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

A few days ago, I published an article in the ‘Sueddeutsche Zeitung’ (a truly rare event, as I have never done this before) where I argued that German pharmacists should consider stopping the sale of homeopathic remedies. It violates their ethical code, I suggested.

While this discussion has been going on for a while in the UK (British pharmacists have stopped inviting me to their gatherings because I get on their nerves with banging on about this!), it is relatively novel in Germany.

After I had submitted my copy to the SZ, an article was published which is highly relevant to this subject. Here I first copy an extract of the German original, and below I try to briefly explain its content to those who do not read German.

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In vielen Apotheken werden Kunden nicht hinreichend gut zu Homöopathika beraten. Zu diesem Ergebnis kommt Professor Tilmann Betsch, an der Universität Erfurt Leiter der Professur für Sozial-, Organisations- und Wirtschaftspsychologie, der mit seinem Team 100 zufällig ausgewählte Apotheken in Stuttgart, Erfurt, Leipzig und Frankfurt auf Herz und Nieren geprüft hat. Im Mittelpunkt der Kundengespräche stand eine Beratung zu einem erkälteten Familienmitglied.

“Zum einen zeigen unsere Ergebnisse, dass im Falle eines grippalen Infektes die überwiegende Mehrzahl von ihnen zu schulmedizinischen Präparaten rät, die mit hoher Wahrscheinlichkeit zu einer Linderung der Symptome führen”, erläutert Betsch. Was die Wirkung von Homöopathika betreffe, so zeichne das Untersuchungsergebnis ein eher düsteres Bild, ergänzt er. Denn in nur fünf Prozent aller Beratungsgespräche sei gesagt worden, dass es für die Wirkung von Homöopathie keine wissenschaftlichen Belege gäbe. In 30 Prozent sei dagegen behauptet worden, die Wirkung von Homöopathie sei entweder in Studien nachgewiesen oder ergebe sich aus dem Erfahrungswissen.

“Nach den Leitlinien der Bundesapothekenkammer soll jedoch die Beurteilung der Wirksamkeit von Präparaten nach pharmakologisch-toxikologischen Kriterien erfolgen. Zumindest was die Begründung ihrer Empfehlungen betrifft, folgte die überwiegende Mehrheit der von uns befragten Apotheker diesen Leitlinien nicht”, so Betschs Fazit. Während die Empfehlungen der Apotheker in der Regel nachweislich wirksame Medikamente enthalten hätten, habe sich ihr Wissen über die Wirkung von Homöopathie mehrheitlich nicht von Laien-Meinungen unterschieden.

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Professor Tilmann Betsch has conducted a study showing that German pharmacists fail their customers when advising them on homeopathy. His team went under cover as patients with flue-like symptoms to 100 randomly selected pharmacists. Only 5% of the pharmacists admitted that homeopathics have no proven efficacy, while 30% claimed homeopathics have been proven to work in studies and through experience. This behaviour, Betsch explains, violates the current guidelines for pharmacists.

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I am delighted with these findings; they confirm my arguments perfectly.

Since, in Germany, homeopathics are sold only in pharmacies, German pharmacists have a pivotal role here. They are ethically bound to inform their customers based on the current best evidence. So, in my day-dreams, I imagine a dialogue between a customer and an ethical pharmacist:

CUSTOMER: I have a flu, is there a homeopathic remedy against it?

PHARMACIST: Yes, there is.

CUSTOMER: Can I have it please?

PHARMACIST: If you insist; but I must warn you: it has been shown not to work, and there is absolutely nothing in it that could possibly work.

CUSTOMER: What? Why do you sell it then?

PHARMACIST: Because some people like it.

CUSTOMER: Even though it does not work?

PHARMACIST: Yes.

CUSTOMER: Is it expensive?

PHARMACIST: Yes.

CUSTOMER: And some people still buy it?

PHARMACIST: Yes.

CUSTOMER: Well, not I! I am not a fool. But thank you for your honest information. Can I have something else that alleviates my symptoms?

PHARMACIST: With pleasure!

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The fate of homeopathy in Germany is largely in the hands of pharmacists, it seems.

But, is it in good, ethical hands? Is there hope that progress can be made?

We will see – so far, I have heard of just one!!! pharmacy that has stopped displaying homeopathics on its shelves.

