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Homeopathic harms vol. 8: Opportunity costs

The excellent Nightingale Collaboration published some figures lately on how much the NHS in England spends on prescribing homeopathy. The figures are publicly available (and linked via the Nightingale Collaboration post), and represent every prescription for homeopathy dispensed by a community pharmacist – anything provided in a homeopathic hospital (or ordinary hospital, though I’d hope that doesn’t happen too often) wouldn’t show up.

You should go and take a look at that post because it’s interesting to see how prescribing has changed over the last 15 years or so.  It did make me wonder though, what is the opportunity cost of all this homeopathy? That is, what opportunities have we lost because we spent that money on homeopathic treatments? These opportunity costs represent one more indirect harm of the continued use of homeopathy.

I accessed a few resources to see what the score is.  Those resources are all publicly available, so you can (and should) double check my workings. I used:

In the 2013 calendar year, the NHS paid £137,000 for homeopathic remedies dispensed in community pharmacies.  By my calculations, that’s enough to pay for:

  • Wages for six newly qualified nurses, dieticians or radiographers or
  • Wages for five specialist nurses or
  • Twenty-six hip replacements (without complications) or
  • Twenty-four knee replacements (without complications) or
  • Delivery of ninety-one babies or
  • One hundred and ninety-six cataract operations or
  • Four hundred and fifty-nine MRI scans

(All numbers are rounded down, since it’s pretty hard to employ 0.4 of a person or replace three-quarters of a hip. Staff are assumed to be at the bottom of their pay band, which is probably a bit optimistic.)

Those numbers might not seem like much, but once again it comes down to cost/benefit analysis.  The best that we can hope that those homeopathic prescriptions achieved was some kind of comforting placebo effect for the patient.  Six nurses, even spread out around the country, could achieve an awful lot more than that.

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Homeopathic Harms Vol 7.1: Professional Ethics

Here’s a teaser for the latest in our Homeopathic Harms series – head on over to A Healthy Dose of Skepticism to read the full post…

As you’ll know by now, I’m a pharmacist. And as such, I have to be registered with the General Pharmaceutical Council (GPhC) to practice in the UK. I’m therefore governed by the GPhC, and in particular their code of conduct, ethics and performance, which has seven main points:

  1. Make patients your first concern
  2. Use your professional judgement in the interests of patients and the public
  3. Show respect for others
  4. Encourage patients and the public to participate in decisions about their care
  5. Develop your professional knowledge and competence
  6. Be honest and trustworthy
  7. Take responsibility for your working practices.

If I-or any of my colleagues- were to act against this code of ethics, we could be held to account by our regulator and reprimanded accordingly. Other healthcare professionals- Doctors, nurses etc- all have similar codes of conduct produced by their regulatory bodies. They all have one thing in common- that the patient is central to everything you do, and if a member steps outside this code of conduct, there is a clear and organized route through which complaints or concerns can be raised. This is as it should be: healthcare professionals have the lives of patients in their hands, and need to be held to account if anything goes wrong. As I’ve written before in this series, homeopaths don’t have to register with a regulatory body and anyone can set themselves up as a homeopath with no training whatsoever. Whilst some ‘professional’ bodies exist in the UK, they have no regulatory powers so are unable to reprimand anyone if they receive a complaint.

Homeopathic Harms Vol 6: Self-awareness & self-criticism

One of the most important mechanisms that people have for regulating their own behaviour is feedback from other people.  This happens from the day we’re born – babies learn that some behaviours earn a smile so they repeat them; toddlers learn that other behaviours get attention, so they repeat them.  As adults we do exactly the same thing – we learn behaviours that make us successful friends, partners or parents based on how people react to us.

This carries over into professional life too, and in some professions is even put into words as codes of conduct, or ethics.  We learn what is and is not acceptable by seeing how people respond to our actions.

Well, that’s a lovely little snippet about human behaviour, but what does it have to do with harm caused by homeopathy?  Sadly, lots.  Homeopaths style themselves as health professionals, meaning people trust and respect them.  In other health professions – let’s take conventional doctors as an example – if an individual gives poor advice or commits an act that’s seen as misconduct, there are mechanisms in place to deal with that.  They can be sanctioned or struck off, re-educated, suspended, and any number of other things.  Crucially, their peers support this process; if a doctor suspects misconduct by another they can act on it, formally or informally.  The same is true in other health professions – nurses, pharmacists, you name it.

So surely homeopaths do the same?  Well…no.

