemann’s theories, when sufficient water has been added todilute the original substance away so that zero molecules remain, the“remedy” was thought to be at its most powerful. Imagine puttingone drop of a substance into a container of water. Only that container

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is 131 light-years in diameter(http://en.wikipedia.org/w/index.php?title=Homeopathic_dilutions&oldid=635646115#30C:_1_ml_in_1.2C191.2C016_cubic_light_years).That’s equivalent to the “30C” dilution that is popular withhomeopaths. You’d have to eat a tablet of sugar the size of the Earth toget a single molecule of the original substance.

Homeopathy and science are mutuallyexclusive

It goes without saying that if homeopathy works in the way envisionedby Hahnemann and homeopaths, than the rest of medicine cannot. Andthat’s exactly what the evidence shows. As would be expected with inertproducts, rigorous clinical trials confirm what basic science predicts:homeopathy’s effects are placebo effects. The two most comprehensivereviews of the evidence are the 2010 Evidence Check from the UnitedKingdom’s House of Commons Science and Technology Committee(https://www.sciencebasedmedicine.org/homeopathy-gets-a-reality-check-in-the-uk/) and the 2014 Australian National Health andMedical Research Council(https://www.sciencebasedmedicine.org/another-damning-homeopathy-report/) review, which reached the following conclusion:

Based on the assessment of the evidence of effectiveness ofhomeopathy, NHMRC concludes that there are no health conditionsfor which there is reliable evidence that homeopathy is effective. Homeopathy should not be used to treat health conditions that arechronic, serious, or could become serious. People who choosehomeopathy may put their health at risk if they reject or delaytreatments for which there is good evidence for safety andeffectiveness. People who are considering whether to use homeopathyshould first get advice from a registered health practitioner. Thosewho use homeopathy should tell their health practitioner and shouldkeep taking any prescribed treatments. The National Health andMedical Research Council expects that the Australian public will beoffered treatments and therapies based on the best availableevidence.

Emphasis added.

Pharmacists should know better

Pharmacists are the health professionals with specialized training inpharmacology, and an education that concentrates on drug design,delivery and understanding how to use medicines effectively and safely.If any health professional should recognize the logical and scientific leapsthat homeopathy necessitates, it should be pharmacists. Regrettably,there seems to be relatively few pharmacies that have made the deliberatedecision not to sell homeopathic remedies. So that’s why it’s so

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heartening to see this recent commentary, from Australian pharmacistIan Carr (http://ajp.com.au/blogs/homeopathy-its-not-the-products-its-the-thinking/), who will not sell homeopathy in hispharmacy:

Fellow pharmacists, it is time to rid our shelves of these shonkyproducts. Every time a consumer is able to pluck their chosenhomeopathic drops from your shelf, you have given credence toquackery. You have increased the possibility that your patient’s nextcall might be to a homeopath, rather than a GP. You have helpedconfuse the market about what “natural” medicine might be. Perhapsyour patient will decide that a homeopathic nosode will more safelyprotect the family from whooping cough than a real vaccine. Thoughno direct harm will come from imbibing from a magic bottle of purewater, there is the danger that proven treatment will be ignored,refused or delayed unnecessarily.

Poor thinking about health will lead to poor health decisions.

Many who choose a homeopathic remedy from the shelves may betotally unaware of its scientific implausibility. Your pharmacy shouldbe ensuring patients are given clear and reasoned counselling, and indoing so, helping them avoid a lifetime of confused and deludedthinking about health.

In another column(https://www.mja.com.au/insight/2014/20/ian-carr-peddling-homeopathy), Carr argued that staff (employee) pharmacists are just asresponsible as pharmacy owners for deciding what’s on store shelves:

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As an independent pharmacist proprietor, I do not stock homeopathicmedicines, diet pills or ear candles. I am free to recommend therapieswhere I am convinced of an evidence base. However, were I anemployee pharmacist in a discount chain, would I have the sameopportunity to exercise my professional discretion and conscience? Orwould I be encouraged to companion sell and recommend the chain’sfavoured brands? Could I tell the truth and expect to keep my job?

An answer might lie in the recent newsletter from the PharmacyBoard of Australia(http://www.pharmacyboard.gov.au/News/Newsletters/March-2014.aspx#directing), which warns: “Action by non-pharmacists(such as managerial staff) which impinges on the ability ofpharmacists to meet their legal and ethical responsibilities may besubject to action under the Health Practitioner Regulation NationalLaw”.

Another category of pharmacist which allows for the profusion ofnonsense products is the uninvolved pharmacist, who sees no need tointerfere with what goes on in the front of shop. Staff training ishanded over to any company that offers it, with no oversight ofquality or ethics. Given the multimillion dollar advertising by vitaminand supplement companies, the exponential growth ofcomplementary and alternative medicines and folk cures, and theextreme level of science and health illiteracy in the populace, thislaissez faire approach is not acceptable.

