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Pharmacies, Professionalism and Homeopathy | Science-Based Pharmacy

Pharmacies, Professionalism
andHomeopathy
JULY 26, 2015JULY 26, 2015 / SCOTT

(https://sciencebasedpharmacy.files.wordpress.com/2015/07/img_83702.jpg)
Can you spot the sugar pills among the medicine?
Retail pharmacies have a sugar pill problem. Homeopathic remedies
look like conventional medicine when theyre stocked on pharmacy
shelves, like the photo above. But unlike conventional medicine,
homeopathic products dont contain any medicine at all. They are
effectively and sometimes literally sugar pills placebos. Not
surprisingly, there is convincing evidence to show that homeopathy is
useless as a medical treatment, and fundamentally incompatible with a
scientific understanding of medicine, biochemistry and even physics.
Questions have been raised worldwide about the ethics of pharmacists
and pharmacies selling homeopathy to consumers who may not realize
what theyre buying. This practice, which appears to be growing, is
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attracting sharp criticism from other health professions. So why do

pharmacies sell them? And will the pharmacy profession change?

Homeopathy is not herbalism

To understand why homeopathy has no place in a pharmacy, its
essential to understand how homeopathy differs from other forms of
complementary and alternative medicine (CAM). Homeopathy is often
misunderstood as a natural remedy, akin to a type of herbalism. The
marketing and labeling of these remedies encourages this perception,
often describing homeopathy as a gentle and natural system of
healing, and putting cryptic terms like 30C beside long Latin names of
what appears to be the active ingredients. In reality, there is little
likelihood that a homeopathic remedy contains even a single molecule of
any listed ingredient. So while there may be hundreds of homeopathic
remedies in a pharmacy, they are chemically indistinguishable, usually
containing just sugar and water. The result is a growing assortment of
placebos on store shelves, alongside medicines and even supplements
that actually contain active ingredients. Homeopathy was invented in
1796 by Samuel Hahnemann, a German physician. He described the
practice as guided by two key principles, which he called laws:
1. The Law of Similars Hahnemann believed substances that
produce specific symptoms in healthy people will cure those same
symptoms in an ill person. Sometimes referred to as like cures like,
the law of similars is simply a form of magical thinking. Homeopathic
remedies can be made with natural ingredients like salt or onions,
but also substances like shipwrecks, light bulbs, the Berlin Wall and
even vacuum cleaner dust or moonlight
(http://naturalhealthanswers.co.uk/madefrom.php). When
infectious material is used, the remedy is called a nosode and

homeopaths believe that these products can cure or prevent

infections
(https://www.sciencebasedmedicine.org/homeopathsthreaten-public-health-selling-sugar-pills-as-vaccinealternatives/). Deciding which substances will cure which
symptoms is determined by a process called a proving which is

entirely without any scientific basis

(http://rationalwiki.org/wiki/Proving_%28homeopathy%29).
(Here are homeopath provings for the Berlin Wall remedy
(http://www.interhomeopathy.org/berlin_wall) and also
sunlight reflected off the planet Saturn
(http://www.interhomeopathy.org/trituration_proving_of_the_light_of_saturn),
as examples of a typical proving).
2. The Law of Infinitesimals Hahnemann believed that the
effectiveness of a remedy increases the more that remedy was diluted.
He advocated a series of sequential dilutions with shaking
(succussion) after each dilution, believing that the water would
remember its contact with the original substance. According to
Hahnemanns theories, when sufficient water has been added to
dilute the original substance away so that zero molecules remain, the
remedy was thought to be at its most powerful. Imagine putting
one drop of a substance into a container of water. Only that container
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is 131 light-years in diameter

(http://en.wikipedia.org/w/index.php?
title=Homeopathic_dilutions&oldid=635646115#30C:_1_ml_in_1.2C191.2C016_cubic_light_years).
Thats equivalent to the 30C dilution that is popular with
homeopaths. Youd have to eat a tablet of sugar the size of the Earth to
get a single molecule of the original substance.