The Society of Homeopaths exists, and has a code of conduct and ethics.  However there’s no requirement whatsoever for a homeopath to be a member of the society, and I couldn’t find anything on their website about disciplinary processes or how to complain about a member. When asked to publicly condemn behaviour that is clearly unacceptable in individuals trusted to give health advice, the society has consistently failed to do so.

But the society doesn’t represent every homeopath, and in any case these are independent people – surely individuals have spoken out about poor behaviour among their peers?  I’d like to say yes, but again, the answer’s no.

When Anthony Pinkus was found by BBC reporters to be promoting homeopathic vaccines (after previously being investigated by the General Pharmaceutical Council for similar behaviour), his fellow pharmacists were outraged at what they saw as acts that put patients at risk and brought their profession into disrepute.  His fellow homeopaths?  Not a peep.

When various homeopaths were found to be promoting homeopathy for the treatment of rape, domestic violence and homosexuality, the general public were rightly angered at the outrageously offensive claims.  Their fellow homeopaths gave barely a whimper.

When Penelope Dingle died after suffering months of excruciating pain because her homeopath told her it was all in her head, the coroner’s report was damning.  The homeopathic community was oddly silent.

When homeopaths peddle their remedies to incredibly vulnerable people in Africa for the treatment and prevention of HIV and AIDS, their peers say nothing about it.  However Peter Chappell, a founder member of the Society of Homeopaths is all in favour, and in fact produces his own range of remedies, as well as others for  malaria, dengue fever, and goodness knows what else.

When Nelsons in London were found to have such poor manufacturing standards that there was broken glass present on their production line, and one in six vials of remedy actually had no homeopathic ingredient added, the Food and Drug Administration (the American drug regulator) pulled no punches in their report.  The UK homeopathic community, of which Nelsons is a part, said nothing.

There are doubtless many, many more examples just like these, but I think I’ve hammered the point home well enough.  And I am sure that some homeopaths who read this will be rather offended, because maybe they did oppose these things; but that’s not enough.  If homeopaths want to be seen as trustworthy providers of complementary therapies they need to change this pattern, they need to be vocal.  Where poor behaviour is evident, they need to shout first and loudest about it, like the pharmacists did with Anthony Pinkus. They need to scream from the rooftops that unethical advice, endangerment of people’s safety is against everything that they stand for, and that an individual who does those things doesn’t represent their community.  Even leaving aside the problems regarding lack of efficacy, how else can anyone ever trust that they can visit a homeopath and receive honest, ethical advice?

Homeopathic Harms vol 5: interactions

I might be a little quiet for the next wee while due to some unforeseen circumstances,  but to tide you over here’s the next installment in the Homeopathic Harms series by @SparkleWildfire – interactions.

In the next installment of our series on the harms of homeopathy, I want to talk about interactions. I’ve covered this a bit in the past, but let’s have a look at this area in a bit more detail.

We all hopefully know by now that homeopathic medicines pretty much have no trace of active ingredient in them by now. Do we need to worry about drug interactions with homeopathic remedies?

Can homeopathic medicines interact with conventional medicines?
The obvious answer is no. Magic Sugar Water Pills are highly unlikely to affect any conventional medicines. There’s a lack of actual evidence to prove this, but I think it’s pretty safe to rely on a theoretical basis here. So that’s great, right, blog post over and see you later. If only it were that simple.

Read the rest over at A Healthy Dose of Skepticism.

Homeopathic Harms Vol 4: OK, there’s SOME evidence

Last time I discussed the problem of missing evidence of harm in homeopathy trials and consequently in systematic reviews.  This time, I’m going to discuss some evidence of harm that we DO have. Sadly, it’s not comforting.

In December 2012, a systematic review of the adverse effects of homeopathy was published in the International Journal of Clinical Practice (aside: for a quick explanation of systematic reviews and adverse effects, take a look at volume 2 in this blog series).  The authors of this review searched five databases of medical literature totalling nearly 50 million published trials (though likely with considerable overlap), and found just 38 articles that discussed case reports and case series of adverse events with homeopathy.

It’s worth noting at this point that if systematic reviews are the pinnacle of the evidence pyramid, case reports and case series are somewhere towards the middle or bottom, depending who you ask.  They’re not ideal, because they’re not rigorous – they rely on someone not only noticing an adverse event and linking it to homeopathy, but taking the time to sit down and write about it and submit it to a journal.  Then of course they’ve got to find a journal willing to publish it.  If any of these steps don’t happen, there’s no published evidence for the rest of us to base our decisions on.  So if our systematic review found 38 published reports, the obvious question is “how many were never recognised, written up, or published?”  We’ll never know the answer to that.  Sadly in the absence of high quality reports of harm from the published clinical trials, this is the highest level of evidence we have.

