Thursday, 31 January 2013

Quack SEO folk attempt Quack SEO on a Quack website

I read with interest this entry on Josephine Jones's blog:

 Basically, SEO folk working for WeightWorld, a website selling a cornucopia of nonsense have requested that Josephine takes down links to the website from her blog exposing them as quackery, because it might harm their SEO efforts

Now, leaving aside the fact that SEO is actually a whole load of cargo cult nonsense, apparently (According to a Skeptics with a K podcast- i can't remember which episode though), this seems like a pretty daft way of working. Where is the ethics in just requesting that any negative press is removed from search results? Especially coming from a field which regularly employs shady marketing techniques like affiliate marketing, just to flood search engines to drown out negative voices. As Josephine points out, this website has had many ASA complaints against them. Do they really think this sort of approach will work? They hadn't considered that it might actually backfire?

Wouldn't it be simply a terrible shame if, by requesting that Josephine removes a link from her website, they've accidentally opened up a bag of skeptical worms, and their web address appears on many skeptical websites, each exposing them as quacks? 

 So that link would be then. Didn't catch that? I'll say it again...  

I recommend blogging about and exposing them as the quacks they are.  

WeightWorld: selling unproven nonsense.

H xxx 


Saturday, 26 January 2013

A shiny new cold sore product

This weekend, I have mainly been working a loooong, quiet locum shift.

Its been a good few years since I regularly worked in community pharmacy, and I notice there are a whole load of new products on the shelves each time I do a shift. Most of them can be dismissed with a quick glance, as they tend to be (more expensive) combinations versions of things that already exist. However, there appears to be a new shiny cold sore product which contains a whole new drug, and is advertised as "a big breakthrough". I'm talking of Blistex cold sore cream, "The only product in the UK to contain docosanol"
Docosanol, according to the manufacturer's information, works to stop infection spreading by protecting healthy cells and speeding healing. 

Now, i'll be honest here. It's late, and I've had a long day, so i'm not going to look right now into the evidence of whether or not it is better than aciclovir (generic version in this particular pharmacy: £1.99). I do, however, have a few points to make without even bothering looking into the evidence.
UPDATE: having had a quick look, it seems there is no comparative evidence for docosanol against the other antivirals, so we don't know whether or not its any better than aciclovir. It appears that it can reduce the time of a cold sore by about 1 day compared to placebo (significant statistically, but how significant is this in real life?). When applied at the early stage, it seemed to reduce progression to a blister by 34% compared to 24% placebo. This is hardly setting my world alight, if im honest.

Apparently this new product works at an even earlier stage than aciclovir does. Well, that's great and all, but how many folk manage to get to a pharmacy immediately when they feel the slightest tingle? I'm sure most pharmacists would agree that the vast majority of people who seek advice for a cold sore already have one, sat proudly atop their lip, throbbing away and generally going about their business of making the sufferer feel like a monster. They are terrible things, and as a fairly regular sufferer I know just how awful they can make you feel. So people are desperate to get rid of the thing as quickly as possible, and its not often that they will listen when i tell them that antivirals do very little once the little beggars are out of their nerve hideyholes. 

So we're left with a new product, which costs a hell of a lot more than generic aciclovir, and its selling point appears to be that you can use it earlier, which very, very few people will. So without that in its favour, it basically appears to exist to play on peoples' insecurities, if you ask me. 

Once your cold sore is out, you'd be better off just rubbing money into it directly than to bother with any antiviral products.

PS. At least this product does have one thing in its favour, namely that it has less likelihood of mispronounciation of its name. People asking for "Zovurax" used to be one of those small, irrational annoyances that would send me into a spiral of anger and hatred for the world. In my head, I would be wildly screeching "It's for a VIRus! It's called ZoVIRax, for goodness sake!"

Friday, 25 January 2013

Big Pharma & Big Homeo. Titans will clash, and ducks will die.

There has been much talk of homeopathy in the media in the past few days. I want to pick up on one point that is being brought up by homeopathy believers everywhere at the moment in response to any criticism.