Homeopathy and science are mutually

exclusive
It goes without saying that if homeopathy works in the way envisioned
by Hahnemann and homeopaths, than the rest of medicine cannot. And
thats exactly what the evidence shows. As would be expected with inert
products, rigorous clinical trials confirm what basic science predicts:
homeopathys effects are placebo effects. The two most comprehensive
reviews of the evidence are the 2010 Evidence Check from the United

Kingdoms House of Commons Science and Technology Committee

(https://www.sciencebasedmedicine.org/homeopathy-gets-a-realitycheck-in-the-uk/) and the 2014 Australian National Health and
Medical Research Council
(https://www.sciencebasedmedicine.org/another-damninghomeopathy-report/) review, which reached the following conclusion:
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 National Health and
Medical Research Council expects that the Australian public will be
offered treatments and therapies based on the best available
evidence.
Emphasis added.

Pharmacists should know better

Pharmacists are the health professionals with specialized training in
pharmacology, and an education that concentrates on drug design,
delivery and understanding how to use medicines effectively and safely.
If any health professional should recognize the logical and scientific leaps
that homeopathy necessitates, it should be pharmacists. Regrettably,
there seems to be relatively few pharmacies that have made the deliberate
decision not to sell homeopathic remedies. So thats why its so
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heartening to see this recent commentary, from Australian pharmacist

Ian Carr (http://ajp.com.au/blogs/homeopathy-its-not-theproducts-its-the-thinking/), who will not sell homeopathy in his

pharmacy:
Fellow pharmacists, it is time to rid our shelves of these shonky
products. Every time a consumer is able to pluck their chosen
homeopathic drops from your shelf, you have given credence to
quackery. You have increased the possibility that your patients next
call might be to a homeopath, rather than a GP. You have helped
confuse the market about what natural medicine might be. Perhaps
your patient will decide that a homeopathic nosode will more safely
protect the family from whooping cough than a real vaccine. Though
no direct harm will come from imbibing from a magic bottle of pure
water, there is the danger that proven treatment will be ignored,
refused or delayed unnecessarily.
Poor thinking about health will lead to poor health decisions.
Many who choose a homeopathic remedy from the shelves may be
totally unaware of its scientific implausibility. Your pharmacy should
be ensuring patients are given clear and reasoned counselling, and in
doing so, helping them avoid a lifetime of confused and deluded
thinking about health.
In another column

(https://www.mja.com.au/insight/2014/20/ian-carr-peddlinghomeopathy), Carr argued that staff (employee) pharmacists are just as

responsible as pharmacy owners for deciding whats on store shelves:

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As an independent pharmacist proprietor, I do not stock homeopathic

medicines, diet pills or ear candles. I am free to recommend therapies
where I am convinced of an evidence base. However, were I an
employee pharmacist in a discount chain, would I have the same
opportunity to exercise my professional discretion and conscience? Or
would I be encouraged to companion sell and recommend the chains
favoured brands? Could I tell the truth and expect to keep my job?
An answer might lie in the recent newsletter from the Pharmacy

Board of Australia
(http://www.pharmacyboard.gov.au/News/Newsletters/March2014.aspx#directing), which warns: Action by non-pharmacists
(such as managerial staff) which impinges on the ability of
pharmacists to meet their legal and ethical responsibilities may be
subject to action under the Health Practitioner Regulation National
Law.
Another category of pharmacist which allows for the profusion of
nonsense products is the uninvolved pharmacist, who sees no need to
interfere with what goes on in the front of shop. Staff training is
handed over to any company that offers it, with no oversight of
quality or ethics. Given the multimillion dollar advertising by vitamin
and supplement companies, the exponential growth of
complementary and alternative medicines and folk cures, and the
extreme level of science and health illiteracy in the populace, this
laissez faire approach is not acceptable.
Pharmacists are well placed to be at the forefront of science-based
medicine, trained and ready to counsel, explain and teach our clients,
and help give them informed control of their health.

Another profession weighs in

The growing pressure on pharmacies to stop selling homeopathy is
coming from other health professionals, too. The president of the Royal
Australian College of General Practitioners (RACGP), Frank R. Jones,

recently criticized pharmacies for selling homeopathy

(http://www.theage.com.au/victoria/pharmacists-urged-todump-dubious-products-if-they-want-to-do-doctors-work20150615-ghol1l.html), linking the professions decision to sell homeopathy
with the simultaneous desire to play a bigger role in the health care system:
We would certainly encourage our pharmacy colleagues to really
critically look at what they are selling at their chemists (pharmacies),
he said. I think they are very, very conflicted and I think really if they
are on board with the rest of the medical community, they have to
practise evidence-based medicine.
This follows the RACGPs formal recommendation

