Posts Tagged Alternative medicine

New Zealand Pharmacy Ethics in Relation to Homeopathy in the Wake of Homeopathy Report Darcy Cowan Feb 24

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Earlier this year I wrote a post (along with fellow Sciblogger Grant) concerning the sale of homeopathic remedies in pharmacies. Monday night saw the release of England’s Science and Technology Committee’s “Evidence Check 2″ report on Homeopathy (also ably covered by Grant). One of the issues covered by the report is that of pharmacy responsibilities regarding sale of these remedies. Essentially the report recommended that sales continue but with adequate disclaimers stating that there is no scientific evidence that homeopathic products work beyond the placebo effect.

I see this as a compromise between commercial freedom to sell safe, though not necessarily effective, products and patient informed consent. It’s reasonable even if I disagree that it is ideal. Regardless, I thought it was a good excuse to look once again at our own pharmacies and see how the selling of scientifically unsupported remedies aligns with their professional responsibilities.

Enquiring into this area I was directed to the Pharmacy Council Code of Ethics for pharmacists. The Pharmacy Council seems to fill the function of professional association and regulatory body for pharmacists their functions including:

prescribe the qualifications required for scopes of practice within the profession, and, for that purpose, to accredit and monitor educational institutions and degrees, courses of studies, or programmes

and

consider the cases of health practitioners who may be unable to perform the functions required for the practice of the profession

Perusing the Code of Ethics (which may be found Here) I found a number of sections that I feel should preclude pharmacists from selling homeopathic remedies in good conscience. In order to try and represent the spirit of the code as accurately as possible I have included here both the relevant over-arching Principles that pharmacists should strive for as well as the Specific Obligations that I feel make my point (any emphases are mine).

The first principle is one of patient autonomy:

Principle 1: Autonomy
The pharmacist shall promote patient
self-determination, respecting the
patient’s right to understandable
information, privacy, and confidentiality

1.4 Professional services
Where the patient is seeking or receiving, from the
pharmacist or from other personnel for whom he or
she has responsibility, any professional service or
intervention, the pharmacist must ensure that the
patient is provided with credible, understandable
information about reasonably expected results,
outcomes or effects of the service or intervention, any
risks of receiving the service or intervention, and any
insufficiency of evidence about the efficacy of the
service or intervention, to allow the patient to make
an informed choice.

This to my reading implies that should pharmacists sell homeopathic remedies they are obligated to inform the patient of the lack of scientific underpinnings for the use of the remedy. One of the objections I have run into regarding the sale of these remedies in pharmacies is that they are commercial enterprises and are within their rights to sell products regardless of their medicinal value. This is partially true but these remedies are specifically sold to treat symptoms, not as entertainment, confection or cosmetic. The Code has several entries covering this aspect the first of which is:

1.5 Independent information
The pharmacist must ensure that their advice is
independent of personal commercial considerations.

Does this not imply that the sale of unscientific medicines should not be undertaken simply because it make financial sense? We will return to this point later.

The next Principle covers patient needs:

Principle 2: Beneficence
The pharmacist shall optimise medicines
related health outcomes for the patient
according to their concerns, needs,
cultural values and beliefs

2.2 Quality use of medicines
The pharmacist must provide scientifically-based,
unbiased medicines information to healthcare
providers, patients and the community in order to
optimise medicines related health outcomes.

My reading of this point leads me to understand that any information provided regarding pharmacy products must have scientific backing and moreover must not be biased by the pharmacist’s own views. Any such information regarding homeopathy must therefore be negative.

But, what if the pharmacist is not asked for this information? After all, I do not usually go in asking for a lecture if I already think I know what I need. I think the next obligation covers this instance:

2.8 Involvement in sale of medicines and other
therapies
The pharmacist must be involved and intervene in the
sale of any medicine, complementary therapy, herbal
remedy or other healthcare product whenever this is
necessary to ensure a reasonable standard of
pharmaceutical care.

Scientifically speaking homeopathy should not be considered to encompass a “reasonable standard of pharmaceutical care”.

