MD, PhD, FMedSci, FRSB, FRCP, FRCPEd.

The ‘Pharmaceutical Journal’ just published a ‘pro/contra’ piece discussing whether UK community pharmacists should be selling homeopathic remedies to the public. Here are the essential parts of both arguments:

PRO

… I do not believe there is good scientific evidence to validate homeopathic remedies as medicines, but it is important to provide patients with choice in an informed environment — pharmacists and pharmacy teams are able to provide this expertise.

It is better for the public to buy these products from a reputable source where the community pharmacist — the expert on medicines — can provide professional advice, which is not available from unregulated online suppliers or other non-healthcare outlets…

So, I’m not here to argue the science: I argue that some people can benefit from homeopathy.

We ought to explore homeopathy’s placebo effect. Placebos are often dismissed as fakes, but they seem to act on the same brain pathways that are targeted by ‘real’ treatments. I wonder whether, through the placebo effect, homeopathy has a role to play in mental health treatment and pain relief. Whether for anxiety, mild-to-moderate depression, sleeplessness or stress, taking a little white tablet may benefit the patient, have fewer side effects than conventional medication, cause no harm, and is better than an excess of alcohol or illegal drugs.

Of course, homeopathy should not replace conventional medicines, and people should continue to be vaccinated, should use their inhalers and take their insulin. Homeopathy should not be funded on the NHS, but we do not live in a nanny state.

The clinical efficacy of many other products sold in the pharmacy is also questionable, but we still provide them. One example is guaifenesin for chesty coughs, which, at over-the-counter strength, provides a suboptimal dose. Many people are sceptical of the benefits of vitamin and mineral supplements. Bach flower remedies claim to tackle stress. We drink herbal tea for its ‘health’ benefits or buy fortified cereals because they are ‘better for you’, but these benefits are not clinically proven.

If the public finds comfort in a complementary therapy — whether it is acupuncture, reflexology, vitamins or homeopathy — I am happy to offer that choice, as long as the chosen therapies do no harm, and people continue to take their prescribed medicines.

If the patient wants my professional advice, I will explain that homeopathic medicines are not clinically proven but they may help certain conditions. I will probably recommend a different product, but at least I am there to do so.

You will not find a pharmacist in a health shop or on the internet, but in the community pharmacy you will find a highly qualified medicines expert, who will advise and inform, and who truly cares about the public’s health.

 

CONTRA

… given pharmacy’s heavy promotion of homeopathy, I feared that the profession was in danger of losing science as its bedrock.

… in 2009, a London-based pharmacy was supplying homeopathic ‘swine flu formula’. This was a dangerous practice but government agencies failed to regulate it effectively or to close it down.

In 2010, the then professional standards director at Boots, Paul Bennett (now chief executive, Royal Pharmaceutical Society), appeared before the Science and Technology Committee in its discussion of homeopathy’s availability on the NHS. Bennett stood by the sale of homeopathic remedies in Boots’ stores: “It is about consumer choice for us,” he said. I disagree with this argument.

Like the sale of cigarettes in US pharmacies, homeopathy threatens to fatally damage the reputation of community pharmacy. Pharmacies that sell homeopathic remedies give them unjustified credibility. Informed patient choice should be king; if pharmacists, pharmacy staff and shelf-barkers fail to clearly inform customers that homeopathic remedies are no more effective than placebo, we have acted unethically.

Yet Boots, perhaps alarmed by the number of subsequent protests against homeopathy outside its stores, got the message. Its website now reflects a more scientific approach: the homeopathic remedies it supplies state that they are “without approved therapeutic indications”. Boots also seems to have modified its range and offering of homeopathic remedies. So there is hope for community pharmacy.

Homeopathic remedies are still sold in pharmacies only because they make a profit. Sales in pharmacy are nonsense because, as most homeopathic practitioners claim, it is not possible to sell homeopathic remedies in isolation of a homeopathic consultation. The consultation determines the remedy. Off-the-shelf homeopathy is a relatively recent phenomenon.

