Tuesday, 30 July 2013

Nelsons- suggesting kids need mood stabilisers from 2 years+

You know of Rescue Remedy, right? You probably had an aunt who would constantly swig a drop for her nerves, or might have even taken some before a driving test or exam.

Rescue Remedy has become a pretty well known brand- so well known, in fact, that most people don't bother finding out whats in it, or what principles its based on. You wouldn't want to know the recipe of Coca-Cola before you take a refreshing swig- you'd just assume that because its a well known brand, its probably going to work.

Rescue Remedy is, however, a whole load of woo nonsense. Sorry, but there's no other way of putting it. Some dude called Edward Bach decided- apropos of nothing- a good few years ago that some flowers, if left out in the sun and dissolved in alcohol,  will be able to balance physical and emotional distress. This is interesting, really, given that its taken the entire fields of neuroscience, psychiatry, and psychology many, many years to get to a point where there are still a vast amount of unknowns regarding mood disorders.

Science is getting there- slowly- when it comes to understanding things like depression. It's a vastly complicated subject. There's no perfect cure-all drug out there for treating such things- mainly because we don't yet understand it that well yet. So forgive me if I am skeptical that some random guy years ago has just randomly (without any basis in science) decided that, for example, mustard flower:
 "is the remedy for deep gloom and depression that descends for no apparent reason out of a clear blue sky. People in this state often list all the reasons they have to feel happy and contented, but still everything looks black and hopeless to them. The remedy helps to dispel the clouds so that we can once again appreciate the joy and peace in our lives."
Rescue Remedy is a blend of some of Dr Bach's made up flower remedies, diluted in brandy. You're supposed to reach for it in times of anxiety, as a soother. Funnily enough, brandy, being alcohol and all, it might make you feel a little bit better, but similarly to homeopathic remedies, they are dilutes such that very little or no levels of active ingredient are likely to remain. So even if Dr Bach were right about the flowers (despite evidence and science suggesting otherwise), there wouldnt be enough flower-stuff in a drop of it anyway to make a difference.

I can't quite get away from the fact that this is a cynical product which Dr Bach made up in an attempt to target wealthy women ("ooh! pretty flowers!") in the days where women were considered "hysterical" and many were labelled as having "problems with their nerves" based entirely on their sex.

Anyway, why am I on about Nelsons, and why am I on about children? Well, because the Bach Rescue Remedy brand- in all of its many, varying, and just-as-cynically money-grabbing-as-Big-Pharma- forms- is sold via Nelson's homeopathic brand. That's Nelson's who the FDA discovered weren't putting magic woo water in all of their magic woo water pills, but were happy enough to put particles of glass in there. That's Nelson's who are all "ooh, we care about you and your healthcare unlike those big meanie pharmaceutical companies who only care about money" all the time.

Well, I happened to stumble across this product of theirs today. Rescue Remedy Gummy Stars- aimed at children from 2 years and onwards. According to Nelsons:

"The first day back at school is a big day so parents should have a secret weapon against tiny tears on standby in the school run bag. RESCUE® Gummy stars - The latest addition to the RESCUE brand come in fun star shapes to help turn a frown upside down at the school gates and each Gummy Star contains four drops of RESCUE, the famous soothing combination of five flower essences."
What's wrong with that? The fact the Nelsons are attempting to medicalise a perfectly normal part of childhood purely for their profit, that's what. Being nervous on your first day of school is entirely normal, especially for a little one. What they need to do is to develop normal coping mechanisms to deal with their anxiety. What they don't need to feel is that their anxiety is abnormal and something which only a medicine can fix.

When encountering the world of complementary or alternative medicine, I often like to stop for a moment and replace the names of the companies with those of Big Pharma. It gives a good indication of whether or not there really is a difference in practices between the two camps, and whether people's reactions would be different
"The first day back at school is a big day so parents should have a secret weapon against tiny tears on standby in the school run bag. PROZAC® Gummy stars - The latest addition to the PROZAC brand come in fun star shapes to help turn a frown upside down at the school gates and each Gummy Star contains 10mg of PROZAC, the famous soothing antidepressant fluoxetine."
Icky, right?