Pharmacists are well placed to be at the forefront of science-basedmedicine, trained and ready to counsel, explain and teach our clients,and help give them informed control of their health.

Another profession weighs in

The growing pressure on pharmacies to stop selling homeopathy iscoming from other health professionals, too. The president of the RoyalAustralian College of General Practitioners (RACGP), Frank R. Jones,recently criticized pharmacies for selling homeopathy(http://www.theage.com.au/victoria/pharmacists-urged-to-dump-dubious-products-if-they-want-to-do-doctors-work-20150615-ghol1l.html), linking the profession’s decision to sell homeopathywith the simultaneous desire to play a bigger role in the health care system:

“We would certainly encourage our pharmacy colleagues to reallycritically look at what they are selling at their chemists (pharmacies),”he said. “I think they are very, very conflicted and I think really if theyare on board with the rest of the medical community, they have topractise evidence-based medicine.”

This follows the RACGP’s formal recommendation(http://www.racgp.org.au/download/Documents/Policies/Health%20systems/PPI-PositionStatement-Homeopathy-v1.pdf) [PDF] that generalpractitioners (family doctors) stop prescribing homeopathic remedies,and that pharmacist stop stocking these products:

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The RACGP supports the use of evidence-based medicine, in whichcurrent research information is used as the basis for clinical decision-making. In light of strong evidence to confirm that homeopathy hasno effect beyond that of placebo as a treatment for various clinicalconditions, the position of the RACGP is:

1. Medical practitioners should not practice homeopathy, referpatients to homeopathic practitioners, or recommend homeopathicproducts to their patients.

2. Pharmacists should not sell, recommend, or support the use ofhomeopathic products.

3. Homeopathic alternatives should not be used in place ofconventional immunisation.

4. Private health insurers should not supply rebates for or otherwisesupport homeopathic services or products.

It’s not just Australia. In the United Kingdom, the Chief Scientist of theRoyal Pharmaceutical Society(http://blog.rpharms.com/england/2015/06/17/homeopathy-should-pharmacists-be-selling-homeopathic-products/) had givensimilar advice:

Is homeopathy’s popularity due to a distrust of modern medicines ashas been recently suggested by the Chief Medical Officer for Englandwho has just called for an independent review(http://www.bbc.co.uk/news/health-33127672) of the safetyand efficacy of medicines? Or it is that patients are worried about theside effects associated with medicines, preferring what they perceiveto be a safer approach; after all homeopathic preparations have notunsurprisingly no known toxic effects in over 200 years of use?Whatever the reason, as an evidence-based profession, why do wecontinue to sell homeopathic preparations in our pharmacies whenthe evidence shows that they do not work?

The public have a right to expect pharmacists and other healthprofessionals to be open and honest about the effectiveness andlimitations of treatments. Surely it is now the time for pharmacists tocast homeopathy from the shelves and focus on scientifically basedtreatments backed by clear clinical evidence.

Pharmacies can prioritize patients aheadof profits

There’s a precedent for pharmacies voluntarily ceasing sales of legalproducts. Most pharmacies worldwide have quit the tobacco habit,recognizing that selling tobacco isn’t compatible with providing healthcare. In the United States, CVS became the first national drug store tostop selling tobacco, as it changed its name to CVS Health(http://www.forbes.com/sites/brucejapsen/2014/09/03/cvs-stops-tobacco-sales-today-changes-name-to-reflect-new-era/)with a bold plan to distinguish itself from its pharmacy competitors. Indoing so it walked away from $2 billion in sales(http://fortune.com/2015/06/22/cvs-retail-strategy-without-

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tobacco/). Recently it even quit the US Chamber of Commerce(http://www.latimes.com/business/la-fi-lazarus-20150714-column.html) over its stance on tobacco sales. The move has been wellreceived and the action has been highlighted as a factor in continuedexpansion into what is now the largest health care organizationin North America(http://www.nytimes.com/2015/07/12/business/how-cvs-quit-smoking-and-grew-into-a-health-care-giant.html?_r=0).Homeopathy isn’t tobacco, but its sale in pharmacies is raising the samequestions about the profession’s intent. With pharmacists stating theywant an expanded role in health care, will they confront the professionaland ethical challenges that homeopathy presents? Simply stating thathomeopathy is legally approved for sale is not sufficient justification todeceive consumers who may not know what they’re buying. This is an ethicalissue for the profession.

