Médecins Sans Medicine?: Volunteer homeopaths in Honduras, funded by Canadian aid.

Less Médecins Sans Frontières and more Médecins Sans Medicine

Via CBC News:

Chagas disease (American trypanosomiasis) is an insidious tropical infection that begins with flu-like symptoms and can end with heart failure.

The only proven treatments are a pair of costly pharmaceutical drugs.

But a group of Canadian homeopaths say they can detect, prevent and treat the disease, and the federal government is paying to take their remedies to sick Hondurans.

Quebec-based Terre Sans Frontières (TSF) is spending $350,000 in aid money from Global Affairs Canada to dispatch more than a dozen volunteer homeopaths to Honduras over five years.

More on the ridiculousness of homeopathy here, here, and here.  Not only is this a waste of money, it’s going to harm Hondurans.

 

 

Former naturopath Britt Hermes awarded John Maddox prize for championing science

This is excellent – Britt Hermes, of Naturopathic Diaries fame, has been awarded the John Maddox Prize.

Hermes said her own professional journey had come at a personal cost and she was being sued for defamation by an American naturopath in a case due to be heard in a German court.

“I was a naturopath, until I looked at the evidence and decided to speak up about the dangerous therapies used in naturopathy, especially those to treat cancer,” she said. “Walking away cost me my friends. I am harassed and being sued for defamation. I am honoured to be recognised by the scientific community for changing my mind.”

Hermes deserves all the accolades she’s getting. As a former naturopath, she’s effectively pointed out that naturopathy is a pseuoscientific practice that is based on vitalistic thinking – and has no place in a modern, science-based health system.

Congratulations, Britt!

See the full story at The Guardian.

 

 

Medical marijuana: Should it be sold in pharmacies?

This year will bring a Canada Day for the history books. Only July 1, 2018, recreational marijuana (also called cannabis) will be legalized and regulated in Canada. The federal Cannabis Act creates a legal framework for producing, possessing and selling marijuana across Canada, meaning that each Canadian province will set its own rules to oversee its distribution, subject to federal government conditions. Provincial and federal governments will share in the responsibility for the oversight of this new system, and will also share in the tax revenue. Different provinces are taking different approaches, similar to how alcohol purchases vary between jurisdictions. This trend follows what we’re seeing at the state level in the United States, with different states moving to decriminalize recreational use.

Marijuana has been legal to some extent in Canada (and in many US states) for some time, in the form of “medical” marijuana. The Canadian government authorized the sale of marijuana for that purpose, while it simultaneously emphasizes that cannabis is not an approved therapeutic product. The medical market, for many, appears to simply be a means to access products for recreational, or non-medical use, and has generated wildly unsubstantiated claims about the medical merits of marijuana for conditions like autism and the treatment of cancer. Dispensaries have appeared across Canada and the US, usually with very easy referrals for prescriptions. Some dispensaries ignore any prescription requirement entirely and will sell marijuana directly to the public without any medical assessment or advice. With the introduction of government-overseen (and in some Canadian provinces, government-delivered) retail sales in Canada later this year, it’s reasonable to assume that unregulated dispensaries will eventually disappear.

With recreational sales imminent in Canada (and already here, in states like California), there are questions about the future market for “medical” marijuana. Should use for medical purposes be treated like recreational use, where consumers make their own selections, and purchases are taxed like other consumer products? Or should some forms or uses of marijuana be treated like prescription drugs, where a health professional remains involved, and products may be even be covered by insurance plans? Given the major changes we are seeing in how we can access marijuana, it’s worth summarizing the current state of evidence for marijuana when used for specific medical purposes. With marijuana becoming much more accessible, physicians, other health professionals, and their patients need high-quality information about its value for different medical conditions. David Gorski reviewed much of the evidence in a series of posts over the past three years. Now, three new documents prepared for Canadian physicians and health professionals concisely summarize the current evidence base for medical marijuana.

Towards more effective supplement regulation in Canada

Unsubstantiated claims for natural health products could be a thing of the past in Canada.

I suppose I owe Health Canada some thanks. It was Health Canada’s lackadaisical  regulation of dietary supplements and natural health products that turned me from a “shruggie” pharmacist into one that started advocating, publicly, for putting consumers’ interests ahead of those of supplement manufacturers. While health regulations are seemingly created to protect consumers, Health Canada has  consistently given manufacturers the upper hand, prioritizing a company’s desire to sell a product over a consumer’s right to a properly regulated marketplace with safe, effective products. It’s now very clear that the Natural Health Products Regulations have led to an industry boom and massive sales, but also a confusing marketplace for consumers and no persuasive evidence that all those supplements have any meaningful effects on our health. Canadian drug store shelves in 2016 are packed with hundreds of products with unsubstantiated claims and untested products, and little credible information to guide selection.  Yet all of these products have been reviewed and deemed to be “safe and effective” by Health Canada.