Thursday, 25 July 2013

Water in a can now available on prescription. No, really.

No, its not a homeopathic sort of magic water this time, but instead Magicool.

Yep, remember when there were cheesy adverts on the TV all the time advertising this breakthrough, world's first spray? The website for Magicool even goes so far as to call it "heaven-sent". What in it? Well, water it would seem. I can't find any of the other ingredients listed on the website, save for a rambling explanation of how they still manage to get away with putting fragrance into it whilst claiming that it is an "unscented" product. Presumably it will have some sort of propellant in it too.

The theory is simple, and to be honest pretty good. When its warm, water on your skin evaporates, drawing out the heat. You feel cooler. So that's good. But its fairly impractical to keep having a cold shower every two seconds if you're at work or out and about, so Magicool is a nice portable option. Fine so far.

However, Magicool have decided to go one step further, and start making medical claims with their Magicool Plus range. They're classed as medical devices (sound familiar?) so don't need to go through the rigorous clinical trials that licensed medical lotions or potions have to. But they're now apparently available on prescription, so there must be some evidence that they work, right?

The Magicool website is frankly appalling. But what I'm looking for is a plausible mechanism of action for why their products work, and some good evidence that they do work. Let's have a lookie, shall we?

Kinetic pulses? anaesthetizing? vital deep cell hydration? adjusting pH? Despite its claims to be unscented, I am smelling pseudoscience at work. And what is with the text speak?! I've had emails from Nigerian princes asking for my bank details so that they can send me millions of pounds that are better written than this supposedly medical resource.

The evidence section appears to be a badly scraped together list of links from places like Trip Advisor and Yahoo Answers, where people have vaguely mentioned in passing that the product worked. But, dear readers, as we know by now, testimonials and reviews certainly do not constitute robust medical evidence, especially when lots of them are merely spam adverts posted on forums etc, as they are here. Again, there's no indication of what the ingredients actually are, so I have no idea whether or not there is even any plausibility in the claims above and beyond the fact that it might make you feel a little bit cooler.

So, if the manufacturer's aren't being forthcoming with any evidence, let's turn to the medical literature. This is made difficult, of course, by fact that I have no idea what is in it, other than water. Searching for the brand name brings up nothing at all, so it would appear that there is a grand total of no evidence whatsoever that this stuff actually works more than ordinary Magicool, or a shower, or standing next to a fan. The manufacturers are claiming that the product has "maximum therapeutic efficacy" on the basis of thin air.

According to Chemist and Druggist, the availability on prescription is coinciding with a large advertising campaign. This means two things:We'll have to sit through more daft adverts filled with smug thin people on holiday cooling themselves down despite not even looking remotely hot (where's the red face and frizzy hair, eh?!) and that some patients will inevitably rock up to their doctors and demand it on prescription.

The cost price to the NHS is £5.77. That doesn't seem like its going to break the bank, but I don't care how small an amount it is, frankly. There is a finite pot of money in the NHS, and we need to use every single penny of it wisely. If £5.77 is being spent on water in a can, that £5.77 can no longer be used to pay for something life saving.


Sunday, 21 July 2013

Prescription Exemptions and the bloody Mail on Sunday.

Today, I feel ranty. So ranty, in fact, that I can't even think of a clever title for this post.

Why? because the Mail on Sunday has riled me up with this story about how pharmacies are failing to check exemption statuses of patients. I have been weak, dear readers, and I have allowed the Mail to affect my emotions.

As a pharmacist, my job is to make sure that patients get the right medicines, can use them safely, and have all the information that they need. My ultimate goal is to make sure that my patients stay as healthy as they can for as long as they can, and to improve their quality of life.

My role is not as a fraud investigator, but as a healthcare professional. Its up to the patient to ensure that their exemption is correct and up to date, and its up to me to ask to see proof of exemption, and to train my staff to do likewise. So that's what I- and many, many other pharmacies- do, day in, day out.