14 Responses to German pharmacists fail their customers when advising them on homeopathy

  • Edzard

    I changed it to suit outcome in India:

    At a PHARMACIST (named Chemist) shop in India, a dialogue between an informed customer and an ethical pharmacist:

    CUSTOMER: I have a flu, is there a remedy against it?

    PHARMACIST: Yes, there is.

    CUSTOMER: Can I have it please?

    PHARMACIST hands over a strip of Tamilflu.

    CUSTOMER: But this is Tamilflu and it has been shown not to work. Do you not have something else and effective?

    PHARMACIST: How can you say so? This is manufactured by Roche. Roche is a company from Switzerland with a very big R&D department.

    CUSTOMER: But there is a Cochrane review that confirms it as a waste of money and many serious adverse events were reported during post-marketing surveillance from Japan, UK, and subsequently from other places.

    PHARMACIST: How can you say that? Roche is a very responsible company. Many countries purchased millions of US$ worth of Tamilflu. Even WHO distributed Tamilflu.

    CUSTOMER: Will that argument can make it a good medicine or doctors who saw real outcome? I believe in doctors’ observations. Just for my interest, what is the price?

    PHARMACIST: Not very much. Roche course for 5 days will cost Rs. 7000. If you agree to Indian equivalent it will cost about Rs.2000.

    CUSTOMER: That is more than one week’s income for most Indians. And people still buy it?

    PHARMACIST: Roche, few. Most prefer Indian equivalents.

    CUSTOMER: Well, not me! I am not a fool. But thank you for your honest information. Can I have something else that offers me better option?

    PHARMACIST: Go to the homeopathic medical store, three shops down on the right. Their doctor has recommended a remedy valid for flu conditions seen this season. I bought for my family and me.

    CUSTOMER: What is the cost?

    PHARMACIST:I suggest you buy one sealed bottle. Costs Rs. 75 and will suffice for your family of 4 for the 3 day course. The good part is that there are no adverse effects either.

    CUSTOMER: You don’t stock homeopathic medicines?

    PHARMACIST: No. Profit margin is not enough. Also no follow up complaints do not help in repeat business. We stock cosmetics. Let me know if you need anything.l

    CUSTOMER: Thank you.

    • Edzard

      The Indian equivalent of Oseltamivir Phosphate costs Rs.429 for a course of 5 days. I regret error.

    • Thanx Iqbal. You nailed it!

      As for research on homeopathy and the flu, there have been three double-blind and randomized trials showing the efficacy of homeopathic Oscillococcinum, including one large trial published in a conventional journal:
      Ferley, JP, Zmirou, D, D’Admehar, D, et al., A Controlled Evaluation of a Homoeopathic Preparation in the Treatment of Influenza-like Syndrome, British Journal of Clinical Pharmacology, March, 1989,27:329-35. http://www.ncbi.nlm.nih.gov/pubmed/2655683

      It is both interesting and important to note that Oscillococcinum is made from the heart and liver of a duck. Biologists and epidemiologists have confirmed that most ducks carry a variety of influenza viruses in their digestive tracts. In 2005, the “bird flu” has become a major media event, and it is becoming more common knowledge that various birds are reservoirs and carriers of flu viruses.

      The fact that homeopaths have used internal organs of ducks since 1925 shows again that homeopaths have been on the forefront of drug discovery

      Plus…

      A pragmatic clinical trial on preventing influenza was conducted in the Brazilian Public Health System in Petrópolis (a major city in Brazil) with children aged from 1 to 5 years old (Siqueira CM, Homsani F, Féo da Veiga, et al, 2016). The medications used were mainly selected based on in vitro experiments (InfluBio, which is a homeopathic dose, 30X, of influenza virus [A/Victoria/3/75 (H3N2)]), and in successful qualitative clinical experiences (Homeopathic Complex composed of Streptococcus and Staphylococcus and inactivated influenza virus in a 30X dilution). Following informed parental consent, subjects were randomly distributed, in a blind manner, to three experimental groups: Homeopathic Complex, Placebo, and InfluBio. Brazil public health officials collected flu and acute respiratory infection symptomatic episodes monthly following the established protocol. The number of these episodes was registered in one year (2009–2010).