Should you try a “natural alternative” before medication?

Natural remedies are popular. But are they an appropriate substitute for medication?

The idea of taking medication can be frightening. And as consumers and patients that want to make our own informed health decisions, it’s understandable and even appropriate to question our physicians when they recommend drug treatments. We need to understand the rationale for any medication that’s recommended or prescribed, the benefits of therapy, the side effects, and if there are any other approaches that might be more appropriate. Dietary supplements and natural health products are widely marketed as being safe and effective, and are occupying more and more shelf space in pharmacies, usually right beside the pharmacy counter. Many of my patient encounters in the pharmacy have included a discussion on the merits of drug therapy, versus the supplements that may have flashy packaging and impressive claims of effectiveness.

One encounter from my time working at a local pharmacy still sticks with me. I met a new patient who was anxious and eager to get my advice. He’d been cautioned by his family doctor that he was on the borderline of being diagnosed with diabetes. He had come to the pharmacy seeking a supplement that could help him avoid diabetes and medication. Rather than recommend any supplement, I suggested that the best approach he could probably take would be to lose some weight and get some exercise – it could be more effective than any supplement or drug, and would definitely help his health. He agreed, and then asked me what supplement he could take that could help him with some weight loss.

This type of discussion occurs all the time, and seems more common when there’s a lack of trust in the physician, or when the goals of treatment aren’t understood. The patient, reluctant to accept the physician’s recommendation, heads to the pharmacy for what they believe is a second opinion. In some cases, the patient may question the physician’s advice: “All my physician wants to do is prescribe drugs,” is a statement I’ve heard more than once. In those that are reluctant to accept medical treatment, there’s often a willingness to consider anything that’s available without a prescription – particularly if it’s perceived as “natural.” Natural products and dietary supplements are thought to be gentle, safe, and effective, while medicine may be felt to be unnatural, harsh, and potentially dangerous. Yet when I explain to patients that there’s actually little evidence to suggest most supplements offer any meaningful health benefits, I am sometimes met with puzzled or dismissive looks. The supplement industry’s marketing has been remarkably effective, glossing over the fact that the research done on dietary supplements is overall unconvincing and largely negative when it comes to having anything useful to offer for health.

Is a profit-first philosophy in retail pharmacy compromising working conditions and patient care?

The tension between the “business of pharmacy” and the professional responsibilities of pharmacists, as health care professionals, has always been present in retail (“community”) pharmacy practice.  For much of the past several decades, pharmacies have generally been owned by pharmacists, elevating pharmacy ethics and professional responsibilities to the level of the owner. But the era of the independent pharmacist-owner-operated pharmacy is disappearing, and the era of the massive pharmacy chain is upon us. In the United States, CVS and Walgreens command 50% of the retail pharmacy business in major cities. In Canada, Shoppers Drug Mart has been purchased by the grocery giant Loblaw, and the Rexall chain has been purchased by American giant McKesson.  And in the United Kingdom, retail pharmacy chain Boots has about 25% of pharmacy market share.

With this retail consolidation, are we seeing a decline in the autonomy of the front-line pharmacist? A scathing series of articles in The Guardian is raising questions about whether pharmacy giant Boots is putting  a drive for profits ahead of safe and appropriate pharmacy care. And pharmacists are speaking up.

Statins for everyone?

Should you take a statin to prevent heart disease?

Preventing a disease, before it occurs, seems intuitively obvious. But when it comes to taking medicine to prevent a disease before it occurs, people tend to be much less comfortable. Not only are there the concerns about the “medicalization” of healthy people, there are good questions about benefits, risks (like side effects), and costs. Cardiovascular disease will kill many of us, so there’s been decades of research studying how to prevent that first heart attack or stroke. But even if you’re born with good genes and do everything possible to prevent heart disease (e.g., don’t smoke, exercise regularly, eat a healthy diet, moderate your alcohol, and keep your weight down) you’re still at risk of heart disease. And if you have one or more risk factors for disease, your lifetime risk goes up dramatically. Once you’ve had your first heart attack or stroke, the effectiveness of medical therapy has been established. Drug therapy with medication like the “statins” class of cholesterol-lowering drugs reduces subsequent deaths from cardiovascular disease. Given their unambiguous effectiveness, and the high likelihood that many of us will eventually have cardiovascular disease of some sort, the idea of “pre-treating” otherwise-healthy people with drug therapy to possibly prevent that first event has been held out as a potential public health strategy. There’s new evidence that tests this hypothesis, and the results are surprising.

The questionable ethics of selling complementary and alternative medicine

Legal to sell, yes. But ethical to sell?