What if a patient says they don't have any proof of exemption? I go right ahead and give them their prescription anyway. What am I supposed to do? Say no, sorry, you can't have this inhaler until you go home and get your exemption certificate and bring it back to me. And then what happens when the patient has an asthma attack on the way back to the pharmacy, and without their medication dies? Funnily enough, I suspect newspapers like the Mail on Sunday would just as gleefully report on my failure as a pharmacist to supply life- saving medicine to a patient, and how I was just being evil and money-grabbing instead of thinking about patient care. So we are literally damned if we do, and damned if we don't.

Of course, we can cross the box on the back of the prescription, which means that a small, random selection of prescriptions may be investigated. But this process is pretty murky, and the details of it are unclear to the majority of patients, pharmacists, and pharmacy staff. We get little to no feedback of any cases which are identified as fraud through this method, so it ends up seeming pretty pointless. You spend years and years of dutifully crossing the box, and you never see it making any difference. Perhaps if this process were clearer, and we could more clearly see some results from it, this would spur pharmacists on to continue with the box ticking exercise.

Ever tried to confront someone about the fact that they may be committing fraud? Ever tried to do so over a counter, when you're working on your own and have a queue of about twenty people behind the person you are accusing? A pharmacy is certainly not the correct place for such things to happen in- the personal security of the staff, the workload, and the potential for a patient to have to go without their medicines all mean that its practically something that we cannot do well, without a massive overhaul of staffing and how pharmacies are designed.

I suspect the reporters at the Mail on Sunday haven't ever had to stand on one side of a pharmacy counter whilst a patient asks which of their medicines is the most important because they can't afford to buy all of them. I have, and its heart breaking. Prescription medicines in the UK are £7.85 right now. We're currently in a time when Atos are merrily declaring- sometimes on very shaky grounds- that people who are crippled by a variety of medical and psychiatric problems are fit for work, and are stopping their benefits. There are people out there who cannot afford to pay £7.85 per prescription item, through no fault of their own, and these are the people who are likely to be taking a variety of different medicines. Do I therefore withhold their prescription, or tell them which is the most important drug for them to take and send them off on their way with a sub-therapeutic drug regime that is going to make them even less able to work and find means of paying for their medicines? I can't imagine the hurt and shame that a patient must have to go through to admit that they can't afford their medicines, but I know I don't want to have to put an already unwell patient through that.

I've had a friend worry how he was going to pay for his prescriptions because of problems with his benefits, problems that he had no control over and were to do with mistakes at Atos. Do you know what I told him? Go to your usual pharmacy, tick the box, and don't say anything. I know that's wrong, but given the options: he becomes very unwell vs a small risk he gets a fine of £100 at a later date when he would hopefully be able to pay it, I'm sorry dear readers, but I'm always going to opt for the former. That may be, as the Mail so charmingly puts it "scandalously careless" of me, but it doesn't feel like it. It feels like I am caring for my friend's health, and that's my job, and my personality. What would feel "scandalously careless" would be to force someone with no income through no fault of their own to choose between food or essential drugs.

Forgive me if I would rather give patients their drugs and keep them as healthy as I can. Do forgive me if I put the quality of my patients' lives ahead of the fear of prescription fraud, which I can do very little about anyway.

This whole system of exemptions and payment is outdated and needs an overhaul. In the meantime, branding pharmacists as lazy debt collectors and desperate patients as robbing prescription cheats doesn't help. As a healthcare professional, my need to provide vital medicines to my patients transcends petty demonisation by a scaremongering newspaper.

Here's an extract of the Mail on Sunday's report:
"Dr Clare Gerada, chairman of the Royal College of GPs, called for a ‘fundamental review of prescriptions’. But a spokesman for the Royal College of Pharmacists said it was ‘not their job to police the Government’s prescription exemption system’, adding: ‘Guidance is very clear that pharmacists must put the clinical needs of a patient first, and not deny someone access to lifesaving medicines because they haven’t got proof of exemption."
Interesting, really, given that the "Royal College of Pharmacists" doesn't actually exist. This is lazy, crappy reporting, if they don't even bother to get the Royal Pharmaceutical Society's name right. You can read how the RPS have responded to this article here. Its a perfectly reasonable response, and in my opinion reflects what actually happens in daily practice.