The remedies are no more effective compared with placebo, anyway. Systematic reviews from the Cochrane Library — the gold standard of medical science — have considered homeopathy in the treatment of dementia, asthma and attention deficit hyperactivity disorder, all of which have confirmed the placebo effect. Irritatingly, supporters of homeopathy will always, in any debate, quote a bunkum study that shows some possible efficacy. Some might argue that placebo, or suggestion, is effective therapy, so why not use it? We must question the ethics of this approach.

Pharmacists act immorally when they sell the products without making clients aware that homeopathy does not work.

… I find that most pharmacists, when asked, appreciate that homeopathy has no scientific basis and provides merely a placebo effect. I sincerely hope that with this insight, pharmacy will finally clear its shelves of this expensive hocus pocus for good.

____________________________________________________________________________

I find both pieces quite weak and poorly argued. In fact, the ‘pro’ – arguments are quite laughable and could easily be used for teaching students the meaning and use of logical fallacies. In my view, all that needs to be pointed out here is this:

  1. Homeopathy is based on implausible assumptions.
  2. Despite 200 years of research and around 500 clinical trials, there is still no proof that highly diluted homeopathic remedies have effects beyond placebo.
  3. Therefore, selling them to the naïve public, while pretending they are real medicines, is dishonest, arguably fraudulent and certainly not the behaviour one would expect of a healthcare professional.
  4. Pharmacists who nevertheless sell these remedies as medicines are in breach of their very own regulations.

_____________________________________________________________________________

Strangely enough, when trying to find the relevant passage from the code of ethics for UK pharmacists, I struggled. The General Pharmaceutical Council’s ‘Standards fro Pharmacy Professionals‘ merely states this:

People receive safe and effective care when pharmacy professionals reflect on the application of their knowledge and skills and keep them up-to-date, including using evidence in their decision making. A pharmacy professional’s knowledge and skills must develop over the course of their career to reflect the changing nature of healthcare, the population they provide care to and the roles they carry out. There are a number of ways to meet this standard and below are examples of the attitudes and behaviours expected.

People receive safe and effective care when pharmacy professionals:

  • recognise and work within the limits of their knowledge and skills, and refer to others when needed
  • use their skills and knowledge, including up-to-date evidence, to deliver care and improve the quality of care they provide
  • carry out a range of continuing professional development (CPD) activities relevant to their practice
  • record their development activities to demonstrate that their knowledge and skills are up to date
  • use a variety of methods to regularly monitor and reflect on their practice, skills and knowledge

This, I admit, is not as clear as I had hoped (if my memory serves me right, this used to be much more explicit; in case anyone knows of a more suitable section in the code of ethics, please let me know); but it does preclude selling placebos, while pretending they are effective medicines.

22 Responses to Pro and Contra: should UK community pharmacists sell homeopathic remedies?

  • “3: Selling ‘remedies’ to the naïve public, while pretending they are real medicines, is dishonest, arguably fraudulent and certainly not the behaviour one would expect of a healthcare professional.”
    I agree 100%.

    The PJ’s piece make the usual mistake of conflating the type I benefit which may be obtained from a consultation with a homeopath (TLC, placebo responses) with the type II benefit of the pillules themselves.

    As the remedies/pillules have never been shown to have any effect (other than assisting the type I placebo effects), pharmacists who sell them are quacks and may be frauds.
    Those who endorse their activities are implicated in a conspiracy.
    It is not good enough to say “the pillules do no harm.” Taking advantage of the gullible and vulnerable is always unethical, and harmful. If for commercial reasons – their activities are fraudulent.
    What else.

  • Fact check
    ‘Off-the-shelf homeopathy is a relatively recent phenomenon.’: WRONG

    ‘Despite 200 years of research and around 500 clinical trials, there is still no proof that highly diluted homeopathic remedies have effects beyond placebo.: WRONG

    Professor Ernst knows that there are MANY homeopathic clinical trials with positive outcomes for homeopathy.

    It is true that there are more with negative outcomes but this does not mean that they are ALL negative.

    Professor Ernst TYPE OF ‘logic’:
    70 negative results
    30 positive results

    Conclusion: All results are negative and all future results are/will be negative. This is bogus science.