      Out of the 600 children recruited, 445 (74.17%) completed the study (149: Homeopathic complex; 151: Placebo; 145: InfluBio). The number of flu and acute respiratory infection symptomatic episodes detected in this clinical trial was low; however, it was different between homeopathic groups and placebo (p < 0.001). In the first year post-intervention, 46/151 (30.5%) of children in the placebo group developed 3 or more flu and acute respiratory infection episodes, while there was no episode in the group of 149 children who used Homeopathic Complex, and only 1 episode in the group of 145 (1%) children who received InfluBio.

      The researchers concluded that the use of homeopathic medicines minimized the number of flu and acute respiratory infection symptomatic episodes in children, signalizing that the homeopathic prophylactic potential should be investigated in further studies.

      Siqueira CM, Homsani F, Féo da Veiga V, et al. Homeopathic medicines for prevention of influenza and acute respiratory tract infections in children: blind, randomized, placebo-controlled clinical trial. Homeopathy. 2016 Feb;105(1):71-7. http://www.pubfacts.com/detail/26828000/Homeopathic-medicines-for-prevention-of-influenza-and-acute-respiratory-tract-infections-in-children

      • “There is insufficient good evidence to enable robust conclusions to be made about Oscillococcinum® in the prevention or treatment of influenza and influenza-like illness”
        Cochrane review by the late Peter Fisher
        https://www.ncbi.nlm.nih.gov/pubmed/25629583
        puls
        Siqueira CM, Homsani F, Féo da Veiga V, randomised ???
        are you sure?
        TELLING PORKIES AGAIN, DANA?

      • But Dana. Ignoring (yet again..) Iqbal dragging his straw man out of the closet, he has advised the purchase of an over-the-counter non-individualised remedy. You repeatedly flail and spout about lack of internal validity when studies demonstrating the lack of efficacy of non-individualised remedies are mentioned because, according to you, remedies HAVE to be individualised. Are you contradicting yourself again? Or is it that non-individualised remedies don’t work unless they do work? It’s almost as if you were making it all up as you go along. Surely not.

        • You know nothing about homeopathy: yet you discuss.

          Genus epidemicus

          Homoeopathic Genus Epidemicus ‘Bryonia alba’ as a prophylactic during an outbreak of Chikungunya in India: A cluster -randomised, double -blind, placebo- controlled trial

          http://www.ijrh.org/article.asp?issn=0974-7168;year=2014;volume=8;issue=3;spage=160;epage=165;aulast=Janardanan

          • You know nothing about homeopathy

            Yet he still knows more about homeopathy than you do. He knows that it can’t possibly work, and he knows that indeed it doesn’t work. And what’s more: that is really all one needs to know about it.

            The rest of the ‘knowledge’ of homeopathy is nothing but fairy tales and smoke & mirrors, aimed at maintaining the old illusion.

            The main thing left to do is to get this knowledge across to the general public, and to prevent false information (i.e. that it somehow does work after all), usually originating from those who sell homeopathy, from reaching the public. The latter is the more difficult task – as this blog post also shows – but slowly, things are getting better.

          • Oh Iqbal. You know nothing about study evaluation, yet you discuss. Cluster designs require designs that take into account the dependence of clusters. I.e. if a cluster has a higher infection rate, the probability of observing more infections is higher. The Indians just mention the citation, but not which models and covariates they used. The study is worthless.

        • Lenny, how simple-minded of you! It IS true that homeopathic medicines are generally most effective when they are individually selected to each patient…BUT there are exceptions. I realize that your simple-mind has difficult with complexity and all..and I realize that you prefer hard and fast concrete rules, but good scientists know better. It is something to strive for…in the meantime, my sympathies…

      • I have tried to look up the paper that you cite by Siqueira et al., but unfortunately you have only linked to the abstract, and I cannot download the full paper as I no longer have full access to Elsevier publications now that I am retired, and I am not prepared to pay to read this one as a one-off. I assume you have ready access to the full paper, and I wonder, therefore, if you could supply some details that would help me evaluate the trial?

        How were the children identified? What were the exclusion and inclusion criteria? How was the randomisation performed? How well-matched were the three groups? Was the study double-blinded, single-blinded or not blinded at all (“randomly distributed in a blind manner” does not explain much)?

        How were the episodes of flu and acute respiratory infection diagnosed? Was it on the basis of viral DNA sampling, or simply reporting of symptoms. Was any distinction made between influenza and coryza?

        Given the high drop-out rate, how were the individuals who didn’t complete the trial dealt with? Were the results analysed on an intent-to-treat basis, or on actual treatment given (a common source of bias)? What were the reasons for non-completion?

