Or: Homeopathic remedies in NZ pharmacies redux
A little over five years ago I wrote suggesting New Zealand pharmacies should not be selling homeopathic remedies.
Over the past few days there have been renewed calls for pharmacies to stop carrying these junk remedies following an Australian survey of the evidence. One call has come from fellow sciblogger, Mark Hanna—see Ethical Pharmacy Practice 3: Running Out of Excuses. However it’s not so much that pharmacies are running out of excuses as that they never had any: it’s not realistic that a soundly-trained pharmacists do not know that these remedies are worthless. Furthermore, their regulations oblige them not to sell worthless remedies.
Another call has come from the NZ Pharmacy Today magazine blog, who write -
Ethically, pharmacists should only be selling health products for which there is credible evidence of efficacy, and they are moving towards being more like primary health centres, so there’s a strong argument for pharmacies not selling homeopathic remedies.
In the past, when Pharmacy Today reporters have phoned around on the issue, many pharmacists have said they stock homeopathic products because patients want them and will buy them elsewhere if they don’t sell them.
We know GPs will prescribe placebo treatments because patients want to take something and there’s credible evidence for the effectiveness of placebos.
However, I feel pharmacies need to reconsider their stance in the light of this report, which is comprehensive and reliable, and consider not selling homeopathic products – as part of their move towards becoming health centres, plus towards being respected members of the primary healthcare team.
It’s excellent to see this coming from within the industry, but having followed this topic over several years now I’m left with some thoughts.
Firstly, as Mark points out, it’s not a case that “pharmacists ‘should’ only be selling health products for which there is credible evidence of efficacy” (alterations mine, emboldened) but that they are obliged to—but choose not to. Their ethical guidelines state -
[PHARMACISTS] MUST:… Only purchase, supply or promote any medicine, complementary therapy, herbal remedy or other healthcare product where there is no reason to doubt its quality or safety and when there is credible evidence of efficacy.
Darcy Cowan wrote more on the regulatory issues in 2010 and earlier articles from Mark no doubt cover similar ground.
Secondly, the argument that ‘other businesses sell junk remedies therefore we shall’ is unsound. One of the key points about the ethical regulations for pharmacies is that customers should be able to walk into a store and have an expectation that the remedies within the store are basically sound. If other businesses elect to be unsound, that’s poor health practice, but no justification to do likewise. On the face of it, it would seem that the profit motive is ruling over sound and ethical practice.
Thirdly, that some GPs subscribe placebos should have no standing in this. There is some arguments for GPs to prescribe placebo remedies in some cases; others would argue that education is a better response in most cases. Either way—and just my opinion—it seems to me that GPs prescribing homeopathic remedies encourages people to think these have real remedial effects. I don’t work within the industry, but I am sure are ways of offering placebos that avoid using off-the-shelf commercial products. One might be that patients only get placebo ‘treatments’ via prescription.
There is no valid, ethical, reason for customers to buy a placebo themselves: they’d be aiming to buy a remedy, but in fact buy something that does nothing. It’s the sort of thing that consumer protection is intended for. Bear in mind here that pharmacists are obliged to tell someone the nature of the remedy if they ask. Imagine responding ‘well, that stuff, it does nothing, we just sell it’.
(I tried asking about homeopathic remedies as a small, anecdotal, experiment a few years ago. Some salespeople sung praises of how the remedy treated whatever it was—clearly unaware that the remedy was worthless, something I believe they’re obliged to know. Some pharmacists mumbled vague things: it seemed clear to me that they knew the remedies were, at best, ‘controversial’, but felt too awkward to say so plainly.)
Fourthly, Pharmacy Today encourages that “pharmacies need to reconsider their stance in the light of this report”. While this is an excellent idea, and one I thoroughly support, I suspect the underlying driver isn’t the report, but media presence on the topic. There is a long trail of evidence over many years showing that homeopathic remedies are not effective for anything.
You’d wish a professional body would track evidence reports on things they sell and respond on their own initiative, rather only responding under pressure. Reports showing that homeopathy has no effect beyond a placebo effect have been published for years. So why now? I’m skeptical that it’s the physical proximity of this report being from ‘just over the ditch’. One difference would be local media coverage showing up the embarrassing state of affairs in our pharmacies. The word ‘local’ being key.
There were similar calls to drop homeopathy in Australia April last year. Mark Hanna has listed some earlier studies. I’ve covered some of these previously, in particular the House of Commons Science and Technology Evidence Check 2: Homeopathy report. There are more surveys still. As just one example there’s a meta-study published in 2007 in the highly-regarded medical journal, Lancet. The author, Ben Goldacre, has also presented this work on-line. It opens,
Five large meta-analyses of homoeopathy trials have been done. All have had the same result: after excluding methodologically inadequate trials and accounting for publication bias, homoeopathy produced no statistically significant benefit over placebo.
The studies “large meta-analyses” referred to range from the 1990s to the mid 2000s. There have been reports and letters in the New Zealand Medical Journal. Looking wider, the Australian survey drew from 176 primary studies and 58 systemic studies. It’s not credible that these were ‘missed’.