Complementary and alternative medicine (CAM) is no longer fringe, and anything but the mom-and-pop image that manufacturers carefully craft. CAM is big business, and most Americans today take some sort of supplement. The impetus for my blogging (and tilting at CAM windmills) emerged from years spent working in a pharmacy with a heavy reliance on CAM sales. If it was unorthodox, this store probably sold it. Conventional drug products (the ones I was familiar with) were hidden off in a corner, and the store was otherwise crowded with herbal remedies, homeopathy, and different forms of detox kits and candida cleanses. All of this was unlike anything I’d ever seen or heard about in pharmacy school – so I started researching.

I looked at CAM from a scientific evidence perspective, the one I was taught in pharmacy school, using the same approach I’d take when assessing a new drug. Did the evidence support the claims made about these products, or not? The answers, as you might expect, were often the same. There was little or no credible evidence to demonstrate CAM had any meaningful benefits. I started blogging my own reviews as a way of documenting my own research, while offering some information to anyone on the Interwebs who might be searching for evidence.

Over time my blogging focus expanded, as I asked myself the inevitable questions: How could implausible products with no scientific backing even be approved for sale at all? I discovered the regulatory double-standard allowed for anything considered a dietary supplement (or in Canada, a “natural health product“) and the history and politics that have made CAM the “Wild West” of health care, with a marketplace that prioritizes a manufacturer’s right to sell over a consumer’s right to purchase a product that is safe and effective. Given the retail marketplace that’s been established by regulators like the FDA and Health Canada, I’ve turned my focus on to health professionals, who have an ethical responsibility to put patient interests above that of commercial interests. From a professional practice and medical ethics perspective, I have argued that health professionals that sell or promote CAM are on ethically shaky ground, and compromise the credibility of the profession.

Despite the lack of evidence that CAM (in general) offers any health benefits at all, it’s been remarkable to watch its popularity grow, to the point where even large pharmacy chains now sell aisles of products that are implausible and often highly questionable. Generally meeting these changes with a collective shrug, the pharmacy profession has even tried to lower its own ethical standards. While I do get the occasional encouragement from some of my peers, most just say “it’s business” or “the customer wants it, and these are legal products.” My argument today is CAM fails even this lower ethical bar.

Are pharmacy-based genome tests credible and useful?

Is genomic testing as useful as pharmacies claim it can be?

Despite science’s ability to develop sophisticated and targeted new drugs, predicting the effect of a drug in an individual is still maddeningly difficult. Not every drug works for everyone that takes it. Similarly, the very same drug can be well tolerated in some, but can cause intolerable side effects in others. So-called “targeted therapies” were supposed to improve our accuracy, by focusing on specific targets on cells. That’s been good – but not sufficient to make drug treatments more consistently effective. Pharmacogenomics is the relationship between your DNA and how your body responds to drugs: how they’re absorbed, how they work, and how they’re eliminated from the body. It has been heralded for some time as the white knight of drug therapy. The genome revolution was supposed to remove (or dramatically reduce) the uncertainty in medicine, telling us which drugs will work more effectively, and which we might want to avoid. And to some extent, the genome-based treatment era is already here. There are over 100 drugs approved by the Food and Drug Administration (FDA) now that include genomic information in their prescribing information. For a small number of drugs, genomic testing is warranted. Increasingly, genomic testing is more accessible, moving from the research bench directly into retail pharmacies for sale when you pick up your prescription. Given pharmacies have a less-than-stellar record of selling laboratory testing that isn’t validated or even useful, I was immediately skeptical when I saw a new story on pharmacy-based genomic testing. Titled “Your pharmacist’s secret weapon: How your DNA can help perfect your medication,” it appeared a recent Globe and Mail column:

Is it ethical to market complementary and alternative medicines?

Very excited to announce that a paper I collaborated on with Dr. Chris MacDonald has now been published in the peer-reviewed journal Bioethics, as part of a series on complementary and alternative medicine.  It’s also open access (for now):

Abstract:

Is it ethical to market complementary and alternative medicines? Complementary and alternative medicines (CAM) are medical products and services outside the mainstream of medical practice. But they are not just medicines (or supposed medicines) offered and provided for the prevention and treatment of illness. They are also products and services – things offered for sale in the marketplace. Most discussion of the ethics of CAM has focused on bioethical issues – issues having to do with therapeutic value, and the relationship between patients and those purveyors of CAM. This article aims instead to consider CAM from the perspective of commercial ethics. That is, we consider the ethics not of prescribing or administering CAM (activities most closely associated with health professionals) but the ethics of selling CAM.

The full paper is here.

Reference:

Macdonald, C. and Gavura, S. (2016), Alternative Medicine and the Ethics Of Commerce. Bioethics, 30: 77–84. doi: 10.1111/bioe.12226