    When one looks at fact and evidence based sources, Wikipedia is considered a source containing factual content. Professor Ernst may have difficulty with accepting this record in Wikipedia, as he does accepting that there ARE positive clinical trials for homeopathy?

    Wikipedia: Edzard Ernst

    In 2005, a report by economist Christopher Smallwood, personally commissioned by Prince Charles, claimed that CAM was cost-effective and should be available in the National Health Service (NHS). Ernst was initially enlisted as a collaborator on the report, but asked for his name to be removed after a sight of the draft report convinced him that Smallwood had “written the conclusions before looking at the evidence”.[14] The report did not address whether CAM treatments were actually effective and Ernst described it as “complete misleading rubbish”.[14]

    Ernst was, in turn, criticised by The Lancet editor Richard Horton for disclosing contents of the report while it was still in draft form. In a 29 August 2005 letter to The Times Horton wrote: “Professor Ernst seems to have broken every professional code of scientific behaviour by disclosing correspondence referring to a document that is in the process of being reviewed and revised prior to publication. This breach of confidence is to be deplored.”[15]

    Prince Charles’ private secretary, Sir Michael Peat, also filed a complaint regarding breached confidentiality with Exeter University. Although he was “cleared of wrongdoing”,[16] Ernst has said[14] that circumstances surrounding the ensuing university investigation led to his retirement.

    In the 1 January 2006 edition of the British Journal of General Practice, Ernst gave a detailed criticism of the report.[17]

    • ‘Despite 200 years of research and around 500 clinical trials, there is still no proof that highly diluted homeopathic remedies have effects beyond placebo.: WRONG
      Professor Ernst knows that there are MANY homeopathic clinical trials with positive outcomes for homeopathy.

      HAVE YOU STILL NOT UNDERSTOOD THAT ‘PROOF’ CONSISTS OF THE TOTALITY OF THE MOST RELIABLE EVIDENCE?

      • What kind of reply is this?

        Lala sweep under the carpet, and hope that Iqbal comes with a deluge to bury these comments.

        Edzard, if this is the best that Professor Ernst can do then he is truly done and dusted.

        • very sorry to hear that you are unable to follow normal logic and common sense.

          • Oh come on Greg.when weighing up whether a claim’s worth its salt, I make four value judgements:
            1. Is it credible? (Incredible claims may simply be poorly expressed, so I look a little further)
            2. Is the argument offered a fully informed one? (Ignorant claims don’t encourage confidence and are frequently indicative of poor journalism)
            3.is the argument for this claim well-structured? (Incompetent arguments reek of lazy advertising)
            4.is the claim presented honestly? (Intentional deceptive assertions are hugely suggestive of a scam)
            On points 1, 2, 3 and 4 I conclude homeopathy is an industry that’s incredibly ignorant and incompetent gibberish that’s intentionally misrepresented. When every claim for homeopathy that I’ve encountered has failed one or more of these tests, it’s time for homeopaths to scrutinise their data and arguments.
            Of course, if you’ve got data or argument that’s credible, informed, competent and not misrepresentative, it’d be a life-changing pleasure to see it.

    • Greg:

      Quote: “Professor Ernst TYPE OF ‘logic’:
      70 negative results
      30 positive results

      Conclusion: All results are negative and all future results are/will be negative. This is bogus science.”

      Prof. Ernst’s conclusion is that homeopathy does not work and not that all results are negative. Given that working treatments result more likely in something like 70 positive trials and 30 negative trials, the observed result fits into two conclusions:

      (a) what we see here is the false positive rate and/or
      (b) there is something seriously wrong in homeopathy research.

      Since high quality homeopathic trials tend to yield a higher p-value (this being less significant) – as determined by several meta-analyses, among them the famous Mathie meta-analysis – this is compatible with (a) but not with (b).

    • Are you familiar with a false positive rate ? Apparently not. A few positive trials do not prove that something works.