Monday, 15 July 2013

How much of (insert drug name) do I need to take to kill myself?

I'm slightly obsessive over checking my blog stats, and I've noticed a trickle of people finding my site by using such terms as the above.

So, if you have found my site by searching for a similar phrase, I just wanted to say a few things to you. I'm not saying this in my capacity as a pharmacist, or skeptic, or anything like that, but just as a human. Don't worry, I won't keep you long.

Firstly: I know and I understand.

Secondly: Please ring these people. No, really, please do. After all, in the grand scheme of things, a delay of a few minutes wont make a massive difference.
In the UK, the number is 08457909090. In the Republic of Ireland, its 1850609090. In the US its 1-800-273-8255. There will be similar numbers in other countries.
If you  could just do that for me, that will be brilliant. 

Thirdly: I'm sorry, but you wont find that kind of information on this site. 

Fourthly: I care about people, and that means I care about you. If someone who has never met you at all cares about you, then its highly likely that some other people out there do too. I know that might not be enough, but it should count for something. I and many others don't want you to.

Oceans of love,


P.S. There is a lesson here for other bloggers/ website owners/ healthcare professionals too. Please be aware of what you are writing if you are covering anything about toxicology.

Thursday, 11 July 2013

Customer walks into a pharmacy...

...and chooses what medicine they want to buy, before taking it to the pharmacy counter. Yes, that's right folks, instead of telling a daft joke, I'm going to witter on yet again about the self-selection of P-meds. This time I want to think about it from a patient's perspective. Some of these considerations may seem small and petty, but i just want to put my thoughts down on virtual paper and you can see what you think.

When I walk into a shop, I can be pretty easily intimidated. I'm shy, and I don't like to bother people. I also hate that uncomfortable feeling when you walk into a shop and you feel like you're being watched by someone and then you feel terrible about not buying something. I can get anxious about the smallest of things, in particular not quite knowing what you're supposed to do in a shop- if I can't find the til, or there's an empty box and i don't know who to ask, or if I can't find something, for example.Of course this is worse when I am feeling a bit poorly and I can be particularly skittish- im likely to go home without buying anything, even if i need it, because i can't be bothered to have to work out what I'm supposed to do. This brings me onto my first point about self selection

1. It could be different everywhere. Not all pharmacies will take up the self-selection option, so I'll need to ask at the counter as i am used to. But in some pharmacies, the packs may be out on the shelves, whilst in others, they might be in security packs or might be empty packs that I need to take to the counter, like an early nineties video rental shop. It sounds daft, but this sort of thing could be quite off-putting.

2. How the hell am I supposed to know what to buy? I tend to acknowledge people who know more than I do about a subject and listen to their opinion. If I go to the hairdressers, for example I tend to ask them what style they think would best suit my hair type and face. After all, they've done some training in cutting hair whilst I am utterly clueless about it. If I walk into a pharmacy, therefore I don't expect to have to do all the hard work of product selection myself. My product selection process for most things usually goes like this:
Its either that, or I stand around reading every single box of every single product. This would take me bloody ages, and would be pretty inconvenient.

3. What If Its The Wrong Thing? After I have found the shiniest product, I take it to the counter, where I am then told that I've picked up the wrong thing and I'm not allowed to buy it. This, frankly, pisses me off and adds even more inconvenience o the whole affair. I've chosen the product, and now some jobsworth glorified shop assistant is saying that I've chosen the wrong thing? how dare they! (I've lost count of the number of times I've been called a glorified shop assistant by patients-and on occasion non-pharmacist managers over the years, by the way). You know like when you're in a hurry, and you've picked something up in a shop and you take it to the counter, and they tell you that its on buy one get one free, but there is a huge queue behind and you're going to be late for your train so you just say "oh its fine, I'll just take that one". I suspect that would end up happening quite a bit as well.

