While I’m now two full decades out of pharmacy school, I am occasionally invited to return to give a lecture or facilitate a workshop. Pharmacy education has changed a lot since the 1990’s. For me, pharmacy was a Bachelor’s degree program you started right out of high school. Today, students must have a few years of university completed before they can apply (some already have one degree), and the more common degree granted is doctorate-level, the Pharm.D. The clinical training has been bulked up and the practical training is much more rigorous. I see all this as positive change, as the practice of pharmacy has changed along with the education standard. The era of the “count, pour, lick and stick” pharmacist is disappearing as these tasks are automated or delegated to others. Today’s pharmacist has the opportunity to deliver care in different ways, including new roles like vaccine provider, and medication review/drug therapy optimizer. Many find positions that allow them to leverage their drug-related expertise to other areas of the healthcare system.
With pharmacists’ knowledge of drug products it should not be a surprise that they are consulted widely for advice by patients as well as other health professionals. Public surveys on trust show pharmacists lead other health professionals on this measure. It should also not be a surprise that pharmacists can be quite influential in shaping drug use, particularly when it comes to advice about complementary and alternative medicine (CAM), especially when it is used with conventional, science-based drug treatments. After all, drug stores are becoming (to my professional embarrassment) purveyors of all forms of CAM, ranging from homeopathic “treatments” through aisles of herbal remedies, vitamins, and other supplements. One pharmacy I used to work at sold copper bracelets, magnets, salt lamps, ear candles, homeopathic “first aid” kits, and detox packages that were purported to “balance” your pH. If there was a plausibility limit to what this pharmacy would sell, I never saw it reached. I gave the best science-based advice I could, but eventually left due to my concerns about what was on the shelves. But my time in that setting showed me the opportunity to improve care: the pharmacist is well positioned to advise on the evidence for or against any particular treatment, as well as explain the potential risks with combining CAM with evidence-based treatment approaches.
From ethicist Dr. Chris MacDonald, a column on Rexall’s recent advertisements promoting homeopathy:
The problem, of course, is there’s no reliable evidence that homeopathy works, nor any plausible reason to think that it even could work. In commercial contexts, that’s pretty bad. And it’s worse still when the company selling the stuff is a company people rely on for competent health advice, and when that company leverages the credibility of a licensed health profession to promote bogus wares.
The commercial world is full of scams, and all too often people with something to sell have unwarranted faith in their products. Greed and ignorance are nothing new, but that doesn’t mean they are excusable. Companies that claim not just to provide a product, but to educate and take care of consumers, ought to do better. They should do their best to sell only those products that they, and their customers, are justified in believing in.
I’ve written about the ethics of selling homeopathy before. As XKCD said about pharmacies selling homeopathy,
Telling someone who trusts you that you’re giving them medicine, when you know you’re not, because you want their money, isn’t just lying–it’s like an example you’d make up if you had to illustrate for a child why lying is wrong.
The other day a parent asked me if she could give her 2-year-old Tylenol liquid along with some cough syrup she had purchased at the pharmacy. I was a bit surprised, as cough and cold products for young children have been pulled from pharmacy shelves for a few years given their lack of efficacy and spotty safety record. “What product did you give?” I asked. “Stodal” she replied. I paused, then replied. “Well the good news is that you can give Tylenol and Stodal together. But you should know that Stodal is a homeopathic product – it contains no medicinal ingredients, so what you’re effectively giving is a sugar syrup.” I explained how homeopathy is permitted for sale in Canada, and sold in pharmacies, despite the fact it is an elaborate placebo system of sugar pills and liquids. The mother was furious – at the pharmacy for selling it, at the store staff for recommending it, and especially at the regulator, Health Canada. “How can they possibly permit this to be sold?” she asked me. I had no explanation – but encouraged her to return the product to the pharmacy and demand a refund. Continue reading
Caution: Straw Man Arguments Ahead
Every time I think I can take a break from homeopathy, something pulls me back to the topic. Today it’s an unbelievably poorly reasoned defense of homeopathy, in, of all places, the British Medical Journal. Glasgow-based general practitioner Des Spence writes,
It was an intentional overdose. To prove a point I poured about 30 tiny tablets into my mouth and crunched them down. Because scientifically, I do not believe that these homeopathic pills have any active ingredient.