(http://www.racgp.org.au/download/Documents/Policies/Health%20systems/PPIPositionStatement-Homeopathy-v1.pdf) [PDF] that general

practitioners (family doctors) stop prescribing homeopathic remedies,
and that pharmacist stop stocking these products:
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The RACGP supports the use of evidence-based medicine, in which

current research information is used as the basis for clinical decisionmaking. In light of strong evidence to confirm that homeopathy has
no effect beyond that of placebo as a treatment for various clinical
conditions, the position of the RACGP is:
1. Medical practitioners should not practice homeopathy, refer
patients to homeopathic practitioners, or recommend homeopathic
products to their patients.
2. Pharmacists should not sell, recommend, or support the use of
homeopathic products.
3. Homeopathic alternatives should not be used in place of
conventional immunisation.
4. Private health insurers should not supply rebates for or otherwise
support homeopathic services or products.
Its not just Australia. In the United Kingdom, the Chief Scientist of the

Royal Pharmaceutical Society

(http://blog.rpharms.com/england/2015/06/17/homeopathyshould-pharmacists-be-selling-homeopathic-products/) had given
similar advice:
Is homeopathys popularity due to a distrust of modern medicines as
has been recently suggested by the Chief Medical Officer for England
who has just called for an independent review

(http://www.bbc.co.uk/news/health-33127672) of the safety

and efficacy of medicines? Or it is that patients are worried about the
side effects associated with medicines, preferring what they perceive
to be a safer approach; after all homeopathic preparations have not
unsurprisingly no known toxic effects in over 200 years of use?
Whatever the reason, as an evidence-based profession, why do we
continue to sell homeopathic preparations in our pharmacies when
the evidence shows that they do not work?
The public have a right to expect pharmacists and other health
professionals to be open and honest about the effectiveness and
limitations of treatments. Surely it is now the time for pharmacists to
cast homeopathy from the shelves and focus on scientifically based
treatments backed by clear clinical evidence.

Pharmacies can prioritize patients ahead

of profits
Theres a precedent for pharmacies voluntarily ceasing sales of legal
products. Most pharmacies worldwide have quit the tobacco habit,
recognizing that selling tobacco isnt compatible with providing health
care. In the United States, CVS became the first national drug store to

stop selling tobacco, as it changed its name to CVS Health

(http://www.forbes.com/sites/brucejapsen/2014/09/03/cvsstops-tobacco-sales-today-changes-name-to-reflect-new-era/)
with a bold plan to distinguish itself from its pharmacy competitors. In
doing so it walked away from $2 billion in sales

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tobacco/). Recently it even quit the US Chamber of Commerce

(http://www.latimes.com/business/la-fi-lazarus-20150714column.html) over its stance on tobacco sales. The move has been well
received and the action has been highlighted as a factor in continued
expansion into what is now the largest health care organization
in North America
(http://www.nytimes.com/2015/07/12/business/how-cvs-quitsmoking-and-grew-into-a-health-care-giant.html?_r=0).
Homeopathy isnt tobacco, but its sale in pharmacies is raising the same
questions about the professions intent. With pharmacists stating they
want an expanded role in health care, will they confront the professional
and ethical challenges that homeopathy presents? Simply stating that
homeopathy is legally approved for sale is not sufficient justification to
deceive consumers who may not know what theyre buying. This is an ethical
issue for the profession.

Homeopathy is unethical
Ethical codes for the pharmacy profession will vary by region, but most
of the ones that I have reviewed make it clear that patients interests are
central to the pharmacists role, and that pharmacists must provide
evidence-based information to support informed decision making. Selling
sugar pills on pharmacy shelves alongside real medicine, without any
explanation, could give patients the impression that homeopathy is
effective. Ive argued at length that the sale in pharmacies give
homeopathy the perception of scientific legitimacy, and that this
approach is fundamentally unethical

(https://www.sciencebasedmedicine.org/placebos-as-medicinethe-ethics-of-homeopathy/). Selling placebos alongside medicine

violates patient autonomy, reflecting a form of medical paternalism (or
perhaps crass commercialism) that retail pharmacists need to eliminate if
they want to be truly accepted as partners in the health care team.
Homeopathy illustrates, with perhaps the most clarity, why selling
unproven or ineffective treatments is incompatible with ethical practice.
This statement from Mark Crislip sums it up nicely

(http://sfsbm.org/index.php?
option=com_content&view=article&id=387:unethicalalways&catid=45&Itemid=435):
This is the paradox of alternative medicine; by understanding, we
render the treatment ineffective. Yet by concealing medical
knowledge, we return to a dangerous, medieval-like approach to
healthcare. It is for this reason why alternative medicine is flawed. As
tempting as it might be to embrace placebo-based treatments, the
ethical standards we would have to sacrifice are infinitely more
valuable.