  • I stay subscribed here because I am fascinated by your war on homeopathy, acupuncture, and alternative medicine generally. It seems to consume all your time. You must know that even if you write for another 50 years, you won’t change anything. What about trying to leave a worthwhile legacy? Is the legacy you want to be known at your funeral the following? “Dr. Ernst tried passionately for (30) years to stop the world believing in alternative medicine and to believe in conventional medicine instead, but he failed.” I’m not saying that you should stop. Do what you believe is right and what you are passionate about. But you know that only if you try to leave a positive legacy will you be remembered favourably.

    Regarding your comment that you fear for my sanity. Thank you for your concern. We simply live in different worlds so to speak. Your feet are fixed deeply in the conventional medicine system, which is failing mankind to some degree. I am not. There’s nothing wrong with that though. Each to his own.

    I await the furious comments from your readers, which I am sure will flood in soon.

    My warmest regards,

    Peter

    • Whilst I am not “furious” I must tell you that it is Dr. Ernst’s book (with Simon Singh) that first opened my eyes. I was always a sceptic, but had fallen prey to several popular fallacies about modren medicine and was spending hard to come by funds on silly remedies (mostly because I live in the US and had no insurance at the time). I am forever grateful to Dr. Ernst for his “wasted legacy”.

    • To help one person avoid taking a bogus path is something our dear Professor should be proud of.
      To have helped uncounted people avoid washing money and health down the drain is something our dear Prof should be applauded for. I’ve no doubt his friends and loved ones are proud of him, but thanks for giving me the opportunity to to express how much I appreciate Edward Ernst decades-long labours.

    • Do what you believe is right and what you are passionate about.

      There finally comes a time when we can boldly state the closest approximation to reality our observations can lead us to. I am sorry to tell you that Dr. Ernst is not doing what he “believes is right”. He is doing what is right.

  • Putting aside the question of pharmacies as retail businesses…

    In the UK, homeopathic medicines can be registered under the National Rules scheme (allowed minor indications) or the Simplified Scheme (no indications). But either way, these products are on the General Sales List. They can be sold anywhere. That makes legal restrictions on pharmacies selling them difficult if not impossible. Oh amd some products that used to be thought of as homeopathic and now treated as food. The Nelsons’ “Rescue Remedies” for example.

    Under the Medicines Act 1968 there are exemptions for retail (as opposed to, say, hospital) pharmacies to compound their own nostrums for sale. In many respects they are treated as unlicensed medicines – hence advertising is forbidden, possession by members of the public with intent to supply is illegal, they can’t be openly displayed and so on. But it’s only a very few pharmacies involved. The vast majority of pharmacies don’t compound homeopathic remedies.

    Some pharmacists are homeopaths. This presents all sorts of problems. Pharmacists do not have prescribing rights – unless they’ve undertake additional study and are an independent prescriber. They can advise on and sell you GSL and Pharmacy only products, but not Prescription Only or unlicensed medicines. Independent prescribers can prescribe a limited range of prescription only medicines but not unlicensed ones. It’s not an issue that the GPhC or the Faculty of Homeopathy are willing to tackle. In essence, unless a pharmacist works in a pharmacy where homeopathic medicines are compounded, it’s almost impossible for them to practice homeopathy legally unless they either i) restrict themselves to GSL and food products and/or ii) get clients to source unlicensed medicines themselves.

    The argument that GSL/food products (eg supplements) should be bought from community pharmacies because the special expertise of staff doesn’t wash. It’s retail really, not proper pharmacy. The only homeopathic products that can legally be bought online in the UK are GSL/food ones (and the illegal ones are a matter for the MHRA).

  • “Velly Funny, Doktol Ernst”!

    Why do you permit the majority of this nonsensical blablabla to be called “responses”?

    In case the respondents cannot explain themselves, it is your duty to inform them their wawawah cannot be understood by a Dutchman like me, and can therefore not be included on your blog.

    What a mess!

  • Pharmacies and “Health” Food stores that sell unproven or fake remedies should be forced to advertise the truth. One example could be “HOLE FOODS, A GREAT SOURCE FOR PROVEN AND UNPROVEN REMEDIES, (ask your licensed physician or pharmacist the difference).

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