Choosing wisely: Homeopathy

Clinical
By
Chris Campbell, Amy Page, Sue Edwards, A/Prof Rebekah Moles, Dr Kenneth Lee, Alyssa Pisano, Dr Shane Jackson & Dr Chris Freeman
-
homeopathy

We don’t see many pharmacists selling magical crystals. For the same reasons, pharmacists should not sell homeopathic products.

Homeopathy is a form of complementary medicine that has been in existence for the last 2–3 centuries. It is based on the underlying principle of ‘like cures like’.1 This means that if you have insomnia, the active ingredient one would take in a homeopathic preparation would be a stimulant – e.g. caffeine. Within this pseudo-science, homeopathic products are produced by continual dilutions of the active substance with water or ethanol.

At each dilution stage, a process of pounding the vessel against an elastic material such as a leather-bound book has been described.2 This pounding or shaking with each dilution is called ‘potentisation’ and homeopathic practitioners believe that this is the process that makes the solution capable of stimulating a person’s natural defences when the product is ingested.2

After the 12th dilution, it has been found that there is no discernible chemical trace of the original substance left in the medicine, but homeopaths believe the preparation retains the qualities of the original substance.3 Regardless of what homeopaths believe, the latest evidence suggests that homeopathic products are nothing other than expensive water.

For these reasons, the PSA provided advice to pharmacists about homeopathy in its Choosing Wisely recommendations that were released last year.4 The recommendation made was:

‘Do not promote or provide homeopathic products as there is no reliable evidence of efficacy. Where patients choose to access homeopathic treatments, health professionals should discuss the lack of benefit with patients.’

There have been several studies that have looked at the effectiveness of homeopathic products for many conditions. Although there have been some clinical trials that have reported positive outcomes,5 other systematic reviews,6-9 and even systematic reviews of reviews,1,10 have shown that these positive results are due to flawed research methods, reporting bias and chance. Ernst et al published his 2010 systematic review in the Medical Journal of Australia,10 in which he concludes that ‘reviews of studies of homeopathy do not show that homeopathic medicines have effects beyond placebo’.10 Whilst taking a placebo, that is in its very essence expensive water, is not harmful in itself, the question to be asked is, is it ethical for the pharmacist to sell these products?

Within Care Principle1, the guidelines include: ‘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’. Similarly, with Integrity Principle 1, the following guideline is given: ‘Will only purchase, supply or promote any medicine, complementary medicine, herbal remedy or other healthcare product where there is credible evidence of efficacy and the benefit of use outweighs the risk.’

Our code of ethics stipulates the following principles:11

Care Principle 1 – A pharmacist makes the health and wellbeing of the patient their first priority.

Care Principle 2 – A pharmacist practises and promotes patient-centred care.

Care Principle 3 – A pharmacist exercises professional judgement in the interests of the patient and wider community.

Integrity Principle 1 – A pharmacist acts with honesty and integrity to maintain public trust and confidence in the profession.

Integrity Principle 2 – A pharmacist only practises under conditions which uphold the professional independence, judgement and integrity of themselves and others.

Competency Principle 1 – A pharmacist demonstrates a commitment to the continual development of self and the profession to enhance pharmacy practice.

Competency Principle 2 – A pharmacist works collaboratively with others to deliver patient-centred care and optimise health outcomes.

An article published in the Journal of Medical Ethics12 stated five reasons for why supporting the homeopathy industry was unethical. At the time of publication the National Health Service in the UK had funding for homeopathic remedies, however this funding has recently ceased.13 Of the five unethical reasons stated, three of these that were not related to the NHS and are applicable to the Australian pharmacy setting, including:

  1. Patients may seek homeopathy in lieu of scientifically proved treatments resulting in suffering and harm by omitting evidence-based medical treatment.
  2. It is deceptive to recommend something that is a placebo and not say it is.
  3. Homeopathy might give a bad name to other complementary medicines that do have evidence.

On top of the scientific-based systematic reviews, there have also been large-scale assessments of homeopathy by national and international bodies. Our own National Health and Medical Research Council (NHMRC) published its statement on homeopathy in March 2015.14

Based on the evidence, the recommendations by the NHMRC and our Pharmacy Code of Ethics, we see no reason why pharmacists should promote or even stock these products. Open communication with our patients about the products they take should be open and honest, and pharmacists should be able to provide evidence-based recommendations. Of course, some patients will still choose to take these products based on their own health beliefs, but it doesn’t mean we should endorse these decisions by stocking such products on our shelves. That is why PSA wrote to all major banner and buying groups asking them to cease all activities that encourage the stocking, promotion, recommendation or marketing of homeopathy (see www.psa.org.au/homeopathy-letter).