The next Principle of relevance concerns fairness:

Principle 4: Justice
The pharmacist shall practise fairly and
justly and promote family, whanau and
community health

4.4 Commercial interests not to override good
practice
The pharmacist must ensure that commercial interests
are not permitted either to override the independent
exercise of their own professional judgement on
behalf of a patient or to compromise the standard of
care provided by them or to affect their cooperation
with other healthcare providers.

Once again the issue of financial gain over patient care is addressed with commercial interests coming off second best when the standard of care is concerned.

The next Principle is one I feel is of especial importance when the reputation of pharmacists in the wider community is considered and their self representation in the media is a factor (remember, they’re the health professional you see most often). This is trustworthiness, pharmacists are seen as, and promote themselves as, first and foremost medical professionals not business interests. The sale of homeopathic medicines is antithetical to this position and undermines their credibility in this regard, in direct contraction to the Code of Ethics as follows:

Principle 7: Trustworthiness
The pharmacist shall act in a manner
that promotes public trust in the
knowledge and ability of pharmacists
and enhances the reputation of the
profession

7.7 Non-medical goods and services
The pharmacist must not purchase or sell from a
pharmacy any product or service which may be
detrimental to the good standing of the profession or bring the profession into disrepute.

If the sale of scientifically worthless remedies such as homeopthy does not do this I don’t know what would, perhaps offering Therapeutic Touch?

Finally the Principle of dignity undermines the pharmacist’s sale of unsupported medicines:

Principle 8: Dignity
The pharmacist shall provide
information about professional services,
medicines and healthcare products in a
dignified manner without making
exaggerated or unsubstantiated claims

8.4 Medicines not ordinary articles of
commerce
A pharmacist must only participate in promotional
methods that do not encourage the public to equate
medicines with ordinary articles of commerce.

If the previous examples of why remedies should not be sold with the sole purpose of earning money for the pharmacist this should put that argument to rest. The sale of medicines (which many people consider homeopathy to be) should not be equated with ordinary articles of commerce. This puts the lie to arguing that these remedies are simply another commodity to be bought and sold like chewing gum regardless of therapeutic value.

8.8 Evidence of efficacy
The pharmacist must only promote to a potential
purchaser that any medicine, complementary therapy,
herbal remedy or other healthcare product associated
with the maintenance of health is efficacious when
there is credible evidence of efficacy.

This last obligation explicitly refers to promotion of a therapy to a patient by the pharmacist which I don’t think any reputable pharmacist would do for homeopathy but arguably the presence of the product in the store constitutes an implicit promotion of it to potential customers. This point goes back to the principle of trustworthiness, the public trusts the pharmacist to stock efficacious products. To include unscientific therapies among their wares undermines and betrays this trust. Perhaps I am naive to think so but I think the Pharmacy Council’s own Code of Ethics backs me up when I say that we should hold pharmacists to a higher standard than your average shop owner.

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Filed under: Alternative medicine, Medicine, Sciblogs, Science, skepticism Tagged: health, Health and Medicine, Health care, Herbalism, Homeopathy, homoeopathy, Medicine, Pharmaceutical drug, Pharmacy, Placebo, Science and Society

What is the Harm of Alternative Medicine? Darcy Cowan Jan 26

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Yesterday fellow Sciblogger Grant posted about homeopathic medications in pharmacies and questioned the legitimacy of reputable organisations selling such patent snake oil. The comments to this entry reveal one of the most frustrating aspects of speaking out against unscientific medicine and can be summarised thusly: “I’m far too sophisticated to be taken in by this stuff myself but other people seem to like it and if it doesn’t work then what’s the harm?”.

This attitude is ever present and comes from a reasonable starting point i.e. everyone is entitled to their own opinion and it’s not my job to save them from themselves. I can totally get behind that, usually. When it comes to ineffective medications of the alternative variety however this impulse though understandable is misguided and I’d like to put down a few reasons why I think so, some are speculative but I think the possibility of harm is great enough that they deserve to be considered.

