What works; homeopathy and Big Pharma

Ben Goldacre’s excellent piece in the Guardian this weekend outlines clearly why it is that we can’t trust much of the data we have about pharmaceuticals. Data gets buried, the wrong questions get asked about what works, and we end up prescribing things that are later shown not to be useful, or even harmful.

Meantime, Des Spence wrote in the BMJ that homepathy is ‘bad science but good medicine’. While making it clear that homeopathy doesn’t work at a cellular level, he said that “The homeopathic doctors I know are caring people, disillusioned with the crudeness of conventional medicine, not your typical aggressive alpha medical type. They are not in the pay of big pharma, whose drugs potentially kill 100 000 people a year in the United States alone.1 They listen, spend time, and offer some explanation for the unexplainable—and their patients like them. The effect of homeopathy is the positive effect of a therapeutic relationship that is reassuring, accepting, and supportive. Society should never underestimate the healing effect of a kind word or the value of a holistic approach. These consultations genuinely improve wellbeing. Homeopathic pills are placebos, but the placebo response is great, maybe even as high as 80%.”

Here we have the crux; the massive dilemma in modern medicine. We have pharmaceuticals which we hope are evidence based but may, if we take into account the poor quality of the evidence, actually not be. Then we have doctors saying that actually, the drugs won’t work for a subset of people anyway; homeopaths are not prone to the excesses of Pharma, and thus homeopathy, with it’s kindness and concern, works. In other words, homeopathy is the best way to protect patients and care for them.

I think this is wrong, hugely and utterly and inescapably wrong.

First: it would be a scandal if the homeopathic consultation were the only way to talk, listen, support and be kind. But it’s not. It is true that the GP consultation has become owned, via the GP contract, to politicians more than patients (the whole of the last bit in The Patient Paradox is all about this.) The answer to this is not homeopathy, but in making the GP consultation about the patient, not about ticking boxes via the GP staring at the computer screen. We must address the GP contract, not add an unethical placebo like homeopathy. As I’ve written about before, there are many things which good general practice can ethically offer that improve outcomes for patients – like continuity of care – and which are not unethical deception.

Second: Some drugs do work. Treatments for HIV, meningitis, organ transplantation, heart failure, stroke. Ben knows this, he writes about this; he is certainly not arguing for non evidence based medicine (like homeopathy). The answer is not to give up on pharmaceuticals. It is to make the way we test and research treatments better. We have to  make the questions researchers ask more useful to patients. This is already happening. The James Lind Alliance works to do just this – to make sure that patients are telling researchers are asking the questions which are important to them, and then taking part in trials which they have ownership of. We need legislation to ensure that clinical trial results are not hidden. This can be done.

Third; It is of huge importance that we get back to the importance of unbiased assessments of the evidence. This  is what Cochrane was set up to do. Biased, bad evidence should be dismissed – which is how Cochrane operates – but good evidence stops us killing people – and here’s the crux -not just by prescribing, but also by not prescribing. So we know that MMR saves lives. But we also know that paroxetine prescribed to young people raises the risk of suicide.

More than ever, doctors, patients, carers, citizens and researchers have to work together. We have to acknowledge and reduce uncertainties about treatments when we can. But we also have to do this ethically; and caring well for patients without deception can  and should be our priority.

 

 

26 Responses to “What works; homeopathy and Big Pharma”

  1. David Drew September 24, 2012 at 11:34 am #

    Des is not so hugely wrong as you say. You have an unrealistic hope that many GPs are going to become caring individuals. The homeopaths are largely working commercially. They will only survive if they generate a high degree of patient satisfaction. That is not an issue in GP land which is largely a sellers market. Homeopaths in general know when they have a patient needing tea, sympathy and a placebo. The rest they pack off to take their chances with the allopaths.

  2. Margaret McCartney
    margaretmccartney September 24, 2012 at 11:41 am #

    I think that’s dreadfully unfair – ‘an unrealistic hope that many GPs are going to become caring individuals’ – are you saying that we are not? Most GPs I talk to say the same things – that we are having our professional skill crushed by politics and not getting a chance to do what we came to medicine to do.