4. Advice Isn't Quite So Forthcoming. When I ask for a specific product in a pharmacy, the counselling and advice I am given tends to be minimal (if at all), whereas if I ask what they would recommend for a particualr symptom (not that I usually have to bother doing that myself, but you know), I tend to be given fuller, more rounded advice as part of the product selection process- I've written about this before. If I want to know something about a product, I have to ask about it, and I might feel a bit stupid doing that when I'm supposed to have picked the product myself. In addition, I might not actually know that I need to ask for advice unless it is offered. With self-selection, I fear that offering routine advice would become the exception rather than the norm, and instead of being proactive in giving advice, we would instead get into a pattern of waiting to be asked.

5. Medicines Are Commodities And Its My Right To Buy Them. I've written before about the paracetamol problem- its so widely available that people think its safe and innocuous, and they can take extra or dismiss it because they've sort of forgotten that its a medicine. I think this may become a wider problem. If medicines are available on the shop floor for me to handle and choose myself, I assume that they're either not very good medicines, or they are so safe that I can use them how *I* like. If I want to take three times the amount of antihistamines that it says on the pack, then I can do, just like how if I want to eat peanut butter out of  a jar with a tablespoon then I should be allowed to, because its my choice to buy it and who is anyone else to judge me and tell me otherwise? this is going to be particularly problematic with codeine-containing medicines and similar.

Anyway, those are a few thoughts for now. I may add to them as time goes on. What do you think?


Tuesday, 9 July 2013

The friendly and respectful homeopath.

I dont want to have to write this post, but it has been bothering me and I find myself thinking about it a fair bit. So, here it goes, and apologies for yet more homeopathy bashing.

I've written before about how i'm sure that a homeopathic consultation is probably quite nice. Spending an hour with someone who really listens to you, as opposed to a 10 minute curt conversation with a harried GP must feel lovely. And of course, homeopaths play on this contrast between holistic care and a more conventional symptom-based approach. They like to portray themselves as caring, benign folk who really care about your health and your rights as a patient.

I'm sure many of them really do care, although by definition misguidedly. Unfortunately, though, there are some who like to portray themselves as caring, but who in actual fact can be so utterly disrespectful it can make your jaw drop and cause you to still be thinking about it after a month has passed.
If you've ever said anything skeptical about homeopathy on Twitter, you will probably have encountered I'm-Not-Really-A-Doctor Nancy Malik. I don't mean this to be an as hominem attack, but goodness does she make it hard to refer to her without resorting to one.

I can't actually really remember the specifics of this conversation, but it involved a couple of us skeptic types questioning something posted by @urbanhealing. The conversation was going in the usual way, namely requests for evidence were being met with all sort of batshit crazy quantum bollocks. When that tactic didnt work, @urbanhealing had resorted to insinuating that we skeptics are stupid. In jumped Nancy Malik, with this bombshell, which took my breath away.

You can see my incredulous response to her, which was met with silence, even despite a couple of follow up tweets.

Motor neurone disease is an absolutely devastating disease, which has huge effects on its sufferers, as well as those around them. When my ex-husband's friends mother was diagnosed with it, the shockwaves and devastation of it were clear to see, even from a distance. It's no laughing matter, and it is certainly not something to fling about as an insult to people who reasonably question you.

Motor neurone deficiency means many things, but it does not mean you're stupid, which is the insinuation in the context of this conversation. It is a rare, severely debilitating disease which impacts on both morbidity and mortality but not IQ, and it is utterly disgraceful and disgusting to say so.

Probably the most famous sufferer of motor neurone disease is of course Stephen Hawking. So what on earth is she thinking using it as an insult to the intelligence of skeptics?!

I don't have motor neurone disease, and nor does anyone who I know directly. But that does not stop me from feeling rather sick and insulted by what Nancy Malik has said. Anyone with a little bit of empathy, heart and respect for other people would probably feel the same as me, I would imagine.