Today, homeopathy is medicine’s whipping boy, repeatedly and systematically beaten to the ground. Yet despite explaining that the tablets are just placebos, homeopathy always gets up to take another beating. Some homeopathy is funded by the NHS, through general practice, and in the few homeopathic hospitals. This fact enrages the growling commissars of evidenced based medicine who want homeopathy purged from the NHS.
“Growling commissars of evidenced based medicine”? Perhaps he’s referring to health professionals (like me) that believe that health interventions and treatments should be evaluated based on a single, scientific standard. And that publicly-funded health systems, like the National Health Service (NHS), should fund what works. Treatments that are not medicine, but are are vitalistic belief systems without evidence of efficacy, don’t make the cut. Continue reading
Homeopathy is nonreturnable
Homeopathy is a popular topic here at Science-Based Pharmacy. I’ve blogged before on the ethics of the provision of these products
, and argued pharmacists have an ethical responsibility not to sell, promote, or encourage the sale or use of homeopathy. It’s a question that has been put to pharmacists before
. So I was I was interested to see the UK pharmacy publication Chemist and Druggist
recently asked their readers about the ethics of the sale of homeopathy
, setting up the scenario as follows:
You are working as a locum in a busy high street pharmacy. A customer comes in and asks about “non-drug” treatments for hayfever. The customer says she “doesn’t trust” pharmacy products and asks if you have any homeopathic remedies. The store does stock a range of homeopathic treatments, but you know they are not considered medicines by the RPS. What should you do?
I was hoping to see a discussion from pharmacists on how they’d approach a description of the products (most don’t contain a single molecule of the listed ingredient) and their efficacy (no effects beyond that of placebo) with some science-based (and perhaps non-drug) measures for allergy management. Here are some of the supportive responses: Continue reading
Homeopathy is nonreturnable
From today’s Guardian: Continue reading
Check out today’s xkcd. Follow the image link to the main site, and move your cursor over the comic to see Randall’s commentary on pharmacies selling homeopathy.
Is it ever ethical to provide a placebo treatment? What about when that placebo is homeopathy? Last month at Science-Based Medicine I blogged about the frequency of placebo prescribing by physicians. I admitted my personal discomfort, stating I’d refuse to dispense any prescription that would require me to deceive the patient. The discussion continued in the comments, where opinions seemed to range from (I’m paraphrasing) “autonomy, shmatonomy, placebos works” to the more critical who likened placebo use to “treating adults like children.” My SBM co-blogger Harriet Hall noted, “We should have rules but we should be willing to break them when it would be kinder to the patient, and would do no harm.” And on reflection, Harriet’s perspective was one that I could see myself accepting should I be in a situation like the one she described. It’s far easier to be dogmatic when you don’t have a patient standing in front of you. But the comments led me to consider possible situations where a placebo might actually be the most desirable treatment option. If I find some, should I be as dogmatic about homeopathy as I am about other placebos?
Nicely, Kevin Smith, writing in the journal Bioethics, examines the ethics of placebos, based on an analysis of homeopathy. Homeopathy is the ultimate placebo in routine use — most remedies contain only sugar and water, lacking a single molecule of any potentially medicinal ingredient. Smith’s paper, Against Homeopathy — A Utilitarian Perspective, is sadly behind a paywall. So I’ll try to summarize his analysis, and add my perspective as a health care worker who regularly encounters homeopathy.
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.
Is it ethical for a pharmacist to knowingly sell a mislabeled product – one that contains no active ingredient, and has been demonstrated to be no more effective than a placebo? That’s the question being asked by Dr. Chris MacDonald over at the Business Ethics blog today:
If someone selling something believes that it doesn’t work, should they tell you so? Does it matter if the person doing the selling is a licensed professional, someone with advanced training and a sworn duty to promote the public good?
Dr. MacDonald is referring to the fallout from the UK Parliament’s Science and Technology Committee Evidence Check on Homeopathy, which I’ve blogged about previously. As I pointed out in yesterday’s post, the regulatory body for pharmacists in Northern Ireland is acting on this report, and has proposed that patients be told that homeopathic products do not work, other than having a placebo effect. Continue reading