It Takes a Village – Skepticism in this Small Town

In my last post, I introduced myself as a pharmacist in a small-ish town, eager to combat the growing acceptance of pseudoscience into the mainstream.  I love living where I live for a multitude of reasons.  But I’ve found it rather challenging to wave the flag of skepticism.  I have no problem displaying my preference for science-based medicine at my workplace, but outside of work a rather large road-block has emerged – social isolation.  While I have found a few kindred spirits in a public health nurse and a high school science teacher, they, too, remain relatively quiet about their skepticism.  I decided a few months ago to push the boundaries, and learned the hard way why others have been forced to keep quiet. Continue reading

The Evolution of a Skeptic Pharmacist

Today’s post is a guest contribution from a Canadian pharmacist who is writing under the pseudonym Sara Russell:

For several years after graduating from pharmacy school, when I’d answer the question “What do you do for a living?”, it would be met with responses like “Good for you!”, “You must be so smart!” or simply “Wow!”.  After a decade-long absence from a role in direct patient-care, I returned to pharmacy.  I noticed that my response to that same question was met with much less enthusiasm, with some people even having trouble hiding their disappointment.  How did this happen?  When did being a pharmacist have less caché than saying you worked in a health-food store? Continue reading

Pharmacists: Ever dispensed a placebo?

From today’s National Post:

The practice is discouraged by major medical groups, considered unethical by many doctors and with uncertain benefit, but one in five Canadian physicians prescribes or hands out some kind of placebo to their often-unknowing patients, a new study suggests.

The article references a paper in the Canadian Journal of Psychiatry which does not appear to be online.

It continues:

McGill’s Prof. Raz and his team conducted a survey of specialists throughout Canada, receiving responses from 606 doctors, 257 of them psychiatrists. About 20% of both psychiatrists and non-psychiatrists said they had used placebos in treating patients. The specific treatments they confirmed using included actual placebo tablets, sugar pills and saline injections. Some — including 35% of psychiatrists — said they also used “sub-therapeutic” doses of real drugs, amounts too small to have any chemical effect on the patient.

Interesting. I’ve been a pharmacist for almost 20 years (gulp) and have never seen a prescription for a “placebo” – nor have I ever seen a bottle of  “placebo” tablets waiting for such a prescription. An informal poll with a few colleagues revealed the same thing: No-one has ever seen a “placebo” dispensed. Perhaps my sample isn’t representative. Or it could be these prescriptions are being dispensed by the physician directly from the office.

So my question is to the pharmacists out there: Have you ever seen a prescription for a placebo? Did you fill it? And what did you fill it with? What are your thoughts about filling prescriptions for placebos? Would you do it? And what would you tell your patient?

Don’t ask your pharmacist about Nervoheel N or Neurexan

Magic beans

I can across a strange full-page ad in yesterday’s Globe and Mail. The headline was huge:

Reclaim your inner peace. Homeopathic Preparations. Scientifically proven effective.

Proven effective? Large comprehensive reviews have concluded that homeopathy is not efficacious (that is, it does not work beyond the placebo effect) and that explanations for why homeopathy would work are scientifically implausible. Consequently, it seems quite a stretch to say any homeopathic remedy is “Scientifically proven effective”.  This particular ad was for two homeopathic products from Heel.  Both Nervoheel N (“calms stressful moments, eases nervousness”) and Neurexan (“restores your natural sleep patterns, improves sleep quality”) are approved by Health Canada as safe and effective. Kim Hebert over at Skeptic North went looking for the published clinical evidence to support these efficacy claims:

  • For Nervoheel N there was one open-label, non-randomized cohort study that stated “The differences between the treatment groups [Nervoheel and lorazepam] were not significant.” The paper concluded that Nervoheel N is non-inferior to lorazepam. No placebo group was included.
  • For Neurexan there were two studies. Both non-random studies compared Neurexan with another unproven treatment, valerian, in the absence of a placebo group. There is no objective way to separate these results from unintentional researcher/patient bias or the placebo effect. Therefore, the results of both are clinically meaningless.

This data was presumably adequate for Health Canada (search their database for products 80007796 and 80004914 here) unless there’s unpublished data that was supplied.  The ad continues:

Both products are suitable for the whole family, for short or long-term use, as they are clinically proven effective, non-addictive, and non-sedative. They have no known side effects, medicinal interactions, or contraindications.

In order to have side effects, first a product has to have effects. So no surprise there.  The strangest statement, however, is at the bottom of the ad:

AVAILABLE IN PHARMACIES AND HEALTH FOOD STORES.

Ask your chiropractor or naturopath for more infomation.