  3. Witch Doctor September 24, 2012 at 12:21 pm #

    Homeopaths (at least those I’ve met) say they believe their concoctions are not placebos. They say they work better than placebos. If they did in fact regard their watery dilutions as placebos, informed patients of this, and tried to explain the placebo effect to them, then perhaps they might have a case if they changed their names to “placebopaths.”

    Jeremy Hunt, the new health secretary, no doubt will see to it that the homeopaths survive. It will be wrapped up in the dictum of “Patient Choice.”

    http://blogs.telegraph.co.uk/news/tomchiversscience/100179258/jeremy-hunt-health-secretary-thinks-homeopathy-works/

    Since JH was appointed by David Cameron, the assumption needs to be that our PM also believes homeopathy is a good idea for one reason or another.

  4. David Drew September 24, 2012 at 12:21 pm #

    I have spent my life working with GPs. Many are very caring. Some not. All would claim to be. Those who are caring not always resourced to care. Distracted by other responsibilities, limited time. Some are just “peopled out.” Homeopaths have more time, a different patient population and need patient satisfaction for their business to succeed. Maybe they are not more caring at heart level but in practice which is what counts they appear to be. I was suggesting that you are unrealistic in hoping that their will be any change in GP land in the near future.

  5. Cal Bryant September 24, 2012 at 12:28 pm #

    The ‘allopaths’ aren’t the ones charging money for water, the ‘allopaths’ are the people actually curing real illnesses, day-in and day-out. The ‘allopaths’ aren’t the ones lying to the public about the basic laws of chemistry, instead having to behave ethically.

    And to say that they don’t care? Ugh.

  6. MarGal September 24, 2012 at 12:42 pm #

    Interesting point: If I am nice to you I am allowed to defraud you.

  7. David Drew September 24, 2012 at 12:46 pm #

    If the homeopaths thought their remedies were placebos they wouldn’t work. That requires faith which is largely engendered by the practitioner. Hence need for double blind. Homeopaths are not charging for water but for their time and caring attitude. I have never seen a homeopath but many of my friends claim to experience marked improvement after doing so. That can’t be bad.

  8. Peter Vintner September 24, 2012 at 1:57 pm #

    This just needs saying for the benefit of all homeopathy advocates: There isn’t in existence a single documented, evidenced case study of homeopathy incontrovertibly curing anything at all – ever. All conjecture as to how it works is to overlook the simple fact that it has never been demonstrated to work as anything other than a placebo (ie. medically inert substance intended to deceive).

    The placebo effect is “available” to all medicine. The difference between real medicine and pretend medicine (because that is precisely what homeopathy is) is that with real medicine the placebo effect can enhance whatever the intended effects of any medically active ingredient. Homeopathy contains no medically active ingredient to enhance so the placebo effect is all there is.
    The placebo effect is a “feel good” deception, no different from giving a hug to a distressed child. It creates an expectation which, in the case of a self-limiting condition, is all well and good when no medication is actually needed – hence the expression “self-limiting”.
    Placebo itself isn’t medicine and can cure nothing.

    As for homeopathy itself, it is incontrovertibly pretend medicine with no basis at all in reality. It is to medicine what black cardboard is to road surfacing materials. The overwhelming majority of homeopaths are as competent to be trusted with serious, non-self-limiting medical conditions, as a child armed with a pair of plastic scissors and a roll of black paper is competent to resurface a potholed road.
    In any other sphere of business it would be regarded as fraud and treated accordingly.

    When you are not medically ill in the first place, when your ailment is psychological rather than pathogenic, or when you are suffering from a strictly self-limiting condition, it is easy to credit your recovery on pretend medicine. To paraphrase the late Professor Richard Feynman, the easiest person to fool is yourself.

    Lastly, to the commenter who referred to allopathy – there is no such thing. It’s an expression dreamed up by Samuel Hahnemann, the inventor of homeopathy, some 200 years ago and is used by homeopaths to denigrate actual medicine. There is medicine and not-medicine. If it works then it is medicine. And if it doesn’t then it isn’t.

  9. Chriski September 24, 2012 at 2:10 pm #

    The discussion here is full of assumptions and as far as I can tell, have no underpinning evidence. First of all, are homeopaths caring people? I wouldn’t make that assumption but would be interested in seeing a study of outcomes comparing different styles of approach.