Homeopathy is unethical

Ethical codes for the pharmacy profession will vary by region, but mostof the ones that I have reviewed make it clear that patient’s interests arecentral to the pharmacist’s role, and that pharmacists must provideevidence-based information to support informed decision making. Sellingsugar pills on pharmacy shelves alongside real medicine, without anyexplanation, could give patients the impression that homeopathy iseffective. I’ve argued at length that the sale in pharmacies givehomeopathy the perception of scientific legitimacy, and that thisapproach is fundamentally unethical(https://www.sciencebasedmedicine.org/placebos-as-medicine-the-ethics-of-homeopathy/). Selling placebos alongside medicineviolates patient autonomy, reflecting a form of medical paternalism (orperhaps crass commercialism) that retail pharmacists need to eliminate ifthey want to be truly accepted as partners in the health care team.Homeopathy illustrates, with perhaps the most clarity, why sellingunproven or ineffective treatments is incompatible with ethical practice.This statement from Mark Crislip sums it up nicely(http://sfsbm.org/index.php?option=com_content&view=article&id=387:unethical-always&catid=45&Itemid=435):

This is the paradox of alternative medicine; by understanding, werender the treatment ineffective. Yet by concealing medicalknowledge, we return to a dangerous, medieval-like approach tohealthcare. It is for this reason why alternative medicine is flawed. Astempting as it might be to embrace placebo-based treatments, theethical standards we would have to sacrifice are infinitely morevaluable.

A pharmacist’s defence of homeopathy

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Harriet Hall’s Skepdoc Rule of Thumb(https://www.sciencebasedmedicine.org/lessons-learned/)states that when encountering a new or questionable claim, always try tofind out who disagrees and why. Why do pharmacists defendhomeopathy? Via Edzard Ernst(http://edzardernst.com/2015/07/a-pharmacists-defence-of-homeopathy/), I found this interview with Christophe Merville(http://www.rodalesorganiclife.com/wellbeing/homeopath-answers-skeptical-critics), the “head pharmacist” at Boiron(https://en.wikipedia.org/wiki/Boiron), one of the largesthomeopathic manufacturers (if that’s the right term) in the world. Hereare some of his arguments in support of homeopathy:

I remember attending the delivery of a woman and the contractionswere very strong, and painful. She had some homeopathic medicineto take just at that time to make those contractions more regular anduseful: less intense but longer and less brusque. I saw that happeningwithin minutes, and I was thinking, “That’s very impressive.” That’sprobably the time when I concluded that there is something to it. Iwitnessed the action of homeopathic medicines on pets also, on youngchildren. I had enough personal anecdotes that I could say there issomething more than just suggestion, or placebo, or just the simple actof being cared for. My attitude is to say, “There are enough signs tosay that it’s really worth exploring more why it works, how it works,when does it work.” We are past the stage where we can say, “No,there is nothing.” It has been around for a long time and if was justmere placebo effect, it would have gone away, as so many differenttechniques did.

His explanation for how homeopathy works is equally muddled:

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The main argument against homeopathy is that a remedy is very, verydiluted, so it cannot work. My reaction to that is to examine whathappens when you dilute something. The act of dilution is not verysimple. Those molecules are interacting together, they are interactingwith the walls of the container, they are interacting with the solvent,and this interaction does not adhere to a precise mathematical law.The skeptics say, “You divide the number of molecules by 100 eachtime, so after awhile, [sic] there is less than one chance to find onesingle molecule.” They have their math right, but they have theirphysics wrong.

Chemists try to use very pure substances. When you buy yourreagent, you buy it at 99.999 percent pure. But you don’t haveanything that’s 100 percent pure. It would take an infinite amount ofenergy to get rid of the last impurity. What I think we should exploreis the fact that after a certain number of dilutions, the process is notvery efficient at removing the last molecules. So there is alwayssomething that stays. That’s one thing. The second thing is inpharmacology for years, we were interested in the ability of largequantities of substances. But what about small ones? I always use theexample of butterflies that can sense pheromones at great distances,salmon finding their way back to their native creek from far away, tosharks being able to detect blood in a huge amount of water. Biologyuses very small quantities. In cells, you have communication betweencells using a few molecules of a certain substance—and it works.

I don’t pretend that I’ve put A and B and C together, and I’m able toprovide you with a complete explanation. But I would say those arethings to explore. Already the research that exists points to possibleaction of homeopathic dilution on activation or deactivation of genes.I won’t go into details, but I welcome the skepticism, I think it’s veryconstructive. But what I don’t really like is people whose mind is seton their misconception of what exactly a dilution is. Of coursehomeopathy doesn’t violate the laws of physics and chemistry,because that’s absurd.