For a start there may well be direct harm caused by using alternative remedies. As there is little to no regulation of these medications then no proof of safety or efficacy is required for sale. Witness the Zicam debacle last year regarding a “homeopathic” cold medication.

Further more the possibility for indirect harm (as multiply alluded to by Grant) may be significant. In case your imagination is not up to the task I will outline a few ways this may be the case. For instance the underlying principles of something like homeopathy are no only unscientific they are in direct contradiction of the last 200 years of scientific understanding. If they are used as the basis of reasoning about health then the results can be more dire than someone getting a bad nights sleep (in the case of the homeopathic sleep aid Grant used as an example).

Use of these therapies for minor ailments by the “worried and wonky well” may increase the possibility they they will be used for more serious health issues where the results could be deadly.

Look no further than the position statement of the WHO regarding the use of homeopathy in the treatment of Malaria and AIDs (among other things). The consequences of such thinking could be incalculable in terms of human suffering and spread of disease. But what’s the harm, right?

Additionally it is one thing for adults to make an informed choice for themselves based on available evidence filter through their particular world view but what about when this choice id forced on their children? The recent case of parents being found guilty of manslaughter over giving homeopathic remedies to their sick daughter is a terrible reminder that sometimes it is innocent children that pay the price for people’s gullibility. But, you know, what’s the harm?

When ostensibly professional medical providers such as pharmacists sell demonstrably irrational treatments they lend credibility to them that the average person uses to base decisions on. I mean the wouldn’t sell it if it didn’t work, right?

So while I understand the commitment to individual autonomy and freedom of choice that leads to the “What’s the Harm?” question, I fail to see how this means that fraudulent therapies must be let off the hook simply because there is a demand for them.

This has been a more vitriolic post than I normally write but what’s the point of a blog if you can’t vent once in a while?

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Posted in Alternative medicine, Medicine, Questionable Techniques, Sciblogs, Science, skepticism Tagged: alternative, health, Health and Medicine, Homeopathy, Medicine, Practitioners and Clinics, Science and Society, Scientific method

Natural Health Expo(sed)? Darcy Cowan Oct 15

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Driving around Hamilton the past few weeks I couldn’t help but notice the signs sprinkled around the city for the “Natural Health Expo” which is to take place here this week end. As I perused the website for this event yesterday I was disturbed by the large number of anti-scientific “treatments” that will be showcased. Like my co-blogger Grant who has already posted on this, I was troubled by the amount of misinformation that will be leveled directly at consumers.

As I was pondering how to answer the bewildering array of AltMed that will be promoted I checked my email and found a great little article just published in Chiropractic & Osteopathy (made available through the open access publisher BioMed Central).

The paper, “Why do ineffective treatments seem helpful? A brief review” written by Steve E Hartman, looks at how practitioners and patients can fool themselves into thinking that ineffective medical interventions actually work. An excellent example of Evidence Based Medicine 101, Steve covers the cognitive biases that hinder our ability to draw logical conclusions in the medical sphere such as the Post Hoc, Ergo Propter Hoc logical fallacy, confirmation bias and cognitive dissonance. Also covered are explanations of how it can seem that a treatment has been directly responsible for improvement in a patient’s condition when it may not  have been.

The paper touches on disease natural history, which simply refers to how a particular malady might be expected to progress without treatment. Self limiting diseases such as colds, headaches and fatigue can be expected to get better on their own . If a patient is taking a treatment at the time, the treatment (rather than their own immune system) might erroneously be given the credit.

This combined with the overlapping arenas of the placebo effect and regression to the mean can be a powerful confounding factor when treatments are not being considered in light of scientifically controlled settings. The placebo effect is referred to frequently in common culture but regression to the mean is a less well known entity for the layman. Steven does a good job of explaining the concept, essentially people experience a variety of different intensities in their symptoms. Also they will tend to seek medical help when the symptoms become severe, knowing that the severity of the symptoms will tend to cluster about a mean value it is likely that whether treatment is sought or not the patient’s condition will tend to get better.