The Australian study that prompted the latest round of interest drew this statement,
Based on the assessment of the evidence of effectiveness of homeopathy, NHMRC concludes that there are no health conditions for which there is reliable evidence that homeopathy is effective.
Homeopathy should not be used to treat health conditions that are chronic, serious, or could become serious. People who choose homeopathy may put their health at risk if they reject or delay treatments for which there is good evidence for safety and effectiveness. People who are considering whether to use homeopathy should first get advice from a registered health practitioner.* Those who use homeopathy should tell their health practitioner and should keep taking any prescribed treatments.
The National Health and Medical Research Council expects that the Australian public will be offered treatments and therapies based on the best available evidence.
Why were the relevant professional bodies not onto this evidence sooner?
(Currently this is striking me as a bit of a theme with those claiming to have the interest of the public on a topic in mind. I find the similar lack of response House of Common Science and Technology report on GMO legislation disconcerting, too. You’d think those with genuine interests in these topics would take up the advice these reports, but we’re not seeing responses despite the clear relevance of both reports to New Zealand and the strong advice they offer.)
In fact, you don’t even really need these studies: a simple understanding of basic chemistry and how these remedies are claimed to work is enough to realise homeopathy is essentially water with a nice story. (Remember while you’re reading this that pharmacists are supposed to be trained in basic chemistry.)
There’s the incorrect idea that like-cures-like concept, that idea a small part of the thing that causes the illness, or causes symptoms shared with the illness, will cure it.
There’s the nonsensical dilutions. Homeopathic remedies are made by taking an ingredient, which is ‘potentiated’ by diluting it; the higher the dilution, the stronger ‘potential’ the mixture is claimed to have. This is contrary to the basic idea of dosage: usually a greatly reduced dosage means the ‘remedy’ will have little effect. Each dilution step is followed by succussion - shaking. The ingredients are most often quite exotic – things we might expect to see in an ancient remedy from before the time of sound medicine.
Take some substance, dilute it 100, so it’s 1% of the solution. Now take that and dilute it 100-fold again. Then take that and dilute it 100-fold again. If the dilution is to be 30C, this is done 30 times one after the other. Obviously you have essentially nothing of the original substance in the final solution.
This was originally premised on the idea of ever-smaller substances, something that even in the day of homeopathy founder, Hahnemann, was being to be known as wrong—that there were atoms. Atoms don’t break down to smaller atoms, they are the smallest unit.
In the same way you can’t make ever-increasingly small dilutions—at some point you’ll remove the last molecule of the substance from the solution and have none of the original active ingredient.
There’s some homeopaths appealing to ‘spiritual healing’ notions or odd claims about quantum physics being involved. (I’m not making that up.)
These are trivially known as unsound today and any reasonable pharmacist should, surely, say ‘That’s bunk’.
There’s the shifting defense, a sign of clinging to a belief rather than recognise it as wrong-headed. Homeopaths recognised that the infinite dilution argument conflicted with the laws of physics many years ago. In response, they shifted to the argument to that ‘water has a memory’, that—somehow—water ‘recalls’ what was in it. This, too, is nonsense. This illustrates the ‘nice story’ aspect to the pitch for homeopathy: that when one story fails, another is held up. More recently this has shifted again, to evoking quantum physics as a defense.
Ben Goldacre has noted that the ‘success’ of homeopathy in Hahnemann’s day was not due to effectiveness of the ‘remedy’, but that it caused less harm that (most of) the alternatives of the day.
Some may feel these remedies do no harm, but ineffective treatments can allow an illness or disease to progress, making them harder to treat later. At an extreme patients with treatable illnesses might suffer unnecessarily (possibly even die in the case of serious illnesses).
Homeopathy is not the same as herbal remedies. This seems a common confusion among consumers seeking out these remedies. Herbal remedies, with all the faults they can have, at least have some active ingredients.
You might think that such remedies would be limited to trivial illnesses, in particular ones that would be expected to come right over time. In practice you’ll find homeopathic remedies from these right through to homeopaths treating very serious illness, like Claire Bleakley homeopath and head of GE Free NZ (formerly RAGE: revolt against genetic engineering) treating cancer patients.
There may well be those who believe in homeopathy, but organisations whose products and practices are supposed to be based on evidenced practices should not be selling or offering it and should respond to evidence reports when they arise.
1. Thanks to Mark Hanna for pointing this out.
2. You might quibble about the meaning of ‘obliged’ here, I’m not going to. The moral issue is enough for me, the legal aspects simply add weight to an already morally dubious position.
3. A winkle to this might be how the stock being offered for sale is chosen. It’s possible that pharmacies being chains or franchises are ‘obliged’ to carry the stock that their parent companies supply. I’m not familiar with this. If this is an issue, this needs attending to.
4. Perhaps that this would also leave a traceable record of prescribing a placebo is also useful?
5. This is off-topic here, but for the curious I’ll be offering more on this soon: one longer piece covering the full report and, hopefully, a more informal piece pulling out the arguments for those less keen on formal reports!
6. Salespeople may not have a background in chemistry, but they’re still obliged to be accurate in describing the products.
Some of the articles on Homeopathy in Code for life: