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

pharmacists

I have written about the ethics of pharmacists selling homeopathic preparations pretending they are effective medicines often – not just on this blog, but also in medical journals (see for instance here and here) and in our recent book. So, maybe I should give it a rest?

No!

I believe that the issue is far too important not to remain silent about it.

A recent article in the ‘Australian Journal of pharmacy’ caught my eye. As it makes a new and relevant point, I will quote some short excerpts for you:

One of the greatest criticisms pharmacists face is the ranging of homeopathic products in pharmacies. It is difficult to deny that ranging homeopathic products provides a level of legitimacy to these products that they do not deserve.

Conclusive evidence now exists [1] that homeopathy does not work. This is different from a lack of evidence for an effect; this is specific evidence that shows that this modality cannot and does not provide any of the purported benefits or mechanisms of action.

This evidence for lack of effect is important, due to the ethical responsibilities of pharmacists to provide evidence-based medicine. Specifically, from the Pharmaceutical Society of Australia’s Code of Ethics [2]:

Care Principle 1 g)

Before recommending a therapeutic product, considers available evidence and supports the patient to make an informed choice and only supplies a product when satisfied that it is appropriate and the person understands how to use it correctly.

It is not possible to adhere to this principle while also selling homeopathic and other non-EBM products – it is incumbent on pharmacists to always notify a patient that homeopathic medicines cannot work. Ranging homeopathic products therefore opens a pharmacist up to conflict of interest, where their professional judgement tells them that there is no benefit to a product, yet a patient wishes to purchase it anyway, even when advised not to. Not ranging a product is the only method of preventing this conflict.

Pharmacists may also find themselves in position where the pharmacy they work in ranges homeopathic or other non-EBM products, yet they do not want to be involved in the sale or recommendation of these products. In this situation, it is important to remember that the code of ethics requires that a pharmacist does not undertake any action or role if their judgement determines that this is not the correct course of action.

Integrity Principle 2

A pharmacist only practises under conditions which uphold the professional independence, judgement and integrity of themselves and others.

Professional misconduct

This leads to the professional risk a pharmacist puts themselves in when recommending or selling a product that lacks evidence … any breach of the code of ethics can be the basis of a report to the Pharmacy Board for professional misconduct. If a pharmacist were to be referred to the Pharmacy Board for recommending a non-EBM product, pharmacists will be put in the position of having to justify their decision to supply a product that has no evidence, especially if this supply harms a patient or delays them from accessing effective treatment. In addition, it will not be possible to make a case defending the decision to supply non-EBM products based on pressures from employers wishes, due to Integrity Principle 2.

Clearly, the use of Non-EBM products, including homeopathy, puts consumers at risk due to delayed treatment and the risk of unexpected outcomes. It also puts pharmacists at risk of professional and ethical reprimand. Relying on evidence, and having a working knowledge of how to access and assess this evidence, remains a critical part of the role of pharmacists in all areas of practice.

[1] https://www.nhmrc.gov.au/guidelines-publications/cam02

[2] https://www.psa.org.au/downloads/codes/PSA-Code-of-Ethics-2017.pdf

END OF QUOTE

I find this comment important: we all knew (and I have dwelled on it repeatedly) that pharmacists can put consumers at risk when they sell homeopathic remedies masquerading as medicines (while in truth they are placebos that cure absolutely nothing). What few people so far appreciated, I think, is the fact that pharmacists also put themselves at risk.

Of course, you might say, this is a view from Australia, and it might not apply elsewhere. But I think, because the codes of ethics differ only marginally from country to country, it might well apply everywhere. If that is so, pharmacists across the globe – most of them do sell homeopathics regularly – are in danger of breaking their own codes of ethics, if they recommend or sell homeopathic products. And violating professional ethics must mean that pharmacists are vulnerable to reprimands.

Perhaps we should all go to our next pharmacy, ask for some advice about homeopathy, and test this hypothesis!

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.

In my previous post, I reported that the NHS has included homeopathy and herbal medicine on the list of medications that might no longer get reimbursed. The news was reported by most newspapers in the UK. All of the papers correctly quote NHS England giving their reasons for black-listing homeopathy and herbal remedies. Some papers also quote critics of homeopathy providing short ‘sound bites’ and opinions. None of the articles bother to explain in any detail why homeopathy is so ridiculously implausible or how strong the evidence against it has become. In this post, I intend to analyse some of this press coverage by copying those excerpts from the newspaper articles which I find odd or misleading and by adding short comments by myself.

THE DAILY MAIL claimed that homeopathic remedies are treatments using heavily diluted forms of plants, herbs and minerals. This is factually incorrect; think of remedies like X-ray! The Mail also quoted Don Redding, director of policy at National Voices, stating: ‘Whilst some treatments are available to purchase over the counter, that does not mean that everyone can afford them. There will be distinct categories of people who rely on NHS funding for prescriptions of remedies that are otherwise available over the counter. Stopping such prescriptions would break with the principle of an NHS “free at the point of use” and would create a system where access to treatments is based on a person’s ability to pay.’  This argument might apply to medicines that are proven to work; it does, however, not apply to homeopathy.

THE INDEPENDENT cited Professor Helen Stokes-Lampard, chair of the Royal College of GPs, who said: “If patients are in a position that they can afford to buy over the counter medicines and products, then we would encourage them to do so rather than request a prescription – but imposing blanket policies on GPs, that don’t take into account demographic differences across the country, or that don’t allow for flexibility for a patient’s individual circumstances, risks alienating the most vulnerable in society.” Again, this argument might apply to medicines that are proven to work; it does, however, not apply to homeopathy.

THE DAILY TELEGRAPH also reported the quote from Don Redding, Director of Policy at National Voices which I cited above.

THE DAILY MIRROR quoted The Royal Pharmaceutical Society claiming that such a move raised “serious concerns” for poorer Brits. RPS England Board Chair Sandra Gidley said: “A blanket ban on prescribing of items available to buy will not improve individual quality of life or health outcomes in England. “Those on low incomes will be disproportionately affected.” THE MIRROR also reported what had to say and added that the NHS constitution states that: “Access to NHS services is based on clinical need, not an individual’s ability to pay; NHS services are free of charge, except in limited circumstances sanctioned by parliament.”

THE NEWS & STAR repeated the above quote from The Royal Pharmaceutical Society.

THE GUERNSEY PRESS repeated what RPS England board chair Sandra Gidley said: “We would encourage people with minor health problems to self-care with the support of a pharmacist and to buy medicines where appropriate and affordable to the individual. However, expecting everyone to pay for medicines for common conditions will further increase health inequalities and worsen the health of patients who cannot afford them. A blanket ban on prescribing of items available to buy will not improve individual quality of life or health outcomes in England. Those on low incomes will be disproportionately affected. They should not be denied treatment because of an inability to pay.”

THE TIMES also quoted the RPS and Don Redding misleadingly (see above and below) and concluded their article by citing Cristal Summer, chief executive of the British Homeopathic Association saying: Patients will be prescribed more expensive conventional drugs in place of homeopathy, which defeats the object of the exercise. The NHS also claims it wants to reduce the amount of prescription drugs patients take, then stops offering complementary therapies which can help achieve this. This clearly ignores the fact that ‘the object of the exercise’ for any health service must be to provide effective treatments and avoid placebo therapies like homeopathy. 

THE SUN quoted The Royal Pharmaceutical Society saying such a move raised “serious concerns” for poorer Brits. But it said banning NHS-funded homeopathy was long overdue. THE SUN continued by citing John O’Connell, Chief Executive of the TaxPayers’ Alliance: “The NHS are absolutely right to look at removing homeopathy from their approved prescription list and it’s astonishing that it hasn’t happened sooner.”

METRO pointed out that actress Gwyneth Paltrow, ex-Beatle Paul McCartney and world record sprinter Usain Bolt are all known to swear by homeopathic remedies.

Generally speaking, the newspaper coverage was not bad, in my view. The exception evidently is THE TIMES (see above). Several other articles also have a slight whiff of false balance, introducing seemingly rational counter-arguments where none exist. Even though the headlines invariably focus on homeopathy, some of the quotes used by the papers are clearly about other medicines black-listed. This seems particularly obvious with the quotes by the RPS. Many readers might thus be misled into thinking that there is opposition by reputable organisations to the ban on homeopathy. None of the articles that I read quoted a homeopath at the end saying something like  WE KNOW OF MANY PATIENTS WHOSE LIVES WERE SAVED BY HOMEOPATHY. JUST BECAUSE WE DON’T UNDERSTAND HOW IT WORKS DOES NOT MEAN IT DOES NOT WORK. A BAN WOULD PUT PUBLIC HEALTH AT RISK.

Only a few years ago, this type of conclusion to an article on homeopathy would have been inevitable! Could it be that UK journalists (with the exception of those at THE TIMES?) are slowly learning?

 

Isn’t it wonderful when your long-held views are confirmed by someone with influence?

This, of course, is a rhetorical question – I can tell you: it is wonderful!

Matthew Stanbrook, MD PhD recently published an editorial in CMAJ which I find delightful; let me present you a few quotes from it:

The multibillion-dollar market for “natural” health products has flourished under lax government regulations. These regulations have enabled manufacturers to exploit the public’s difficulty in distinguishing nonprescription drugs, with scientifically proven therapeutic benefits, from herbal or homeopathic preparations and supplements that often make similar health claims with little or no evidence and are frequently grounded in unscientific belief systems about health and disease…

In pharmacies, supermarkets and convenience stores, natural health products are displayed side by side with nonprescription drugs. Both tout their approval by Health Canada as an implicit endorsement of efficacy and safety on package labels that make similar health claims. However, although nonprescription drugs and their therapeutic claims require scientific evidence that is carefully scrutinized by Health Canada, natural health products have a separate regulatory system that typically imposes such minimal requirements that it is effectively a rubber stamp. Unlike nonprescription drugs, if a problem arises with a natural health product, Health Canada has little or no authority to compel any changes to its manufacture, labelling or sale.

…Risk is often difficult to perceive accurately without direct evidence. For example, under the proposed framework, Health Canada would continue to classify most homeopathic preparations as low-risk products and, thus, exempt from scientific review. Recently, a homeopathic product sold in the United States that claimed to relieve teething pain in infants and supposedly contained a very dilute extract from the belladonna plant was associated with several deaths of infants who manifested classic signs of anticholinergic poisoning…

…If consumers are unable to separate products with no scientific proof behind them from products supported by evidence, then we need to separate them in stores. Natural health products should be pulled from the shelves where they are mixed with nonprescription drug products and confined to their own separate section, away from any signage implying a therapeutic use.

The double standard perpetuated by both regulators and retailers that enables the deception of unsuspecting Canadians must end. Alternative medicines with claims based on alternative facts do not deserve an alternative, easy regulatory road to market — at the very least, they need to be moved to an alternative shelf.

END OF QUOTES

This, of course, is Canada. But elsewhere progress is also being made.The Australian reported about plans in Australia whereby pharmacies would be banned from selling useless and possibly dangerous homoeopathic remedies. The Australian last year ­revealed a review of pharmacy regulation, headed by Stephen King from the Productivity ­Commission, identified a potential conflict of interest in pharmacists selling vitamins, for example, that may not have a significant ­evidence base, alongside more stringently regulated and government-subsidised medicines. In its interim report, the review panel was “concerned that the sale of complementary medicines alongside other medicines may mislead consumers”. It therefore concludes that “complementary medicines should be held in a separate area within community pharmacies, where customers can easily access a pharmacist for appropriate advice.”

“To avoid potential harm, or the confusion between the efficacies of different types of medicines, pharmacists need to be easily ­accessible to give needed advice when consumers choose a complementary or pharmacy-only medicine,” the review panel said. It was scathing of homo­eopathy and the perception of legitimacy given to those so-called remedies sold in pharmacies. “The only defence put to the panel regarding homoeopathy was that it was harmless and able to be used as a placebo in certain circumstances,” the review panel noted. “The panel does not believe that this argument is sufficient to justify the continued sale of these products in pharmacies …”

AUSTRALIAN JOURNAL OF PHARMACY (AJP) noted that the interim report of the Review of Pharmacy Remuneration and Regulation states that “there are unacceptable risks where community pharmacies are allowed to sell homeopathic products”.

In 2015 Pharmaceutical Society of Australia (PSA) said it did not support the sale of homeopathy in pharmacy. “Our position is that pharmacists must use their professional judgement to prevent the supply of products with evidence of no effect,” PSA president Joe Demarte said at the time. Ian Carr, of Saxby’s Pharmacy in Taree, NSW, and Friends of Science in Medicine member, told the AJP that “in terms of homeopathic products being recommended not to be sold by PBS-approved pharmacies, I one hundred per cent heartily agree with that finding. “I love saying that I believe homeopathy works. But it has never been shown to work better than placebo. There are many things that will work as well as placebo, but it’s not ethical to be selling them as a cure or treatment for something. I would have a bit more time for it if there was a plausible theory behind it, but its basis is entirely implausible – it pushes all the buttons for being a pseudoscience, so I agree it has no place in Australian pharmacy. However, I am at a bit of a loss to understand why they haven’t carried some of that logic over into the comments on complementary medicines generally.”

Mr Carr also told the AJP that “If one conceives of complementary medicines as being vitamins and minerals, that’s one thing. But the marketing of those items has become so diffuse and so wide that on most of these CM shelves we have traditional medicines, we’ve got herbal medicines, we’ve got items that are basically just marketing formulas for certain conditions. The evidence behind most of these things is very very slim, and we still have the possibility of health fraudsters just marching in and taking advantage of the lack of regulation in the industry.”

So, Canada and Australia are making progress in protecting consumers from bogus healthcare products and from pharmacists selling them.

Hurray!!!

When, I ask myself, are the UK, the US and other countries following suit?

 

Alternative medicine differs from conventional medicine in numerous ways. One important difference is that patients often opt to try this or that product without consulting any healthcare professional at all. In such cases, the pharmacist might be the ONLY professional who can advise the patient who is about to purchase such a product.

This is why the role of the pharmacist in alternative medicine is crucial, arguably more so than in conventional medicine. And this is why I am banging on about pharmacists who far too often behave like shop-keepers and not like ethical healthcare professionals. A new review addresses these issues and provides relevant information.

Pharmacists from the University of Macau in Macau, China conducted a literature review to extract publications from 2000 to 2015 that related pharmacist to alternative medicine products. 41 publications which reported findings from exploratory studies or discussed pharmacists’ responsibilities towards such products were selected for inclusion.

Seven major responsibilities emerged:

  • to acknowledge the use of alternative medicine products;
  • to be knowledgeable about such products;
  • to ensure safe use of such products;
  • to document the use of such products;
  • to report ADRs related to such products;
  • to educate about such products;
  • to collaborate with other health care professionals in respect to such products.

One point that is not directly covered here is the duty of pharmacists to comply with their own ethical codes. As I have pointed out ad nauseam, this would mean in many instances to not sell alternative medicine products at all, because there is no good evidence to show that they are generating more good than harm and thus are potentially harmful as well as wasteful.

Some pharmacists have realised that there is a problem. Some pharmacists are trying to initiate discussions about these issues within their profession. Some pharmacists are urging to change things. Some pharmacists are well-aware that healthcare ethics are being violated on a daily basis.

All this has been going on now for well over a decade.

And has there been any noticeable change?

Not as far as I can see!

Perhaps it is time to realise that not merely the sale of bogus medicines by pharmacists is unethical, but so is dragging one’s feet in initiating improvements.

 

David Needleman, a pharmacist at Wilkinson Chemist in Barnet, UK, has published a brilliant article explaining that complementary medicine such as homeopathy, nutrition and aromatherapy could make smaller pharmacies “more viable and competitive”, as they look to “survive” the funding cuts across England. In doing so, he made it clear that retail pharmacists are shop-keepers, not healthcare professionals, as previously assumed.

“We need to explore other ways of maintaining profitability. One of these is to enter profitable niche markets”. Mr Needleman – who is also joint principal of The School of Complementary Medicine (TSOCM) – helped set up a homeopathic dispensary in a North London pharmacy while studying for his qualification in 1987. “Within a year, the various homeopathic remedies, various other nutritional supplements and herbal medicines we stocked accounted for nearly 40% of the pharmacy’s turnover, with a considerably higher margin. This 40% turnover was the difference between bankruptcy and survival [of this pharmacy],” he added.

Mr Needleman and his colleague at TSOCM have designed a two-year “comprehensive complementary medicines” course for pharmacists and technicians, which will launch at the London School of Pharmacy in September. “It is going to cover nutrition, homeopathy, herbal medicine, flower remedies, aromatherapy and Chinese medicines and will lead to a [certificate] for pharmacists to become registered with a professional body,” Mr Needleman said. He said “it is early days” but “everyone I have spoken to has shown an interest” in the training. Mr Needleman is now looking to expand the offer to pharmacists across the country, “possibly Manchester next”.

Mr Needleman said he reacted with “sadness” to the news that some clinical commissioning groups (CCG) plan to scrap homeopathy funding. “Homeopathy has been under a lot of threat and a lot of pressure for some considerable time. It is going to disenfranchise thousands of people who can’t afford to pay. When you think that between six and 10 million people a year use complementary medicines…it is rather a large chunk of business that pharmacies are missing out on. There are only about six dedicated homeopathic pharmacies in the country, but there are a number of pharmacies that will dispense remedies and give advice. Anything that can take us away from NHS dispensing has got to be useful for the survival of community pharmacy,” he added. A full copy of Mr Needleman’s letter can be found here.  

I want to personally thank Mr Needleman for this statement. It avoids all the BS pharmacists tend to unpack when asked about homeopathy or other bogus treatments they sell. I agree entirely with Needleman, no need to beat about the bush! Pharmacists who sell homeopathic remedies do so mostly to make money, they are essentially shop-keepers. I find it easier to deal with the truth – even though it may be slightly embarrassing for the profession of pharmacists – than with the excuses pharmacists usually provide when asked why they sell disproven nonsense to the unsuspecting public. I guess, I prefer a slight embarrassment to a painfully big one.

The downside of the behaviour of the shop-keepers in the pharmacist profession is, of course, that they violate their own code of ethics. But who cares about ethics? Who cares about responsibly advising patients on the best therapy for their conditions? Who cares about evidence? The aim of the game is not about niceties, it is about saving the pharmacists’ income!!!

In its ‘quick guide’ to homeopathy, the Royal Pharmaceutical Society (RPS) said it “does not endorse homeopathy as a form of treatment because there is no scientific basis for homeopathy nor any evidence to support the clinical efficacy of homeopathic products beyond a placebo effect”.

The notorious tendency of pharmacist to behave like shop-keepers when it comes to the sale of bogus remedies has been the subject of this blog many times before. In my view, this is an important subject, and I will therefore continue to report about it.

On the website of the AUSTRALIAN JOURNAL OF PHARMACY (AJP), we find interesting new data on Australian pharmacists’ love affair with bogus alternative medicine. The AJP recently ran a poll asking readers: “Do you stock Complementary Medicines (CMs) in your pharmacy?” The results of this little survey so far show that 54% of all participating pharmacists say they stock CMs, including homeopathic products. About a quarter (28%) of respondents stock CMs but not homeopathic products. And 9% said they “only stock evidence-based CMs”. Three percent completely refuse to stock CMs, while 2% stock them but with clear in-store labels saying that they may not work. One person stated they stock CMs but have recently decided to no longer do so.

The President of the Pharmaceutical Society of Australia (PSA) Joe Demarte commented on these findings: “The latest survey results, showing over 40% of pharmacists are adhering to PSA’s Code of Ethics on complementary medicines, are very encouraging… However it’s disappointing that some pharmacists are still stocking homeopathy products, which are not supported by PSA’s Code of Ethics or our Position Statement on Complementary Medicines… Irrespective of the products stocked in a pharmacy, the important thing is when discussing the use of complementary medicines with consumers, pharmacists must ensure that consumers are provided with the best available information about the current evidence for efficacy, as well as information on any potential side effects, drug interactions and risks of harm… It’s important for pharmacists to provide a fair, honest and balanced view of the current evidence available on all complementary medicines,” Demarte added.

NSW pharmacist Ian Carr, who is a member of the Friends of Science in Medicine group, commented that many pharmacists may not have much choice when it comes to stocking complementary and alternative medicines. “CMs policy is not being filtered through the professional assessment of the pharmacist… It’s basically a business deal with the franchise, and as a pharmacist taking on a franchise you’ve basically got to sign those rights away about what you get to sell. Some of the chains offer basically everything that is available, no questions asked. As an independent pharmacist I am able to make my own decisions about what to stock… We’ve got a ‘de-facto’ corporatisation happening with marketing groups and franchises, and I’m concerned the government will look at this trend and ask, why are we not deregulating the industry to reflect the apparent reality of pharmacy today? We’re only playing into the hands of people who want deregulation… We should be telling people in no uncertain terms that if something is on the shelf it doesn’t mean it’s been assessed or approved by the TGA… There is no doubt that there has been a long-term relationship between the supplement industry and pharmacy. But it was also a few decades ago that researchers started applying the concept of evidence-based medicine to healthcare generally. That should have been the point where we said, ‘we’re not just going to be a conduit for your products without questioning their basis in evidence’. That’s where we lost the plot. The question now is: where do we draw that line? I’m really trying to say to my fellow pharmacists: Please let us reassess the unquestioning support of the CM industry, or we’ll all be tarred with the same brush. I and many others are concerned about – and fighting for – the reputation of the pharmacy profession.”

A BMC Complementary and Alternative Medicine survey by researchers from Alfred Hospital in Melbourne found that 92% thought pharmacists should provide safety information about CMs, while 93% thought it important for pharmacists to be knowledgeable about CMs. This shows a huge divide between what is happening in Australian pharmacy on the one side and ethical demands or public opinion on the other side. What is more, there is little reason to believe that the situation in other countries is fundamentally different.

And did you notice this little gem in the comments above?  “…over 40% of pharmacists are adhering to PSA’s Code of Ethics…” – the PSA president finds this ‘VERY ENCOURAGING’.

When I saw this, I almost fell off my chair!

Does the president know that this means that 60% of his members are violating their own code of ethics?

Is that truly VERY ENCOURAGING, I ask myself.

My answer is no, this is VERY WORRYING.

 

A recent article in the Guardian revealed that about one third of Australian pharmacists are recommending alternative medicines with little-to-no evidence for their efficacy, including useless homeopathic products and potentially harmful herbal products.

For this survey of 240 Australian pharmacies, mystery shoppers were sent in to speak to a pharmacist at the prescription dispensing counter and ask for advice about feeling stressed. The results show that three per cent of the pharmacists recommended homeopathic products, despite a comprehensive review of all existing studies on homeopathy finding that there is no evidence they work in treating any condition and that ‘people who choose homeopathy may put their health at risk if they reject or delay treatments’. Twenty-six percent of all pharmacists recommended Bach flower remedies to relieve stress. A comprehensive review of all existing studies on Bach flower remedies found no difference between the remedies and placebos. Fifty-nine per cent of people were just told the complementary and alternative product recommended to them worked, and 24% were told the product was scientifically proven, without any evidence being provided to them.

Asked about these findings, Dr Ken Harvey, a prominent Australian expert, said they demonstrated that some pharmacists were failing in their professional duty to consumers. “Pharmacists are giving crazy advice, and it is dangerous in some cases,” he said. “My view is that pharmacists, if they are going to sell these products, need to have a big shining sign over the shelves of the complementary and alternative medicine section that says ‘these products have not been assessed by the government regulators to see if they work, please talk to pharmacist’.Pharamacists are giving poor advice and they clearly have a conflict of interest,” Harvey said.

If you had hoped that in other countries pharmacists behave more responsibly, I must disappoint you. The information available shows that, when it comes to alternative medicine, pharmacists across the globe act much more like shop-keepers than like health care professionals. They are in the habit of putting profit before their duty to abide by the rules of evidence-based practice. And, in doing do, they violate their own ethical codes so regularly that I ask myself why they bothered to even implement one.

On this blog I have written so often about this issue that one could come to the conclusion that I have a bee under my bonnet:

The truth, however, is not that I am the victim of a bee.

The truth is that this is a very important public health issue.

The truth is that pharmacists show little signs of even trying to get to grips with it.

The truth is that pharmacists who sell bogus medicines put profit before professional ethics.

The truth is that such behaviour is not that of health care professionals but that of shop-keepers.

The truth is that I intend to carry on reminding these pharmacists that they are behaving like charlatans.

Some homeopaths advise parents not to vaccinate their kids and use homeopathic vaccinations or ‘homeo-prophylaxis’ instead. Despite the fact that it has long been clear that this approach is not effective and even dangerous, some homeopathic pharmacies have been selling the remedies used for that purpose. In the UK, Helios has been at the forefront of this dubious trade. But, a few days ago, they have changed their ways.

Here is a screenshot of the results of a search for the word ‘vaccine’, with the ‘remedies’ that were subsequently removed highlighted:

Helios vaccine remedies 1

Click the image to enlarge.

This is undoubtedly a step in the right direction. The question I ask myself is WHY DID HELIOS MAKE THIS CHANGE? Was it because they had to? Or was it because they saw the light and realised that the evidence did not support the remedies in question?

If it was the latter motivation, we will soon know – because, in that case, they will surely do the same with the entire rest of their remedies.

Why?

BECAUSE THERE IS NOT GOOD EVIDENCE THAT ANY HIGHLY DILUTED HOMEOPATHIC REMEDY IS MORE THAN A PLACEBO.

It has been reported that ‘Boots the Chemist’ have filed several legal complaints against The Guardian in relation to articles published by the paper in relation to its April 2016 investigation. The Guardian articles in question alleged that Boots, the UK’s largest pharmacy chain, had placed undue pressure on its pharmacists to perform medicines use reviews so that it could claim the maximum payments possible from the NHS. In other words, The Guardian implied that Boots was trying to get more money from our NHS than might have been due.

Personally, I am always uneasy when I hear that someone takes legal action on such matters. I think that legal complaints of such a nature can turn out to be counter-productive, both in general and in this particular instance.

Why?

There could be several reasons. For instance, such actions might give someone the idea of filing complaints against Boots. I am sure it is not difficult to find reasons for that.

In the realm of alternative medicine, for example, someone might question whether selling homeopathic remedies in Boot’s section ‘pharmacy and health’ is not misleading. These remedies might be seen by a naïve customer as masquerading as medicines. As readers of this blog know all too well, they do not, in fact, contain anything (other than lactose) that has any pharmacological activity. Therefore Boots should best market them in the category of ‘confectionary’.

One might even suspect that Boots are fully aware of all this. After all, a spokesperson for the company stated years ago during a parliamentary inquiry: “I have no evidence to suggest that they [homeopathic remedies sold by Boots] are efficacious …”

And it is also not the first time that Boots have been challenged for selling products they know to be placebos. This is what The Guardian reported in 2008 about the issue: “Ernst accuses the company [Boots] of breaching ethical guidelines drawn up by the Royal Pharmaceutical Society of Great Britain, by failing to tell customers that its homeopathic medicines contain no active ingredients and are ineffective in clinical trials.”

A similar void of evidence also applies to Boot’s wide range of Bach Flower Remedies and aromatherapy oils.

Or am I wrong?

Perhaps Boots want to post links to the evidence in the  comment section below?

I am always keen to learn and only too happy to change my mind in view of new, compelling evidence!

Boots also sell a very wide range of herbal medicines, and here the situation is quite different: herbal medicines actually contain molecules that might have pharmacological effects, i. e. they might heal or might harm you. And many of these products imply indications for which they should be taken. I will pick just one example to explain: HERBAL SLIM AID.

Yes, you are absolutely correct – this product is (according to its name) not for gaining weight, it’s for reducing it. Each coated tablet contains 45 mg of extract (as dry extract) from Bladderwrack thallus (Fucus vesiculosus L.) (5:1) (equivalent to 225 mg of Fucus) Extraction solvent: water, ,30 mg Dandelion Root (Taraxacum officinale Weber ex Wigg), 27 mg of extract (as dry extract) from Boldo leaf (Peumus boldus Molina) (4-6:1) (equivalent to 108-162 mg of Boldo leaf) Extraction solvent: Methanol 70% v/v, 10 mg Butternut Bark (Juglans cinerea L.).

Now, I thought I know quite a bit about herbal slimming aids, after all, we had a research focus on this topic for several years and have published about a dozen papers on the subject. But oddly, I cannot remember that this mixture of herbs has been shown to reduce body weight.

Perhaps Boots want to post evidence for the efficacy and safety of this product as well?

I certainly hope so, and I would instantly withdraw any hint of a suspicion that Boots are selling unproven or disproven medicines.

Where is all this going?

I have to admit that am not entirely sure myself.

I suppose all I wanted to express was that it might be unwise to throw stones when one is sitting in a glass-house – a cliché, I know, but it’s true nevertheless.

 

 

 

CONFLICTS OF INTEREST:

None [except I don’t like those who easily take legal action against others]

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