In summary, homeopathic products are widely available to consumers from a variety of platforms including the internet, supermarkets and health stores. Many consumers are not aware that there is no reliable evidence to support the use of homeopathic products to treat or prevent ailments.

There may be a public perception that these products have health benefits. But consumers may put their health at risk if they choose homeopathic products and reject or delay treatments for which there is good evidence for safety and effectiveness. Many products are being sold with little or no information.

All health professionals, particularly pharmacists and doctors, have a critical role to educate consumers so they can make informed decisions about how best to manage their health using evidence based medicine.4

NHMRC Statement

Based on the assessment of the evidence of effectiveness of homeopathy, NHMRC concludes that there are no health conditions for which there is reliable evidence that homeopathy is effective. Homeopathy should not be used to treat health conditions that are chronic, serious, or could become serious. People who choose homeopathy may put their health at risk if they reject or delay treatments for which there is good evidence for safety and effectiveness. People who are considering whether to use homeopathy should first get advice from a registered health practitioner. Those who use homeopathy should tell their health practitioner and should keep taking any prescribed treatments. The NHMRC expects that the Australian public will be offered treatments and therapies based on the best available evidence.

References

  1. Ernst E. A systematic review of systematic reviews of homeopathy. British journal of clinical pharmacology. 2002;54(6):577-82. At: https://www.ncbi.nlm.nih.gov/pubmed/12492603
  2. Hahnemann S. The Organon of Medicine 1982. Available from: http://drcherylkasdorf.com/wp-content/uploads/2017/01/Organon-of-Medicine-6th-edition.pdf
  3. Better Health Channel. Homeopathy 2015 [28.03.2019]. Available from: betterhealth.vic.gov.au/health/conditionsandtreatments/homeopathy
  4. Pharmaceutical Society of Australia. 5 Things Clinicians and Consumers should Question 2018. Available from: psa.org.au/wp-content/uploads/2018/12/PSA-Recommendations-v4-jg-121218-ACC.pdf
  5. Cucherat M, Haugh MC, Gooch M, Boissel JP. Evidence of clinical efficacy of homeopathy. A meta-analysis of clinical trials. HMRAG. Homeopathic Medicines Research Advisory Group. European journal of clinical pharmacology. 2000;56(1):27–33. At: https://www.ncbi.nlm.nih.gov/pubmed/10853874
  6. Heirs M, Dean ME. Homeopathy for attention deficit/ hyperactivity disorder or hyperkinetic disorder. Cochrane Database of Systematic Reviews. 2007(4). At: https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD005648.pub2/epdf/standard
  7. McCarney RW, Linde K, Lasserson TJ. Homeopathy for chronic asthma. Cochrane Database of Systematic Reviews. 2004(1). At: https://www.ncbi.nlm.nih.gov/pubmed/14973954
  8. Smith CA. Homoeopathy for induction of labour. Cochrane Database of Systematic Reviews. 2003(4). At: https://www.ncbi.nlm.nih.gov/pubmed/11687203
  9. Hawke K, van Driel ML, Buffington BJ, McGuire TM, King D. Homeopathic medicinal products for preventing and treating acute respiratory tract infections in children. Cochrane Database of Systematic Reviews. 2018(9). At: https://www.ncbi.nlm.nih.gov/pubmed/29630715
  10. Ernst E. Homeopathy: what does the ‘best’ evidence tell us? Med J Aust. 2010;192(8):458–60. At: https://www.mja.com.au/journal/2010/192/8/homeopathy-what-does-best-evidence-tell-us
  11. Pharmaceutical Society of Australia. Code of ethics for Pharmacists 2017 [28.03.2019]. Available from: psa.org.au/wp-content/uploads/2018/07/PSA-Code-of-Ethics-2017.pdf.
  12. Shaw DM. Homeopathy is where the harm is: five unethical effects of funding unscientific ‘remedies’. Journal of Medical Ethics. 2010;36(3):130–1. At: https://www.ncbi.nlm.nih.gov/pubmed/20211989
  13. The Telegraph. High Court backs NHS decision to stop funding homeopathy 2018 [Available from: telegraph.co.uk/science/2018/06/05/high-court-backs-nhs-decision-stop-funding-homeopathy/
  14. National Health and Medical Research Council. NHMRC Statement: Statement on Homeopathy 2015. Available from: nhmrc.gov.au/sites/default/files/images/nhmrc-statement-on-homeopathy.pdf
See PSA’s six recommendations to the Choosing Wisely initiative at: www.psa.org.au/choosing-wisely/

BY PSA CHOOSING WISELY WORKING PARTY: CHRIS CAMPBELL, DR AMY PAGE, SUE EDWARDS, A/PROF REBEKAH MOLES, DR KENNETH LEE, ALYSSA PISANO, DR SHANE JACKSON & DR CHRIS FREEMAN