This is not indicative of a caring, holistic practice, but instead is cynical, unthinking and brutally insensitive. And its made all the worse by the constant portrayal of homeopathy as more caring than conventional medicine.

Oh, and of course it goes without saying that I will be more than happy to hear exactly what Nancy Malik meant with her tweet, and I will of course welcome an apology from her for the offence she has caused.


Monday, 8 July 2013

When Z-day comes, think pharmacy

A little while ago, it occurred to me that I hadn't watched many zombie films in my life. I therefore made it a bit of a project to watch a whole load of them. I got myself a mentor (my friend Frankie) and together we perfected the art of walking back from the cinema in a zombie fashion whilst giggling hysterically.
I've watched good zombie films, bizarre zombie films, Christmas zombie films, thoughtful zombie films, and absolutely terrible zombie films starring Billy Connelly. So I sort of know the ropes when it comes to the genre. On the advice of Nancy, I started listening to the We're Alive podcast, and now extol the virtues of it to any who will listen. Although I dont recommend listening to The Archers right after it, as you find yourself waiting for zombies to jump out and ruin the Ambridge flower festival.
So I've just gotten back from World War Z. It was better than expected, and it managed to squeeze more entertainment than I thought may be possible out of a lab in Wales and Peter Capaldi wearing a jumper. Although given I have a bit of  a thing for Peter Capaldi and Brad Pitt, I was happy enough as soon as he arrived on screen. All that was missing was Hugh Laurie. And a better ending. And more gore. And less CGI. And less not realising that with a pen and paper and the camera he could easily get the people in the know to tell him which vial to choose. And wouldn't there be an intercom in a WHO lab with infectious diseases in it anyway?!
Anyway, I digress. Aside from all the problems with the film that no one else would probably notice, I did note one shining light in all of the z-day carnage. Brad Pitt, like any good citizen should, Thinks Pharmacy. In need of an emergency supply of a salbutamol inhaler, off he goes to the local, friendly community pharmacy.
I don't think this is much of a spoiler, given apparently pretty much the whole film is in the trailer, but after barging into the supermarket pharmacy (probably unlikely: in real life he would have just coughed loudly and shouted "shop!") he is greeted by a friendly professional, white coated  pharmacist who offers him an NMS consultation. Okay, maybe not. He's wearing  hoody and carrying a gun, but, ever the professional, still manages to give some health advice when handing over three inhalers. "Children grow out of asthma" he says, helpfully, which may be true, but I think is unlikely to be the case by the time the  3 inhalers are used up.
He even link sales, passing over some bottles of what I presume to be paracetamol liquid too. How very helpful.
Its nice to see a pharmacist in a film or TV show doing something other than serial killing, murdering, nearly killing orphans with poison when drunk, or merrily doling out vicodin to Dr House without a prescription. Its nice to see a pharmacist resolutely doing what he can to help. It reminds me of all those stories you see in Chemist and Druggist, where there has been horrendous floodings but the pharmacy staff still manage to open up and do their deliveries in a makeshift canoe. The ones who, despite broken shutters or six foot deep snow or pandemic Ebola still turn up to make sure all the collections are done and the order is put away.
The pharmacist in question doesn't do any WWHAM questioning though. I'm not convinced Which? Would have been very happy with him.

Self-Selecting P Meds- The evidence

The other week, the lovely folks at The Pharmacy Show Community (they are really lovely, my flattery of them is nothing whatsoever to do with the fact that they are linking to and publishing bits of my blog) held a tweet chat all about the self-selection of P meds, led by the mysterious and always entertaining @MrDispenser.

There are a few concerns that I- and it seems many other pharmacists share about the self-selection of P-meds. I've covered some of my concerns here, but the tweet chat threw up many others too. Other pharmacists have also shared their concerns, and you can find some of them in the links below:
The Pharmacy Show Blog
Dr A R Cox
James Andrews

Right now I want to look at the evidence that self-selection works. The theory is that allowing patients to choose their own medicines leads to greater adherence. As the patient feels they have more ownership over their healthcare decisions, they might use the drugs more effectively for a better outcome. But is there any cold, hard evidence that this is the case when it comes to over the counter medicines?