Thus the patient will feel relief and attribute that relief to what ever modality they are using at the time. Practitioners are not immune to these effects either and will in their practice see time and again that patients are getting better after their pet therapy is applied. In which case they will feel justified in proclaiming it works in the absence of confirming studies (or even in the face of disconfirming evidence).

The one aspect that I felt was missing from the paper, although it may have been obliquely implied, is the role of prior plausibility in evaluating treatments. Many modalities that will be on offer at the Natural Health expo are not only unusual they fly in the face of currently understood science. Scientific plausibility is our compass, without it we can become lost in the wilderness of fanciful ideas without any method of discerning the way forward. This concept is what separates Science Based Medicine from simply Evidence Based Medicine. The former takes the plausibility of a treatment into account when deciding the threshold of evidence needed before it can be considered effective. The later only measures outcomes and so is less able to distinguish true effects from chance outcomes.

Consider the following scenario: I claim to be able to influence the outcomes of coin tosses by virtue of what I had for breakfast on a particular day. If I have eggs then tails with predominate, lettuce produces more heads. Now without considering the plausibility of the setup we could run a trial, perform statistical analysis and find that my predictions are correct. But given that there is no good reason to suspect that my diet can influence a coin toss the positive is more likely to be because of chance than because of a real effect. In this case then a higher standard of evidence would need to be achieved than if I had said I could alter the probabilities be sticking a piece of gum to one side.

All-in-all though this a very nice paper and my complaint is a small one, given the probable readership of the journal the inclusion of plausibility may even have alienated those that might otherwise have been receptive to the other points presented. I recommend reading it for yourself, it is a very easy and informative read.

Posted in Alternative medicine, Medicine, Questionable Techniques, Sciblogs, Science, skepticism Tagged: Alternative medicine, altmed, Expo, Hamilton, health, Health and Medicine, Medicine, Review, Science and Society

Vitamins and Exercise Darcy Cowan Jul 31

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I think it’s safe to say that in recent years the push to “Become Healthier” has become much stronger than it was previously. Statistics like 1/4 of New Zealand adults are obese and New Zealand being the “3rd Fattest” country in the world are used to promote a lifestyle that is aimed at making us healthier. Many of us have taken this message to heart (pun intended) and attempted to shape up but sometimes it’s not clear exactly what is healthy. The primary action people are urged to take is exercise and it’s a good one. There are many recognised benefits to regular exercise including reducing risk of Type II diabetes and possibly even reversing the condition.

Another item that is also touted as a general health promoter is antioxidants. Here’s where things start to get tricky, in order to reap the benefits of excersise there has to be some way that the fact that you are exerting yourself is communicated to the cells of your body. A promising candidate for this signal is ROS, or Reactive Oxygen Species. In other words – Oxidants. This brings up an interesting question, if you are taking antioxidants and exercising in your attempt to be healthy – what happens? A study released early this year suggests that the antioxidants reduce the beneficial effects of excersise in the body.

Researchers looked at two markers of insulin sensitivity: Glucose infusion rates and plasma adiponectin levels (high Glucose infusion rate and high adiponectin levels correlates with high insulin sensitivity = no diabetes for you). They found that taking two antioxidants (Vitamins C and E) while engaging in exercise (not literally, friends don’t let friends jog and pill-pop) actually reduced the before and after exercise difference in these markers. This result strengthens the evidence that ROS are involved in signalling changes in cells and that taking antioxidants interferes with this process.

The drawback of this study is that the participant numbers were quite small. The intial group was made up of forty men, 20 that had athletic backgrounds and 20 that didn’t. These where then split into two goups either recieving supplements or not. So the end was 4 groups of ten, not exactly a significant cross-section of the population. Even so the results are compelling and should be investigated further.

I think the moral still holds, beware of taking too many suplements, you don’t always know what the side effects will be.

Posted in Alternative medicine, Medicine, Sciblogs, Science, skepticism Tagged: Alternative medicine, altmed, antioxidants, diabetes, Exercise, health, obesity, Research, Science, study, Vitamin C, vitamin E