Back to the review.  The 38 retrieved reports contained information relating to 1,159 people from all over the world.  Surprisingly, only 17 of the reports related to indirect harms – the results of substituting conventional care with homeopathy – although some of those indirect harms were severe.  Several people were admitted to hospital (including intensive care) due to replacing their conventional medicines with homeopathy, at least one was left with permanent effects, and one person died.

That leaves 1,142 people who suffered *direct* adverse effects as a result of using homeopathy.  This seems rather counter-intuitive, and I’m at a loss to explain to explain many of them given that your average homeopathic remedy contains precisely no active ingredient.  The authors of the review suggest that perhaps allergic reactions or ingestion of toxic metals (like arsenic or mercury) might be partly to blame.  They also suggest that low dilutions of remedies might be a potential source of adverse effects, but point out that the vast majority of these reports were associated with remedies at 12C potency or below.  To be clear, 12C is the dilution factor at which the chance of a remedy containing even one molecule of the original parent substance is effectively zero.

But whatever the mechanism, it seems clear that the review provides evidence of direct harm being caused by homeopathy.  Some of these harms were reported simply as “mild”, with no other details offered.  Some were potentially very distressing, like dermatitis, hair loss, and migraine.  Some were very serious indeed, including anaphylaxis (life-threatening allergy), acute pancreatitis, cancers, and coma.  Once again the consequences of the effects included hospitalisation, admission to intensive care units, and death.  For a treatment modality generally touted as totally safe, that’s a pretty alarming set of side effects.

So what can we learn from it?  There’s a valid argument to be made that there’s little point conducting more randomised controlled trials of homeopathy, because all of the good quality ones end up showing the same thing: no benefit over placebo.  But where more trials are conducted, we should be demanding that all adverse effects are collected and reported in the same manner as trials of new medicines.  Case series and reports are not proof of causation, but there is a bulk of evidence here that is concerning, and which should be addressed.  The best way to do that is in good quality trials.

In the mean time, is there anything else we can do?  Yes there is – in the UK at least.  The medicines regulator in the UK, the MHRA, runs the Yellow Card Scheme.  This is a mechanism by which anyone can report any side effect they experience after taking a medication.  I would strongly urge anyone who has suffered an adverse event after using homeopathy (or who knows someone who has) to visit www.mhra.gov.uk/yellowcard.  It’s quick and simple, and will help make remedies safer for everyone.  Similar schemes will be coming into effect throughout the EU soon, but if you live elsewhere please check and see if there’s anything similar.  We need all the data we can get!

Homeopathic Harms Vol 3: Poor Advice

The third post in mine and @SparkleWildfire’s blog series on the harms of homeopathy is now online!  Here’s a little taster :

Indirect harms due to homeopathy can, as we’re trying to cover in these posts, come in various different guises. In my opinion, there is none more dangerous than this: poor advice from homeopathic practitioners.

To set yourself up as a homeopath in the UK, you don’t need any medical background. You also don’t need to register with any regulatory bodies or undergo any standardized training. Medical homeopaths, i.e. doctors who practice it on the side, are of course regulated by the GMC, but your common or garden variety homeopaths could basically be anyone.

To read the rest, head on over to A Healthy Dose of Skepticism.

 

Does homeopathy have a place in therapy?

Given the current blog series I’m collaborating on regarding the potential harms of homeopathy, I thought it might be useful to stop for a moment and discuss its appropriate place in therapy. Do I believe that informed, consenting adults should be able to choose homeopathy as part of a treatment regime? Yes.

Are most people fully informed, and therefore able to give full consent? No, I don’t believe they are.

If people are making their treatment decisions based simply on assertions like “it’s safe” or “it’s gentle and natural” or (worst of all) “it works for me”, they are not fully informed. (To see why “it works for me” isn’t adequate, take a look at my post on anecdotes). This creates an ethical problem that should be insurmountable for any decent healthcare provider.

The evidence in favour of homeopathy simply does not reach the standard that we demand of conventional medicines. The evidence that it has the potential to cause harms (as we are showing with the Homeopathy Harms blog series) is very real.  Does a patient tend to feel better after seeing a homeopath?  Probably.  In these days of seven minute GP consultations the chance to sit down for an hour with someone who wants to listen, and dig deeper, and really *help* you is probably a really lovely thing.  Should we mistake that for thinking that homeopathy is a beneficial discipline? No.  Should we allow double standards by accepting lower quality evidence for homeopathy (or any complementary medicine) than we do for conventional medicine? No way.