Even the head pharmacist at Boiron admits he cannot explain howhomeopathy can work. These are just excerpts of an extended interview andI encourage you to read the entire text(http://www.rodalesorganiclife.com/wellbeing/homeopath-answers-skeptical-critics) to appreciate the arguments that Merville ismaking. To his credit, Merville is clear that homeopathy doesn’t replacemedicine like vaccines, nor can it cure cancer or diabetes. However hisbasis for concluding that homeopathy is effective seems groundedentirely in anecdotes and his own observations, neglecting to considerhow easy it is to fool ourselves. The Australian review(http://www.nhmrc.gov.au/guidelines-publications/cam02) Imentioned above considered this specific argument in its review, andgave a good explanation as to why we must look at the totality of thehighest quality evidence, rather than trust anecdotes or personalexperiences:

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It is not possible to tell whether a health treatment is effective or notsimply by considering individuals’ experiences or healthcarepractitioners’ beliefs. One reason personal testimonials are not reliableis that people may experience health benefits because they believe thata treatment is effective. This is known as the ‘placebo effect’. Anotherreason is that healthcare practitioners cannot always tell whetherchanges in a person’s health condition are due to the treatment orsome other reason. For these reasons, medicines must be tested in aplanned, structured scientific research project designed to preventthese kinds of experiences giving the false impression that a medicineis more or less effective than it really is.

And importantly, why we cannot cherry pick individual trials that maysuggest positive results:

Even where researchers take care to design studies in a way thatminimises bias, there is a chance that the results will show astatistically significant difference in favour of a treatment, when thereis actually no effect. Therefore, the results of individual studies needto be repeated in other independent studies, to make sure the effectsseen were not just due to chance. The most reliable information comesfrom research that combines the results of all available similar studiesand analyses the results together (systematic reviews).

Freedom to choose?

As an advocate for removing homeopathy from pharmacies, I’ve beenaccused by homeopathy advocates (both pharmacist and non-pharmacist)of wanting to limit “freedom of choice”, either the freedom to sell alegally approved product, or the freedom to buy legally approvedproducts from pharmacy retailers. The case for not selling homeopathy inpharmacies seems pretty clear: pharmacists need to put patient interestsabove the desire to sell inert products that look like medicine and mayconfuse patients. Ending pharmacy sales does not ban homeopathy, norwill it stop the sale of homeopathy in the market. Nor is it meant to. Thisis simply a call for pharmacies to cease selling the products. Homeopathic“remedies”, as long as they’re legally permitted for sale, can be soldelsewhere, just like tobacco remains for sale outside pharmacies. Pullingthese products out of pharmacies will signal to patients and other healthprofessionals that (1) Homeopathy has no medicinal value (2) Pharmaciesand pharmacists see homeopathy as incompatible with science-based,patient-centred, evidence-based health care.

Putting patients first

Community or retail pharmacy is a unique mix of health care deliverywithin a private, for-profit retailer. Yet pharmacies have a specific,designated role in the health care system. For that reason, pharmacies canand should to do more than what we might expect from another retailer.

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The comic XKCD said it best in a comic on “alternative literature”(http://www.explainxkcd.com/wiki/index.php/971:_Alternative_Literature)that is captioned with a quote about today’s pharmacy practice:

I just noticed CVS has started stocking homeopathic pills on the sameshelves with–and labeled similarly to–their actual medicine. Tellingsomeone who trusts you that you’re giving them medicine, when youknow you’re not, because you want their money, isn’t just lying–it’slike an example you’d make up if you had to illustrate for a child whylying is wrong.

Pharmacists ought to know better, and they ought to do better. It’s timefor the profession to act in the interests of patients. Homeopathy has noplace in today’s pharmacy practice. This is a cross-post from Science-Based Medicine(https://www.sciencebasedmedicine.org/its-time-for-pharmacies-to-stop-selling-sugar-pills/#disqus_thread).Comments are open there, and at SBP’s Facebook page. 

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One thought on “Pharmacies,Professionalism and Homeopathy”

1. cabrogalJULY 27, 2015 AT 2:42 AMSome good suggestions for pharmacists here (though I’m skeptical ofCarr’s suggestion that either the PBA or the Health PractitionerRegulation National Law will protect the job of an employee whorefuses to sell her employer’s stock) but what can the rest of us do?

I for one avoid giving my business to pharmacies that prominentlypromote shonky products, but unfortunately that hugely reduces myoptions. Even the ones that don’t flog homeopathy, iridology, etc haveshelves full of diet products, supplements, arthritis treatments, etcthat have never been shown to be effective despite numerous studies.If you add the allopathic medicines with very poor evidence base andrisk benefit ratios (e.g. SSRI antidepressants) you’re left with nooptions whatsoever for ethical consumer choice.

When it comes to homeopathy, yep I’m repulsed by it’s bogus claimsand shonky science, but even taking into account the extra harms thatcan arise from implicitly endorsing it I think having a promotionalscheme designed to sell large quantities of diphenoxylate (“Buy fiveor more packs and get a free carry bag” says the sign at my nearestpharmacy) is likely to be more harmful to customers and should besubject to greater condemnation. And that’s because diphenoxylate ismore than just a placebo.

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