"But Big Pharma has many problems! Just read Bad Pharma by Ben Goldacre!"

There are a few reasons why this is an utterly terrible argument.

The Logical Fallacy
This is not a two option scenario, so this is a false dilemma. homeopathic supporters are attempting to suggest that because Big Pharma has its problems, homeopathy is a better alternative. But here's the problem: These are not the only options in the world. Big Pharma does have massive, endemic problems, but that bears no resemblance to whether or not homeopathy works. Even if there were no evidence that any conventional medicine works ever, there still wouldn't be any evidence that homeopathy works either.

There's definitely an element of a "You too!" fallacy here as well. Big Pharma has its problems, but this is no reason to expect anything less than impeccable ethics from any other sector.

The Misleading Rustic Image
Homeopathic manufacturers would very much like us to have a fluffy, warm, reassuring image in our heads of some nice, compassionate people making a tincture from plants, shaking it in a special way, and making a nice, safe medicine from it. In actual fact, the image is rather more grubby, with diseased body parts, conventional medicines, and limbs being used in the manufacture. Oscillococciinum, supposedly the most popular homeopathic remedy for flu, involves killling a muscovy duck and using its heart and liver to produce a mother tincture. I wonder if folks who are against animal testing and the likes in the pharmaceutical industry are aware of this fact? For the purposes of this blog post, lets call our duck Dave.
A Muscovy Duck, who i have decided is called Dave.
Homeopathy is not usually made by ethical practitioners in their kitchens. And frankly, if it were, i'd be pretty concerned about hygeine etc and would be wanting inspectors to go round to check it. Its mainly made by large companies who are ultimately concerned with profits. In fact, until very recently, New Era homeopathic products (ooh, sounds all new agey and nice and hopeful, doesn't it?) were made by Merck (Sounds-and indeed is- a pretty damn large corporate pharmaceutical company).

We also know from the FDA that homeopathic manufacturers can be less than meticulous to say the least in their standards. Broken glass? That's not a problem, just leave it there on the production line, no one will mind. More info on this story can be found at The Quackometer

The Massive Mark Up Margins
Pharmaceutical companies spend a HUGE amount on research and development of new drugs. First they have to employ people to find a new chemical entity, whether that be in the rainforest or in the lab. Then they have to find out if it works, which involves a huge amount of lab work. If that seems postive, they then have to do trials, which is hugely expensive. At any of these stages, there is a huge likelihood of failure and it is a very, very small minority of new chemical entities that actually get through to a stage where they can be marketed. At that point, price margins can be pretty damn high, which is in part to cover all of those R&D costs. Yes, there are also huge profits that are made in the pharmaceutical industry, and there are all the associated problems covered in Bad Pharma. This is certainly not an ideal scenario, but at least at the end of the day we are left with some drugs that work.

Big Homeo, on the other hand, puts little-if any- funds into research and development. If it did, we would have a load more trials than we do now. The work in drug discovery has been done for them, by Hahnemann et al who have written Materia Medica and the likes. So not many outgoings there then.

What about the costs of the ingredients? Well sugar is cheap, as is water. And even if your mother tincture comes from a valuable substance, you can make a hell of a lot of homeopathic medicine from it. Here is the recipe for Boiron's Oscillococcinum (according to Wikipedia)
  • Active ingredient: Anas Barbariae Hepatis et Cordis Extractum (extract of Muscovy Duck liver and heart) 200CK HPUS 1×10−400 g[9]
  • Inactive ingredient: 0.85 g sucrose, 0.15 g lactose (100% sugar.[10])
So to make 1 gram of oscillococcinum, you only need 1×10−400g of extract of poor Dave's heart and liver. This is a ridiculously tiny amount, and as you will hopefully now know, there will be VERY VERY VERY little chance of any of Dave's molecules remaining in the resulting solution. 

I have no idea how much the heart and liver of Wor Duckie Dave would weigh. I also have no idea how much an extract made from him would cost. I'm guessing, however, that the number of packs of homeopathic pills I could make from his unfortunate organs would mean it is very, very lucrative, and I would be laughing all the way to the bank with my profits were I a company with few scruples about selling nonsense to vulnerable people.