But knowing all of this, knowing that the most “potent” homeopathic remedies have precisely no active ingredient, that there is no evidence of benefit beyond placebo effect, that at best they’ll derive no therapeutic effect and at worse they may experience serious side effects, should an adult be allowed to choose homeopathy for themselves? Sure.  Do many users of homeopathy meet these basic criteria for informed consent? I very much doubt it.

Homeopathic Harms Vol 2: where’s the evidence?

We often harp on about the evidence for homeopathy working or otherwise, and I’m not going to touch on that here, because it’s been covered beautifully by many more eloquent writers than me.  What you don’t often see though, is comment on the evidence for homeopathy doing harm.  In the last post in this series the lovely @SParkleWildfire touched on medicalisation, an indirect harm that’s very real but tough to quantify; but what about direct harms?  I’m glad you asked…

In conventional medicine, randomised controlled trials are the best kind of study we can do of a drug to see if it works and if it it’s safe.  What maybe doesn’t mentioned quite so often is that there’s an even *better* form of evidence – the systematic review.  These are produced when someone sits down to do the very tough but remarkably important job of finding every single scrap of evidence they can on a given topic, and pooling it all together to try and get closer to the definitive answer.  The result is a document that represents the best evidence possible for how well a drug (or anything else, for that matter) works, and how safe it is.

One of the biggest and most respected sources of these systematic reviews is the Cochrane Collaboration, who cover all areas of medicine.  Happily, they also have a few reviews related to homeopathy, and that seems as good a place to start as any.  The most recently published is:

 Homeopathic Oscillococcinum® for preventing and treating influenza and influenza-like illness

The authors searched multiple databases of medical literature, covering a time period dating back to the mid-60s and all the way up until August 2012.  That’s a lot of literature.  Out of all the results they found six randomised, placebo-controlled trials of Oscillococcinum that were similar enough to be directly compared.  Since we’re not really interested in efficacy in this review, I’ll skip straight to the safety part: out of these six trials, including a total 1,523 people, there was one reported adverse event.  One. It happened to be a headache. Let’s stop and think about that for a moment.

A good quality randomised controlled trial collects every single adverse event that happens to every single patient.  And the use of the term “adverse event” is very deliberate, because it includes absolutely everything unexpected and unwelcome that happens (and here’s the key part) whether or not it’s likely to be related to taking the drug.  That might sound counter-intuitive, but the reason is simple – we want to pick up every possible side effect of drugs, and sometimes side effects are…weird.  So it might sound odd to include as an adverse event that someone got hit by a bus, but what if the drug they were taking made them dizzy, or confused, or clumsy?  It’s not unreasonable to suggest that any one of those things could end up in getting you involved in a traffic accident.  So every single little thing is recorded, and once the trials is over you do some sums to work out the key question – are these things *more likely to happen in the people who took the drug*? If 20 people broke a leg but they were equally spread out among the trial groups then nothing further needs to be said; if 19 of them were on the drug being studied then there might be something to worry about.  The flip side of that of course is that if 19 were in the placebo group, you might want to wonder if the drug is (perhaps unintentionally) promoting better balance and co-ordination, for example (or if everyone in the placebo group was a keen but inept snowboarder).

Is that one single adverse event out of over 1,500 people taking Oscillococcinum starting to look fishy yet?  What about if I drop in the snippet that some of the people involved (327, to be precise) took the remedy every day for four weeks, to see if it stopped them from getting flu in the first place?  How many times in four weeks would an average, healthy person experience something that you could call an adverse event – a headache, a tummy upset, indigestion, a strained ankle, a touch of insomnia?  I’ve had three of those things in the last 24 hours, and I wouldn’t say I’m a particularly remarkable individual.

So hopefully you can see from this that there’s simply a huge, yawning hole in the evidence about safety in homeopathy.  There are ways and means to address this (though they’re far from perfect), and I’ll address one of those in my next post in this series.

Homeopathic Harms Vol 1: Medicalisation (Cross-posted from A Healthy Dose of Skepticism)

As discussed in my previous, brief post, this is part of a series of blog posts written by my and my good friend HJo.  This piece is cross-posted from her blog A Healthy Dose of Skepticism; look out for more to follow soon!

In February 2013, my friend Nancy and I delivered a Newcastle Skeptics in the Pub talk entitled Homeopathy: Where’s The Harm? As a follow up to this, we’ve decided to write a series of blog posts about a number of points we covered in the talk. Here is the first:  

Doctor’s appointments: often you feel like you’re in and out before you know it, and they can’t get you out the door quick enough. They have a target number of minutes to spend with each patient, and sometimes you can feel like they don’t have as much time as you’d like to discuss all the things you want to with them.