A pharmacists defence of homeopathy

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Harriet Halls Skepdoc Rule of Thumb

(https://www.sciencebasedmedicine.org/lessons-learned/)
states that when encountering a new or questionable claim, always try to
find out who disagrees and why. Why do pharmacists defend
homeopathy? Via Edzard Ernst

(http://edzardernst.com/2015/07/a-pharmacists-defence-ofhomeopathy/), I found this interview with Christophe Merville

(http://www.rodalesorganiclife.com/wellbeing/homeopathanswers-skeptical-critics), the head pharmacist at Boiron
(https://en.wikipedia.org/wiki/Boiron), one of the largest
homeopathic manufacturers (if thats the right term) in the world. Here
are some of his arguments in support of homeopathy:
I remember attending the delivery of a woman and the contractions
were very strong, and painful. She had some homeopathic medicine
to take just at that time to make those contractions more regular and
useful: less intense but longer and less brusque. I saw that happening
within minutes, and I was thinking, Thats very impressive. Thats
probably the time when I concluded that there is something to it. I
witnessed the action of homeopathic medicines on pets also, on young
children. I had enough personal anecdotes that I could say there is
something more than just suggestion, or placebo, or just the simple act
of being cared for. My attitude is to say, There are enough signs to
say that its really worth exploring more why it works, how it works,
when does it work. We are past the stage where we can say, No,
there is nothing. It has been around for a long time and if was just
mere placebo effect, it would have gone away, as so many different
techniques did.
His explanation for how homeopathy works is equally muddled:

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The main argument against homeopathy is that a remedy is very, very

diluted, so it cannot work. My reaction to that is to examine what
happens when you dilute something. The act of dilution is not very
simple. Those molecules are interacting together, they are interacting
with the walls of the container, they are interacting with the solvent,
and this interaction does not adhere to a precise mathematical law.
The skeptics say, You divide the number of molecules by 100 each
time, so after awhile, [sic] there is less than one chance to find one
single molecule. They have their math right, but they have their
physics wrong.
Chemists try to use very pure substances. When you buy your
reagent, you buy it at 99.999 percent pure. But you dont have
anything thats 100 percent pure. It would take an infinite amount of
energy to get rid of the last impurity. What I think we should explore
is the fact that after a certain number of dilutions, the process is not
very efficient at removing the last molecules. So there is always
something that stays. Thats one thing. The second thing is in
pharmacology for years, we were interested in the ability of large
quantities of substances. But what about small ones? I always use the
example of butterflies that can sense pheromones at great distances,
salmon finding their way back to their native creek from far away, to
sharks being able to detect blood in a huge amount of water. Biology
uses very small quantities. In cells, you have communication between
cells using a few molecules of a certain substanceand it works.
I dont pretend that Ive put A and B and C together, and Im able to
provide you with a complete explanation. But I would say those are
things to explore. Already the research that exists points to possible
action of homeopathic dilution on activation or deactivation of genes.
I wont go into details, but I welcome the skepticism, I think its very
constructive. But what I dont really like is people whose mind is set
on their misconception of what exactly a dilution is. Of course
homeopathy doesnt violate the laws of physics and chemistry,
because thats absurd.
Even the head pharmacist at Boiron admits he cannot explain how
homeopathy can work. These are just excerpts of an extended interview and
I encourage you to read the entire text

(http://www.rodalesorganiclife.com/wellbeing/homeopathanswers-skeptical-critics) to appreciate the arguments that Merville is

making. To his credit, Merville is clear that homeopathy doesnt replace
medicine like vaccines, nor can it cure cancer or diabetes. However his
basis for concluding that homeopathy is effective seems grounded
entirely in anecdotes and his own observations, neglecting to consider
how easy it is to fool ourselves. The Australian review
(http://www.nhmrc.gov.au/guidelines-publications/cam02) I
mentioned above considered this specific argument in its review, and
gave a good explanation as to why we must look at the totality of the
highest quality evidence, rather than trust anecdotes or personal
experiences:

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It is not possible to tell whether a health treatment is effective or not

simply by considering individuals experiences or healthcare
practitioners beliefs. One reason personal testimonials are not reliable
is that people may experience health benefits because they believe that
a treatment is effective. This is known as the placebo effect. Another
reason is that healthcare practitioners cannot always tell whether
changes in a persons health condition are due to the treatment or
some other reason. For these reasons, medicines must be tested in a
planned, structured scientific research project designed to prevent
these kinds of experiences giving the false impression that a medicine
is more or less effective than it really is.
And importantly, why we cannot cherry pick individual trials that may
suggest positive results:
Even where researchers take care to design studies in a way that
minimises bias, there is a chance that the results will show a
statistically significant difference in favour of a treatment, when there
is actually no effect. Therefore, the results of individual studies need
to be repeated in other independent studies, to make sure the effects
seen were not just due to chance. The most reliable information comes
from research that combines the results of all available similar studies
and analyses the results together (systematic reviews).

Freedom to choose?
As an advocate for removing homeopathy from pharmacies, Ive been
accused by homeopathy advocates (both pharmacist and non-pharmacist)
of wanting to limit freedom of choice, either the freedom to sell a
legally approved product, or the freedom to buy legally approved
products from pharmacy retailers. The case for not selling homeopathy in
pharmacies seems pretty clear: pharmacists need to put patient interests
above the desire to sell inert products that look like medicine and may
confuse patients. Ending pharmacy sales does not ban homeopathy, nor
will it stop the sale of homeopathy in the market. Nor is it meant to. This
is simply a call for pharmacies to cease selling the products. Homeopathic
remedies, as long as theyre legally permitted for sale, can be sold
elsewhere, just like tobacco remains for sale outside pharmacies. Pulling
these products out of pharmacies will signal to patients and other health
professionals that (1) Homeopathy has no medicinal value (2) Pharmacies
and pharmacists see homeopathy as incompatible with science-based,
patient-centred, evidence-based health care.

Putting patients first

Community or retail pharmacy is a unique mix of health care delivery
within a private, for-profit retailer. Yet pharmacies have a specific,
designated role in the health care system. For that reason, pharmacies can
and should to do more than what we might expect from another retailer.

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The comic XKCD said it best in a comic on alternative literature

(http://www.explainxkcd.com/wiki/index.php/971:_Alternative_Literature)
that is captioned with a quote about todays pharmacy practice:
I just noticed CVS has started stocking homeopathic pills on the same
shelves withand labeled similarly totheir actual medicine. Telling
someone who trusts you that youre giving them medicine, when you
know youre not, because you want their money, isnt just lyingits
like an example youd make up if you had to illustrate for a child why
lying is wrong.
Pharmacists ought to know better, and they ought to do better. Its time
for the profession to act in the interests of patients. Homeopathy has no
place in todays pharmacy practice.
This is a cross-post from Science-Based Medicine

(https://www.sciencebasedmedicine.org/its-time-forpharmacies-to-stop-selling-sugar-pills/#disqus_thread).
Comments are open there, and at SBPs Facebook page.
articles

HOMEOPATHY
PHARMACY ETHICS
PRACTICE
PROFESSIONAL PRACTICE

PHARMACY

One thought on Pharmacies,

Professionalism andHomeopathy
1. cabrogal
JULY 27, 2015 AT 2:42 AM
Some good suggestions for pharmacists here (though Im skeptical of
Carrs suggestion that either the PBA or the Health Practitioner
Regulation National Law will protect the job of an employee who
refuses to sell her employers stock) but what can the rest of us do?
I for one avoid giving my business to pharmacies that prominently
promote shonky products, but unfortunately that hugely reduces my
options. Even the ones that dont flog homeopathy, iridology, etc have
shelves full of diet products, supplements, arthritis treatments, etc
that have never been shown to be effective despite numerous studies.
If you add the allopathic medicines with very poor evidence base and
risk benefit ratios (e.g. SSRI antidepressants) youre left with no
options whatsoever for ethical consumer choice.
When it comes to homeopathy, yep Im repulsed by its bogus claims
and shonky science, but even taking into account the extra harms that
can arise from implicitly endorsing it I think having a promotional
scheme designed to sell large quantities of diphenoxylate (Buy five
or more packs and get a free carry bag says the sign at my nearest
pharmacy) is likely to be more harmful to customers and should be
subject to greater condemnation. And thats because diphenoxylate is
more than just a placebo.
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