As a skeptic, the words "Where's the evidence?" are often found escaping from my mouth. Sometimes the need for evidence is countered by the risk averse pharmacist side of me, where the theoretical likelihood of a risk outweighs the need for evidence. As with all things in healthcare, a balance needs to be taken into account: what are the risks vs what are the benefits?  In this case of self selection, I can see there being a real risk of fatalities. Any evidence of benefit to patients needs to be robust in order to outweigh the risks, in my opinion.

So I've made a start by looking at Embase and Medline. I've also had a look at NHS Evidence and have even googled. And I've been able to find very, very little on the subject. I found one Dutch paper about self-selection in the pharmacy, but that has no abstract.

I found this World Self-Medication Industry website which states:
"A study done in the United Kingdom showed that consumers welcome the opportunity to self-select medicines in that country's pharmacy class. Three out of four of the British consumers in the study felt that re-configured pharmacies with easier access to nonprescription medicines was a good idea, half because it would save their own time or that of their doctor, and the remainder because it offered greater choice."
But this doesn't appear to be referenced, so I can't find the study to see how reliable it is.

Have I missed anything? If you're aware of any evidence for the efficacy of self-selection of P-meds, please do let me know by dropping me an e-mail at healthydoseofskepticism@gmail.com. I would be particularly interested in any evidence that could be provided by the GPhC, and might drop them a line to see what they have to say on the matter.

In contrast, I stumbled across a study from New Zealand, which concludes that, when purchasing a pharmacy medicine for the first time, in 62.2% of cases the sale was influence by pharmacy staff. This study has its limitations of course, but if true (and from my personal experience of many years of community pharmacy work it would appear about right), it would seem a shame to eliminate this from the medicines buying experience.

There is also some evidence that patients who approach the pharmacy counter with a specific product in mind are given poorer advice than those who ask for a recommendation based on their symptoms- again something I have experienced both as a pharmacist and a customer.

Of course patients can still ask for the expertise of pharmacy staff, but how many of them will know to ask, and how many will simply pick the nearest thing and hope for the best?

I'm going to hopefully write another post about my concerns about how the patient experience will be affected. If you have any thoughts on this, again do get in touch. If you're a customer in a pharmacy, I would love to know whether you think self-selection of Over-The-Counter medicines would be good for you.

Wednesday, 3 July 2013

The Society of Homeopaths and what passes for Evidence.

So today has seen some great news for rationality, science, and above all patients. The ASA has announced this ruling, leading to the Society of Homepaths taking down a rather large chunk of their website- the bit about what homeopathy can be used for.

However, using their search function, you can still find some of the nonsense they are promoting. I stumbled across this article, for example, entitled "Homeopathy Offers Alternative Relief for hay fever sufferers". I'd be very surprised if this article doesn't get taken down soon also, to be honest. It really should, given part of the ASA's ruling relates to their claims over the efficacy of homeopathy for hay fever.

That use of the word alternative (as opposed to complementary) is interesting. That in itself suggests that the Society of Homeopaths are advocating patients not using conventional medicines in favour of their homeopathic products.

One thing that I have learnt about homeopaths is that, despite the fact that they often claim that randomised controlled trials (and indeed science in general) can't explain their wondrous treatment because of its individualised nature and quantum nanoparticles blah blah all the other words that they're clinging onto, they like to cite trials. A lot.

Homeopaths will often spout names of trials and provide links to PubMed abstracts with abandon, even when the trials say little about the clinical use of homeopathy in humans. In vitro or animal trials are favourites, and on the odd occasion where I have been sent a human trial, the result usually show that homeopathy is no better than placebo, and in some cases actually worse than placebo. At best, I'm guessing this is just ignorance- maybe they have misread the results of the trial? At worst (and more realistically), its a pretty obvious and petty method of obfuscation, and a pretty rubbish one at that. Presumably they think I will be so vowed by the fact that a trial exists that I wont bother to check the actual results of what the trial is saying.