The Pointlessness Of It All

Poor Dave. Dave has been killed to make a medicine. However, none of Dave's molecules actually make it into that medicine in the end, because it has been diluted to such extremes. There's no memory of Dave in the water or sugar left in the medicine, only in the minds of his little duckie friends and his family who miss him dearly. There are huge outcries about bear bile being collected for use in chinese traditional medicines- why is no one speaking out for Dave?

At the end of the day, evidence suggests that after all the sacrificing, succussing, potentization, and all the other fancy words they use for magic rituals, what we are left with is an inert sugar pill.We could have saved ourselves all the bother, and saved Dave's life, if we just made an inert sugar pill in the first place and didn't bother with all the pretending.

Won't anyone think of the ducks?

Friday, 18 January 2013

Homeopathic vaccines: an impassioned challenge

Its been a hard week for us pharmacists. To be honest, I'm sort of at a loss as to where to start, but the most obvious place is in London, at a pharmacy called Ainsworths, where a man called Tony Pinkus works.

Ainsworths is a real life, registered pharmacy, and Mr Pinkus is a real life, registered pharmacist. The main problem with this story, however, is that Mr Pinkus is not selling real life medicines to his real-life patients, and in doing so he is putting peoples' lives at risk.

In an expose by BBC News, Mr Pinkus has been caught recommending by email that homeopathic whooping cough "vaccines" are used instead of getting a proper, real-life vaccine. In the email exchange, Mr Pinkus is careful to express his recommendations as personal choice, and this will presumably form his defence. However in my eyes this is absolutely no defence at all. For years, the pharmacy profession has been slowly but surely promoting ourselves as the trusted healthcare professionals that we are, therefore we have a responsibility to be aware of the position of high esteem we may be held in by the public. We have a duty to know that any 'personal recommendations' we make will constitute medical advice in the eyes of many patients.

Mr Pinkus also states that the patients' GP "will undoubtedly throw a lot of fear in your direction". Now, I remember having it very firmly drummed into me that we need to be careful in our role as a pharmacist not to break the trust a patient has in their GP. Obviously, this doesn't mean that we should cover up any mistakes or errors from them, but it does mean some quite careful wording as enquiries arise. Mr Pinkus is clearly and flagrantly attempting to reduce the trust this patient would have had in their GP's advice and showing a shocking lack of respect to the GP in question, despite knowing absolutely nothing about their practice. I wonder if he has ever considered the longer term implications of such wording. "oh, the GP has told me I should be worried about this lump in my breast, but of course they'll just throw a lot of fear in my direction", for example.

Mr Pinkus has also been investigated by pharmacy's governing body before. In 2006 he was caught selling homeopathic travel vaccines. In 2009 he was investigated by the PRSGB for selling homeopathic swine flu vaccines. In 2011 he was investigated for marketing homeopathic travel vaccines again and malaria prophylaxis. In each case the regulator has let the public down by not taking decisive action over a pharmacist who is regularly and routinely endangering lives, all in the name of "free choice". I don't think i actually need to point out the serious indirect harms that could happen if a patient were to use a sugar pills to prevent malaria, or yellow fever etc.

Free patient choice is not a defence when patient's lives are at risk.

I've been asking for a response to the case from the GPhC on twitter for a few days now and have heard nothing. I'm also wondering why the story hasn't appeared in some of the major pharmacy news publications (Chemist and Druggist, I'm looking at you). 

This story has really angered me, and i can pinpoint exactly why. I've written before about the constant fear I and many other pharmacists feel whilst at work- the fear that one little throwaway mistake could have huge implications for a patient's life. And there's an added, secondary fear that, if something goes wrong, a regulator could step in and your whole livelihood and career could be at stake. This is a fear that all good pharmacists carry to some degree, and it  can weigh heavily on your life. And yet here strides Tony Pinkus, who waves away any notion of patient safety, and flagrantly (I know it's the second time I've used this word, but it seems to fit the situation rather well) ignores the standards of the regulatory body without, apparently, a care in the world.