    Second, what do you mean by caring? The theoretical and empirical basis of this topic is huge. Do you mean emotional labour? Natural caring qualities? I like Tronto’s view for her universalism – care involves attentiveness, responsibility, competence and responsiveness. If we unpack this topic then we realise that caring becomes a hugely complex matter.

  10. Penny Wolff September 24, 2012 at 4:25 pm #

    Interesting debates, mostly unsupported by evidence I have to say!!
    As far as I am concerned, one side of my family has a track record of being homeopaths dating back to early last century, and thus appeared to have escaped some of the downsides of the iatrogenic/side effects of pharmaceutical drugs, at least from my observations. It is worth noting that in these cases, individuals,including myself when younger, were registered with GPs who had undergone a conventional medical training (usually in Scotland) followed by postgraduate courses (in Glasgow). The GPs were thus able to prescribe either allopathically or homeopathically, as they judged appropriate.

    It may be worth pointing out that RCT’s of many drugs are of relatively recent origin, as is the inception of NICE and the use of meta- analyses -so evidence in relation to efficacy, interaction effects with other drugs, and risk factors may be only sparse for any particular drug.

    Placebos do appear to have useful positive effects according to well evidenced scientific trials – this being so even when the individual taking them is aware that they are taking placebos.( I can suppply the reference for this latter) Above all they have no direct deleterious effects,( although it could be argued that in cases where appropriate drug intervention is delayed – this is in itself likely to be deleterious). However, I do sense there is a touch of over-reaction in all of this………on both sides…..
    Let the debate continue!!!!

  11. Dr. Nancy Malik September 24, 2012 at 6:11 pm #

    By the end of year 2010, there have been 245 human studies published in 98 peer-reviewed international medical journals (80 integrative, 9 homeopathy and 9 CAM) including 11 meta-analysis, 6 systematic reviews, 1 Cochrane Review and 100 DBRPCT in evidence of homeopathy.

  12. Skepticat_UK September 24, 2012 at 7:07 pm #

    David Drew said, “Homeopaths are not charging for water but for their time and caring attitude.”

    You think they give the remedies away for free? Think again. My hairdresser recalls being charged around £13 for bottles of useless homeopathic remedies to treat his baby son’s eczema. With the additional charge for the homeopath’s “time and caring attitude” he managed to waste over £500 before realising he was being sold a crock. Of course, if he’d witnessed any improvement in his son’s condition, he’d probably be as sold on homeopathy as your friends are by now.

  13. MarGal September 24, 2012 at 7:08 pm #

    @nancy malik: first, a bachelor in homeopathic medicine and surgery whatever that should be doesn’t make a doctor of you. Second: peer reviewed by integrative homeopathic and CAM supporters? Why should that give us better results than bad parma reviewing their own new drugs? Seems bad pharma and alt med use the same dirty methods.

  14. Peter Vintner September 24, 2012 at 9:08 pm #

    @Nancy Malik If homeopathy works then you would be able to provide one properly documented and evidenced case study of homeopathy incontrovertibly curing something. You would be able to lay your hands on thousands if not millions. But you can’t lay your hands a single such item.
    No homeopath has ever produced a genuine case study of an incontrovertible cure. And the reason is obvious – homeopathy is a simple but effective scam. Homeopathy has never incontrovertibly cured anything. It simply cannot do that, any more than a solid gold ingot can double as a swimming float.

    The basis on which homeopaths such as yourself claim efficacy is absolutely dishonest. To claim efficacy for anything at all on a zero success rate would in any other sphere of human endeavour be seen for the fraudulent practice it is.

    Many homeopaths are clearly deluded. Many more in my opinion are clearly mendacious.

    Homeopathy is a demonstrable, incontrovertible fraud. It is as demonstrably and incontrovertibly wrong as a geocentric universe, a flat earth, astrology, phrenology, phlogiston theory, alchemy…. In the 21st century it is disgraceful that this fraud can legally be perpetrated and profited from. Given the sum of human knowledge at this point (understanding homeopathy requires knowledge of only the most basic chemistry and physics), that it even needs to be discussed demeans intelligent people.

    Homeopathy is fraud. No more. No less.