        There is no mention in the abstract of adverse events or symptoms in any of the groups. One would normally expect these as a matter of course, simply by following up any group of children over a period of time. What were the findings here?

        The abstract gives a significance level of P<0.001, but does not give any indication of what statistical test this refers to. Could you fill in the missing details here? Indeed, what sort of statistical analyses were the data subjected to.

        Given that the results quoted (with at least 138 episodes in the placebo group and only one in the other two groups) would seem unlikely in any clinical trial, do the authors discuss other explanations, possible sources of bias etc.?

        Have there been similar trials elsewhere reproducing these results?

        Unfortunately without this information (of the sort required to read any medical paper) it really isn't possible to evaluate the link you have supplied.

  • in my day-dreams, I imagine a dialogue between a customer and an ethical pharmacist…

    I think that proper information is a crucial factor in the whole debate about alternative treatments, and that even in Germany, pharmacists are just one of several points where properly informing customers fails. After all, pharmacists are merely the point of sale, but information (good and bad) reaches the public through many other channels; in the context of this blog post, pharmacists act as the final gatekeeper, the last point of information before people actually decide to spend money on a product. And yes, it is of course desirable that this information be as accurate as possible, if only because patients should be able to trust pharmacists for independent(!) advice, without running the risk of being sold a useless product.

    As far as I can see, there are in essence two reasons why people buy alternative ‘remedies’:
    1. People start buying these products because they received information that these products might work.
    2. People continue buying these products because they think that they really helped, and because they do not receive information that they may be fooling themselves (through the placebo effect, regression to the mean etc.).

    False information starts with manufacturers and suppliers of alternative products. Even though in many countries, these parties are required by law to include disclaimers in their patient information, everything is aimed at the exact opposite: trying to convince people that the product actually works – with the disclaimer often present in the proverbial small print and/or in suggestive, obfuscating language.
    Let’s take the (Dutch) information leaflet for oscillococcinum as an example. The first misleading phrasing is a consistent use of the term ‘homeopathic medicine‘ (‘homeopathisch geneesmiddel’). Even though these inert sugar crumbs are NOT ‘medicine’ by any definition of the word, the word ‘medicine’ is liberally sprinkled throughout the text, strongly suggesting customers that, yes, they are really buying something that works!

    Then there is the obligatory disclaimer, under heading #1:
    “Homeopathic medicine without specific therapeutic indication, used in accordance with the principles of homeopathy.”
    Most people do not understand what this means, in particular the crucial part ‘without specific therapeutic indication’ – and people being people, they simply ignore it. This is what it should say, in my opinion:
    “Homeopathic sugar crumbs with no proven effectiveness for any illness.” (And perhaps this wording can even be simplified further, to preclude any misunderstanding.)

    Next up, under heading #3, “How to take this medicine”, we find the next bit of suggestive deception:
    “Always take this homeopathic medicine exactly as prescribed in this leaflet, or as instructed by your doctor or pharmacist.” (emphasis mine)
    This falsely suggests that doctors and pharmacists actually prescribe this product, or at least take it serious enough to tell people how to use it, further enhancing the impression that we’re dealing with real medicine, not with hocus pocus sugar pellets.
    Some other things to raise the impression of genuine medicine are clauses about what to do in case of an overdose, what to do if you forgot a dose, where to report side effects etcetera (although these things may be mandatory by law for the product to be sold).

    Last but not least, under heading #6 we find the list of ingredients, and also the biggest lie so far:
    “Which substances are present in this medicine?
    – The active substance in this medicine is Anas barbariae, hepatis et cordum extractum 200 K.”
    This is an egregious lie, because this ‘active substance’ is NOT present AT ALL.
    The ONLY substances present are the excipients mentioned on the second line, sucrose and lactose. I even believe that mentioning an ingredient that is not present at all violates one or more consumer laws, but somehow, homeopaths seem to get away with it scot-free so far.

    Summarized, the ‘information’ from the manufacturer of this oscilloquackinum product is NOT reliable at all. It is suggestive and even untruthful. When people base decisions about their health and spending on ‘information’ like this, they are being defrauded, plain and simple.

    Yes, pharmacists should also tell people that they’re about to spend money on unproven treatments, but first and foremost, manufacturers of these products should stop providing false and suggestive information, not in the last place because this is about people’s health.

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