Well, I'm taking to heart the GPhC standards for conduct, ethics and performance, one of which is:
"Be prepared to challenge the judgement of your colleagues and other profesionals if you have reason to believe that their decisions could affect the safety or care of others"

So this, Mr Pinkus (and any other homeopathic pharmacists who would recommend a homeopathic vaccine) is me challenging your decision, because I believe it most definitely could affect the safety and care of others.

UPDATE: Chemist and Druggist have now covered the story (registration required). The comments section is interesting, with a couple of folk showing a staggering lack of knowledge about homeopathic products.
The Pharmaceutical Journal have also covered the story (registration required). This includes some interesting tidbits, like the fact the MHRA have been investigating 20, yes TWENTY unlicensed medicines being sold on the Ainsworth's website. And the post script is particularly interesting:

'Some of you have noticed that the pertussin products highlighted in the BBC investigation are still on sale. We've clarified this with the MHRA - a spokeswoman confirmed that the MHRA asction (sic) was against products labelled as vaccines.
"Substances and products labelled with the names of serious diseases such as pertussis are part of a wider, ongoing investigation," she said. So it's watch this space for the outcome of that branch of the investigation."'

This wider, ongoing inestigation sounds very interesting indeed.

Monday, 14 January 2013

Malik's Mesothelioma Magic

I'm still pretty new to this skepticism thing, but I'm starting to become immune to the bog-standard nonsense claims that I see homeopaths constantly making. There are still the odd ones, however, that knock me for six and leave me feeling rather staggered at the sheer dangerous nature of the claims.

It'll come as no surprise to some of you that the culprit of the most recent of these claims is "Dr" Nancy Malik, who yesterday posted the following on twitter:

That's right, people, apparently mesothelioma is curable with "alternative and natural treatments". And so, with bated breath and already-slightly-higher blood pressure, I followed the link provided by I'm Not Really A Dr Malik. What I was faced with was, to say the least, rather misleading and made my blood boil. Take this paragraph for instance:

"If mesothelioma patients have the desire to maintain quality of life, often they will choose alternative and natural treatments for the disease. The survival rates for those having success with natural treatments greatly enhance quality of life during treatment due to the fact that they forego poisoning their systems using toxic chemicals that hamper the body's immune system."

In other words: if you choose conventional medicine, you're an idiot who is essentially killing themselves by choosing poison. So what would they recommend instead, this website which has no references at all to back up their claims, and who appear to be desperately trying to sell me various nonsense books? 

There is one thing I can say in defense of this website is at least it appears to be peddling herbal medicines rather than homeopathy. I wonder if "Dr" Malik has realised this, as she seems to have been furiously retweeting and promoting things from this website. 

They recommend Nigella sativa, celandine, mistletoe, and cat's claw. Oh really? let's check that, shall we, by having a lookie at the evidence for these products in mesothelioma, brb....
Nigella sativa: no evidence.
Celandine: insufficient evidence to rate effectiveness for cancer.
No evidence in mesothelioma

Mistletoe: insufficient evidence to rate effectiveness for cancer. No evidence in mesothelioma
Cat's claw: no evidence.

Well, that was quick then. For transparency, I checked the evidence using the Natural Medicines Comprehensive Database, a gold standard resource for information on herbal medicines. 

This website does of course close with the obligatory "It's all a big conspiracy and big pharma and the medical profession just want everyone to die horribly" statement, so any teensy tiny miniscule scrap of plausability has gone out the window even without the total lack of evidence to back up their claims.

Do these people really not realise the danger they put people in by encouraging them not to use conventional medicine (which we have evidence to say it works at least some of the time) and to use alternative medicines (which there is zero evidence to say if it works or not) So where is the conspiracy here, folks? Is it really from the people who know about physiology and pharmacology, and who are primarily motivated to help people? Or does it come from the "alternative" camp, who seem hell bent on selling various books and expensive remedies and are happily peddling misinformation like there is no tomorrow?