  15. Peter Vintner September 24, 2012 at 9:34 pm #

    @Penny Wolff there is no such thing as allopathic medicine. There is no alternative medicine, only medicine. If it works it is medicine It’s really that simple.
    In an alternative reality, Alice in Wonderland for example, you can have alternative anything you like – alternative engineering, alternative geometry, alternative chemistry, alternative physics, alternative biology, alternative facts…
    But in the real world one can insist as much as one likes, and make whatever claims one likes, but when you are in reality ill with a real non-self-limiting life-threatening condition you will likely die without real medicine, just as one’s ancestors did.

    If you live in an arid climate, where it never rains or snows, you can cover your roof with paper with printed tiles on it. It will serve its purpose well and you can believe as much as you like the claims of the roofing company that it will keep the water. out .
    Likewise, if you aren’t suffering from a non-self-limiting medical condition (as most people aren’t) you can believe as much as you like the homeopaths claims to be able to cure just about anything. The simple fact is that self-limiting conditions rarely need medical intervention, because as the name implies, they tend to resolve themselves. You would get as much benefit and probably more enjoyment if you ate a Werthers Original rather than any amount of homeopathic water or sugar pills. And it would cost a lot less.

    Homeopathy isn’t harmless http://tinyurl.com/y8u9pxn

  16. steve September 25, 2012 at 7:48 am #

    Dr Spence says “Our energy would be better used addressing the much bigger issue of the iatrogenic harm of conventional medicine” I would ask – why can we not do both? Challenge mumbo-jumbo AND the various iatrogenic problems of modern healthcare?

    Homoeopathy lacks any evidence basis to show that it is better than placebo – in other words it is no better than a “sugar pill”. Those who claim otherwise are guilty of ignoring the scientific evidence. If they fail to tell their patients about the complete lack of an evidence basis that homoeopathy is better than placebo then they are guilty of deception, something of which the GMC should take a dim view if they are doctors. It is also wrong to refer to homoeopathy as complementary therapy. Complementary is defined in the dictionary as that which completes or makes up a whole – when talked about in the same context as evidence – and science-based modern medicine homoeopathy can in no way be described as complementary because it defies the laws of physics and our understanding of physiology. Thus it can only legitimately be referred to as alternative therapy.

    Now if that’s the context in which the NHS funded homoeopathy and equal funding, time and weight was also given to things like reflexology, cranio-sacral therapy, hot stone massage, Hopi ear candles or waving crystals around your body to identify your aura then that would be quite legitimate and Dr Spence might have a valid point.

    I don’t deny that homoeopathy helps a lot of people but why should the NHS pay for it if it is not prepared to pay for osteopathy, chiropractic, aromatherapy, hot stones massage, reflexology, candles in your ears, tubes up your bottom, footbaths that turn brown? That for me is the fundamental question. Why should the NHS fund some irrational 18th century snake oil scheme just because some people claim that it helps them? (For those who haven’t yet read them I strongly recommend the chapters on homoeopathy by Ben Goldacre and Ernst and Singh in their respective books). Far better to spend that money on counsellors or CBT therapists if you really want to help medically unexplained symptoms.

    Hey, but what do I know – I’m just a tax payer who thinks, at a time of overt rationing, the NHS has an obligation to spend my taxes more wisely in future.

    To those who would state “What do you know – you haven’t studied homoeopathy or subatomic physics” – I have studied homoeopathy to the level required for MFHom and it’s the only time in my life that the more I learned about something the less I believed it. In addition, I have been reading about quantum theory and subatomic physics for 25 years and I have a fair lay understanding of both. There is nothing in either that provides a good evidence basis for homoeopathy – otherwise I would have been the first to say so and outline why.

    However, I digress. The main point of Dr Spence’s article is not whether homoeopathy works at a higher level than the placebo effect – he has effectively admitted himnself that it does not. Rather he is arguing that the NHS should fund it as it’s good for patients and good for the NHS. This is where I beg to differ. If people want to spend their own money on whatever makes them feel better I’m all for that – 100%. But when every day brings another story of the NHS rationing things that we know make a real difference to patients or when the NHS refuses to adequately resourse things like cognitive behavioural therapy then I have a real issue with it spending £40 million a year on homoeopathy because “people like it”. I would love a weekly massage and would definitely feel much better for it. Can I have that on the NHS please?