Presumably they don’t want you to ask your pharmacist for more information. What kind of response might a pharmacist give about the scientific evidence supporting this, or any other homeopathic remedy? Hopefully, a science-based one.

Defender of Science-Based Medicine Sued

When you first started seeking the facts about “alternative” medicine, where did you turn? For me, it was Quackwatch. Before there were blogs or podcasts, there was Quackwatch. It’s been around since 1996, which is prehistoric by internet standards. Quackwatch is an enormous site: if there’s a dubious health intervention, there’s a pretty good chance that Quackwatch has a page about it. I’ve linked to it repeatedly on this blog, as I consider it to be a credible source of information.

Unfortunately, taking an evidence-based approach to medicine, and putting that evidence in the public eye, puts you at all kinds of risks. From personal smears, to unfounded allegations of conflicts of interest, to legal threats, advocates for pseudoscience do whatever they can when they cannot refute the facts. And that’s what’s happening to the founder of Quackwatch: Dr. Stephen Barrett is being sued by a laboratory called Doctor’s Data. Continue reading

Homeopathy and Consumer Protection

Editor’s Note: It’s World Homeopathy Awareness Week.

Today’s guest post is from Dr. Chris MacDonald, PhD. Dr. MacDonald is Associate Professor, Department of Philosophy, Saint Mary’s University, and a Nonresident Senior Fellow at Duke University’s Kenan Institute for Ethics. Dr. MacDonald blogs at the Business Ethics Blog.

What should we think about homeopathy, from the point of view of Business Ethics? We can begin by asking the same questions about homeopathy as we would ask about any other product. Those questions fall under two main headings:

  1. Is it generally ethically OK to sell this product? Is it a product that should be on the market at all?
  2. If it’s generally ok to sell this product, what are the obligations of companies selling them? Are there any ethical limits on how or to whom they are marketed?

In a free society, there’s a general presumption in favour of free commerce. If Party A has a product and says to Party B, “Hey, you might like this,” and if Party B says, “Hey, I think I’d like some of that, here’s some money!” then they should generally be free to make the transaction. But there are limits. Some things cannot ethically be bought or sold (children or votes, for example). Other things can be sold, but only under special circumstances (cigarettes and alcohol, for example). And more generally, there is a very broad requirement that all transactions must be carried out without force, fraud, or deception.

Now, discussions over alternative therapies like homeopathy tend to be combative, rather than constructive, particularly on the Internet. That’s unfortunate, because a lot is at stake. Finding ways to have a constructive discussion is essential, but few make that effort. But there is common ground in the debate, and we should make good use of it. Both sides of the debate agree, for example — indeed they ethically have to agree — on the importance of consumer protection, though they may disagree on the right way of achieving it. Health is complex, and important, and the average consumer typically needs to be able to turn to experts to get good advice. There are plenty of unscrupulous individuals and companies out there willing to try to make a fast buck by preying on the gullible or the uninformed. Anyone who truly cares about health has to recognize that that’s a serious problem.

So, let’s look at homeopathy through the lens of consumer protection. Most generally, consumer protection means, first, making sure that products are safe (or “safe enough”, since almost all products carry at least some risk), and, secondly, making sure that products do what the manufacturer or seller says they’ll do.

Although I happen believe that homeopathy (like most other alternative therapies) does not in fact work, I want to have a constructive discussion about consumer protection with those who think it does. So I’m going to assume, for the sake of argument, two things that many skeptics are likely to deny.

  1. First, I’m going to assume that homeopaths (and supporters) genuinely believe in the power of homeopathy. That is, I’m going to assume that most homeopaths are not outright frauds. (Actually, that’s not just for the sake of argument. I strongly believe that to be a justified assumption. I strongly suspect that the vast majority of homeopaths and homeopathic pharmacies are 100% well-intentioned, and seek only to promote the health of their patients and customers.)
  2. Secondly, I’m even going to assume — again for the sake of constructive argument — that homeopathy works. I’ll assume that the anecdotes of homeopaths and their patients confirms the positive effects that Randomized Controlled Trials have thus far been unable to detect.

Next, given these assumptions, I’m going to pose two questions for homeopaths to answer, questions that I would likewise pose to any other kind of reputable business, especially any other reputable business in the field of health.