This hayfever page overs a great example of this:
"A number of research trials have shown that homeopathic treatment can produce a significant improvement in hay fever symptoms,(4-7) but what does this involve?"
 Let's have a look at the "number of research trials", shall we? 

Reilly DT, Taylor MA, McSharry C, Aitchison T. Is homeopathy a placebo response?
Controlled trial of homeopathic potency, with pollen in hayfever as a model. Lancet,1986;2: 881-6.
This is a trial from 1986. Really, that's the best they can do, in 2013? The abstract of this trial appears impressive: "The homoeopathically treated patients showed a significant reduction in patient and doctor assessed symptom scores", but neglects to mention the most important part of a study like this: blinding. How can we assess the placebo effect in a study that isn't blinded? especially when the results rely on only reported outcomes. We can tick this one off the list as being a pretty rubbish effort at a trial. Must try harder.

 Kleijnen J, Knipschild P, ter Riet G. Clinical trials of Homeopathy. Br Med J, 1991; 302:316-22.
Ahh, the early nineties. We're getting thoroughly modern and hip now, eh? This is a meta-analysis. hay fever isn't mentioned in the abstract at all, and the conclusion of the paper is that studies performed in homeopathy are rubbish, and better ones need to be done. Hardly a conclusive statement that homeopathy works for hay fever. We can tick this one off the list too.

We're now left with two trials to back up that statement above. To me, two trials is not "a number" of trials, even at this point. Even if these two trials were massive, robust, good quality randomised controlled trials, I still wouldn't be entirely convinced: I'd want to see the result replicated in as many different trials as possible. Anyway, we shalll soldier on, in the hopes of being dazzled by the brilliance of these two references.

Launsø L, Kimby CK, Henningsen I, Fønnebø V. An exploratory retrospective study of people suffering from hypersensitivity illness who attend medical or classical homeopathic treatment. Homeopathy, 2006; 95: 73-80.
Oh dear. A retrospective study. So not a controlled trial at all then? The results? "The two groups of patients were similar in respect of their health at the start of the treatment, 57% of the patients who consulted a CH experienced an improvement of their state of health compared to 24% of the GP patients." well, that's all very well and good, but there is no blinding here whatsoever, and only 88 patients completed the study. means nothing at all, except for- as even the authors put it- as an exploratory study, maybe to try to find ways of how to conduct as more robust actual trial in the future.

That's it, down to the final trial. I'm expecting great things. 

Kim LS, Riedlinger JE, Baldwin CM, Hilli L, Khalsa SV, Messer SA, Waters RF. Treatment of Seasonal Allergic Rhinitis Using Homeopathic Preparation of Common Allergens in the Southwest Region of the US: A Randomized, Controlled Clinical Trial. Ann Pharmacother, 2005; 39(4): 617-24.
HURRAH!!! It's double-blind! We've gotten there! We've gotten some good, robust evidence tha- oh hang on, its only got 40 participants in it.IT's just a wee ickle little study that's far too small to draw any conclusions from.

So there you have it. This page is still up there on their website, using crappy references that don't back up their claims. The Society of Homeopaths- and quacks in general- need to realise that, no matter how hard they try, just trying to shoehorn poor excuses for studies in wherever they like isn't good enough.

Here's how it should go: you look at the evidence, you evaluate the evidence, and you make your claim on the basis of that evidence. Not: "I shall claim this, then try desperately to find something that vaguely looks like it backs me up, and I'll just hope for the best that no-one else bothers reading it. It seems the Society of Homeopaths are going in for the latter, and good on the ASA for pulling them up on it.

"We told the Society of Homeopaths not to discourage essential treatment for conditions for which medical supervision should be sought, including offering specific advice on or treatment for such conditions. We also told them not to make health claims for homeopathy unless they held sufficiently robust evidence of efficacy." -ASA ruling