There is, then, one aspect of homeopathic practice which can be superior to that of conventional medicine: the consultation. A homeopath might spend an hour or more assessing each individual, not just asking about particular symptoms but about their personality as well, how they think and feel about the world. I’ve never been to see a homeopath, but I’d imagine this is really valuable to a patient, particularly those with minor mental health complaints. I know myself that when I’ve been to see a good GP who I feel has really listened to me, I leave feeling a bit better already.

I suspect that the consultation itself may be part of what provides benefit to patients, rather than the sugar pills that are given out at the end of it. I’m not aware of any evidence that compared individualised homeopathic treatment to the OTC stuff though, which would be the only way to tease out and quantify any benefit from the consultation.

So what’s the problem here? If a consultation with someone who appears to listen to you and care makes you feel better, where’s the harm in that? The sort of subtle, indirect harms that we’ll be discussing in this series of posts are often theoretical and would be very, very difficult to assess via hard, clinical evidence, so you’ll have to bear with me while I discuss them with you and see if they make sense at the end of it. Consider the following story:

Imagine I’m quite an anxious person (in actual fact I am, so it doesn’t take that much imagining to those who know me). Imagine I’m particularly anxious at the moment because I maybe have a public speaking event (something like Skeptics In The Pub, say!) to deliver in a few week’s time. I might be finding it hard to sleep, I find I’m worrying about it quite often, and getting some physical symptoms- my heart is beating quite fast at times, say, and my stomach hurts at times, but it’s nothing too serious.

I go to visit a homeopath (admittedly, this would be an unlikely thing to do if I was actually talking about myself) who takes time to discuss with me my problems. I get on well with them, and feel like they are really listening to me. During the discussion, I find that vocalising my anxieties helps me to rationalise them and my fears are allayed somewhat. Just the act of talking about it makes me feel better- in other words, the homeopath is delivering a talking therapy service to me. By the end of the consultation, I’m already feeling more in control of my anxieties, yet I’m still given some tablets to take home, and I dutifully follow the instructions I’m given.

As I’ve discussed elsewhere, there is a stigma about mental health issues. This also, unfortunately, extends to talking therapies too. Its quite likely that some people would be happier to declare “I’m seeing a homeopath” than “I’m seeing a counsellor” in front of their friends or acquaintances. The handing over of the sugar pills at the end of the consultation will no doubt suggest the talking bit is more “justified”, and they can convince themselves that they’re not mad, or the sort of weak person who would have to resort to a talking therapy. And thus, the stigma is reinforced. Talking therapies shouldn’t be something to be ashamed of. You don’t need some inert sugar pills to justify and hide the fact that, now and then, you just need to be able to talk to someone about your problems or feelings.

There are wider issues with this kind of thing too. The visit to the homeopath has made me feel better. I’ve been to see someone, left with some pills in my hand, and I’ve improved, reinforcing the fact that I feel better when given something to take. Let’s say that in the next few months, I feel a bit rubbish because I’ve had a bit of a cold and I’m left with a cough that’s been there for a couple of weeks. I go to see my Dr, who tells me that my chest is clear, and the cough should clear up of its own accord. However, I’ve expected to get something out of the visit- I don’t want to leave the surgery with no pills in my hand, as I know that last time I left a consultation about my health I was given pills at the end of it and I felt better. It’s left to the Dr to explain to me that I don’t need antibiotics, and this can be a notoriously difficult thing to do. Some Drs might relent and give me a prescription for an antibiotic, contributing to the catastrophic situation we’re in now with antibiotic resistance. If the Dr doesn’t give me a prescription, I’m left with a bad taste in my mouth and a bit of mistrust in the conventional health care system. ‘Next time I’m feeling ill’, I think, ‘I’ll go back to that homeopath. They take me seriously because they gave me pills’.

And so the cycle goes on….

H Jo

Homeopathic Harms: A blog series

Recently my good friend and I gave a talk to the Newcastle chapter of Skeptics in the pub on the harms associated with homeopathy.  It seemed to us that while the perceived benefits (or otherwise) are often covered in great depth, no one really looks at the harms.  The response to the talk was great, and we both felt like we covered some things that could do with immortalising in a form that’s a little more…permanent.  With that in mind, we’re teaming up to write a series of blog posts on the subject.  You can find HJo’s posts over at A Healthy Dose of Skepticism (and mine will of course be here), but we’ll  cross-post the first one or two and share links to the rest for ease of reading.  Hopefully we can bring something new to the table, or at least make some people stop and think twice about the implications of homeopathic remedies.

EDIT: The first two posts in the series are available for your entertainment!

Volume 1: Medicalisation

Volume 2: Where’s the evidence?