  1. How do we detect phoney homeopathic preparations? In order to protect consumers, we need to be able to detect fake remedies — fake versions (sold by counterfeiters) that are really just inert look-alike copies of genuine remedies. In an age of international trade and Internet-based pharmacies, phoney pills are a big problem. So, is there any way to test a homeopathic preparation to verify that it is genuine? If I buy homeopathic tablets, is there any test that can be done to see if they’re real or counterfeit? If authorities suspect a criminal organization of selling fake homeopathic tablets, how can they tell the difference between the criminal organization’s tablets and those manufactured by an honest homeopathic pharmacy?
  2. What advice would you give a potential patient/customer who is trying to choose among various alternative therapies? How should a potential customer/patient choose between homeopathy, Therapeutic Touch, acupuncture, Angel Therapy, and so on? In other words, how can consumers know that they’re about to buy something good, rather than something bogus? “Trust me” won’t do as an answer. Trust, in itself, is neither a good nor a bad thing; what we value is justified trust. What is it that justifies consumers in trusting you, rather than someone else? “Try it” also isn’t a good answer. When health is on the line, we shouldn’t have to experiment on ourselves. We should have some assurance ahead of time. Consumers deserve that. One alternative, of course, is to deny that this is an important question at all, by claiming that literally all alternative therapies work. But that would make little sense. There surely are fraudsters out there, offering stuff they know can’t work. And even ignoring outright fraud, the homeopathic philosophy claims to have identified the true nature of disease; other philosophies, it seems then, must have it wrong. Which ones? Consumers deserve your input on this important issue.

These are questions I expect any reputable business to be able to answer. They are also questions to which I have not yet heard homeopaths give good answers. (In fact, I asked a version of the 2nd question on my blog, with depressing results.) I’m honestly interested to hear any an answer.

In the end, what I’m really looking for here are reasonably generalizable standards of consumer protection across various categories of health products. What standard of evidence and safety should be applied to products offered for sale, quite generally? If homeopathic preparations are not expected to stand up to the rigours of Randomized Controlled Trials, why, in all fairness, should the products of the major pharmaceutical companies be forced to meet that standard? Surely Merck and GlaxoSmithKline would love to avoid having to jump through those hoops. Surely Big Pharma would love to be able to give vague answers to my questions above. But we don’t let them. And we’re right not to let them. The question is, can the Homeopathic industry demonstrate its commitment to ethics by giving clear answers, too?

Singh vs. the BCA: A Libel Reform Update

I’ve blogged in the past about the case of Simon Singh who has been sued by the British Chiropractic Association (BCA) for making the following statement:

The British Chiropractic Association claims that their members can help treat children with colic, sleeping and feeding problems, frequent ear infections, asthma and prolonged crying, even though there is not a jot of evidence. This organisation is the respectable face of the chiropractic profession and yet it happily promotes bogus treatments.

Rather than refute Simon’s comments with evidence to substantiate their claims, the BCA decided to sue. When organizations seek to supress debate and discussion about science by using legal means, it causes “libel chill”, where speech is suppressed by fear of legal action. Singh’s case is the impetus to a campaign for libel reform in the United Kingdom, where libel laws are horrendous, putting the onus and the costs solely on the defendant. An initial ruling went against Singh, and he appealed. Yesterday’s ruling was in his favour, and will allow Singh to use a “fair comment” defence in his arguments.

What was very encouraging for Singh, and for all who comment on the legitimacy and credibility of scientific matters, was the following comment from the Court:

’34. We would respectfully adopt what Judge Easterbrook, now Chief Judge of the US Seventh Circuit Court of Appeals, said in a libel action over a scientific controversy, Underwager v Salter 22 Fed. 3d 730 (1994):

“[Plaintiffs] cannot, by simply filing suit and crying ‘character assassination!’, silence those who hold divergent views, no matter how adverse those views may be to plaintiffs’ interests. Scientific controversies must be settled by the methods of science rather than by the methods of litigation. … More papers, more discussion, better data, and more satisfactory models – not larger awards of damages – mark the path towards superior understanding of the world around us.”‘

You might be asking – What does this case have to do with Science-Based Pharmacy? Quite a bit. It’s essential for health professionals to have the freedom to comment openly about the scientific evidence supporting any drug, treatment or health intervention. Criticizing data (or the lack of data) is fair comment.  Data and evidence should determine which treatments are deemed credible – not legal threats to silence critics.

It’s too early to declare victory, as Singh points out himself  in today’s Guardian column. The BCA could still appeal. But this entire saga has been such a public relations disaster for chiropractors worldwide. As press coverage has grown, so has the scientific and mainstream scrutiny of chiropractic. And it hasn’t been positive.

The battle for free speech and fair comment continues. Sign the petition at www.libelreform.org.

For more comment and discussion on yesterday’s ruling: Kim at Skeptic North; Orac at Respectful Insolence; Jack of Kent.