  17. Dr. Nancy Malik September 25, 2012 at 9:30 am #

    @Margal
    1973: The legal status of homeopathy medicine in India is on an equal footing with conventional, Ayurveda (recognised since 1969), Unani, and Siddha medicine. It is recognised by Central Council of Homoeopathy , Deptt. of AYUSH, Ministry of Health & Family Welfare, Govt. of India since 1973.

    @Peter
    One cochrane study in favour of homeopathy for you to decode
    http://drnancymalik.wordpress.com/2012/08/13/ask-for-evidence/#comment-3922

    A condition that is self-limiting does not mean that medical intervention would not bring the condition to an end more quickly.

  18. MarGal September 25, 2012 at 1:05 pm #

    @nancy malik: could it be that this wide acceptance of non conventional and non effective treatments in India is one of the causes of the highest children mortality rates in the world?

  19. Louise Mclean September 25, 2012 at 9:45 pm #

    Why does NOBODY ever mention the fact that the placebo effect is just as likely to occur with pharmaceutical medicine as homeopathy or any other medicine for that matter???

  20. MarGal September 26, 2012 at 5:51 am #

    @Louise Meclean: placebo effect is the reason for the double blinding in trials. Patients and doctors don’t know if they are using the medicine or the placebo. In this way it’s possible to see if the medicine works or not. If same test is replicated by many others and provides similar results, and there is a significant difference between placebo and medicine you know it works.

  21. steve September 26, 2012 at 9:02 am #

    @Louise McLean – the placeba component of therapy is mentioned all the time in the medical literature – and not just for various drug therapies. Seek out the classic trial that looked at arthroscopy (telescope examination) of painful knees in orthopedics.
    There are lots of studies that show that analgesics (pain killers) work better if they are coloured red rather than blue (and for anti-depressantts it’s the other way round).
    As MarGal points out the ideal is that the drugs we use should have been shown in repeated clinical trials to have a beneficial effect that is more significant than placebo. We are getting much better at that but there are still some drugs in common use where the benefit beyond placebo is marginal if it is there at all or where the benefit does not outweigh the harm and these are things which we should be taking just as seriously as the quackery that abounds out there. My own current bete noirs are statins in primary prevention (see Margaret’s recent blog on “statins for all”) and quinine used as a treatment for night cramps (which has been effectively banned in Australia and the USA for this purpose but is still widely used in the UK).

  22. Dr. Nancy Malik September 26, 2012 at 11:32 am #

    @Louise
    Placebo effect size same in conventional & homeopathy medicine (2010)
    http://thewrightdoctor.com/wp-content/uploads/2010/11/Placebo-effect-sizes-in-homeopathic-compared-to-Conventional-Drugs.pdf

  23. steve September 26, 2012 at 11:43 am #

    @Dr. Nancy Malik and Louise – the difference is that homoeopathy has shown no consistent evidence that it is better than placebo unlike, say, antibiotics or antihypertensives. That’s the point!
    I am all in favour of using the placebo effect and that’s what homoeopathy is good at. However, if you fail to fully inform patients that that is what you are doing and instead dress up your sugar pills to be something more effective than that with competely unsubstantiated claims about their benefits (or lack of) then, in my view, you are guilty of decpetion and that has no place in modern medicine.

  24. steve September 26, 2012 at 10:43 pm #

    @CelticLeopard – agree and that’s why we have to challenge it wherever and whenever it occurs as Margaret and Ben Goldacre and even myself try to do.

  25. Malvolio September 28, 2012 at 8:05 pm #

    Des Spence gives a reasonable, proportionate, pragmatic opinion on the use of homeopathic treatments, and Margaret McCartney thinks “this is wrong, hugely and utterly and inescapably wrong”. Is it just possible that Margaret might have got things a little bit out of proportion?

  26. Derek Tunnicliffe September 30, 2012 at 5:56 pm #

    Surely one doesn’t just turn up at the door of a homeopath as one does at one’s GP’s? You make a positive choice to go there, rather than to your GP (the recognised first point of contact for medical advice/treatment). Thus, you are half-way sold on the idea that homeopathy works? (Placebo effect).

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