H xxx

The Commenting Conundrum

My commuting-podcast of choice this morning was The Pod Delusion. I was really interested to hear their piece on the effects comments have on someone's opinion of science information.

You can listen to the piece here:

It featured an interview with Dominique Broussard, who had been involved in some research which ultimately showed that people's opinions of a science article (nanotechnology was the basis for the research) could be swayed by the comments left on the page. Essentially, the research found that abusive comments could actually lead to more polarised opinions in the reader, so if someone had vaguely held views against nanotechnology, and the comments on the piece were derogatory to the science in the paper, they would end up with more strongly held views against nanotechnology.

This got me thinking about a bit of research that me and my colleague Nancy (of Evidence Based Skepticism fame) did a while ago. We looked at information available if you searched for antineoplastons on google, and whether the quality and types of concepts used on websites differed depending on the motivations of the writer. I'm not going to cover the whole Burzynski saga here, because its been done much better elsewhere, but I just wanted to focus on one really interesting finding.

We split the concepts found in original articles from those found in comments left on each article, and one thing became very glaringly obvious: Hardly any sites that had "pro-Burzynski" sentiments had the facility for commenting, whereas those that were questioning the value of his treatments tended to have comments available, in which rather heated debates would strike up (in some cases, becoming rather abusive at times, mainly on the part of the pro-Burzynski supporters).

When I set up this blog, I decided to have open comments. I'm happy to invite debate and feel confident enough in my arguments because they are backed up in evidence as much as possible, and if they're not, I will have said so in the post. I don't want to be accused of not publishing comments from people who disagree with my views. But it strikes me that, based on this new evidence, this may not be the best tactic. Should we, as skeptics, rethink how we invite commenting on our blogs and websites, and take on the tactics of, for example, Burzynski supporter websites and just close down commenting? To me, this feels like the wrong thing to do, and it seems to counteract a lot of principles that i think we as skeptics share. But we also need to reassess our stance given evidence to the contrary.

Do we need to consider the risk that someone who may have vaguely held views reads something we write, then sees the sort of comments we are becoming used to from anonymous shills or those who disagree with the evidence, which makes them disagree with us more?

I guess it's ironic to now invite comment, but I would love to know what other people think on this subject.

H xxx

Friday, 4 January 2013

The paracetamol paradox

I'll often bang on about how "natural" does not necessarily mean safe, and you'll often hear me muttering about how new drugs can be a cause for concern because of lack of safety data. Today, however, I want to talk about some problems with one of our oldest, most reliable friends in the drug world: paracetamol (acetaminophen to our US friends).

Paracetamol appears to have first been used clinically as far back as 1887. It's very widely used in the UK and is very easily accessbile: packs of 16 tablets are classed as GSL medicines, meaning they can be sold pretty much anywhere. Its accepted as a social norm: adults take paracetamol for headaches, and they give their children Calpol (a branded liquid paracetamol) at the first sign of illness.

And herein lies my first point: its almost so widely available that I think people are starting to forget that it works. I've come across patients and friends who instantly dismiss paracetamol for their pain because "its not strong enough" or "it won't work, this headache's too bad". I'm starting to think that its dismissed offhand without trying it because its so well accepted its almost forgotten in the general public's mind that it is still a medicine, and one that works well. People are too quick to dismiss plain old paracetamol in favour of a shiny new combination product which costs more but works less well, or they're taken in by the promise of a "stronger" painkiller like co-codamol (with little evidence of benefit over paracetamol alone, but a whole lot more problems). Paracetamol has hardly any significant side effects, and it does actually work well for mild to moderate (and even some types of severe) pain, but many people won't even give it a chance. I'm interested to know what you guys think of this and whether or not you would agree that this is the case- do let me know by leaving a comment or tweeting me @SparkleWildfire. Do you think this yourself, or have friends that do? If you're a pharmacist or another healthcare professional, have you noticed a similar attitude? Or is it just me?

More scary, though,  is my second point: Because people seem to be sort-of-forgetting its a medicine, they are forgetting that it can be dangerous. Horrifically so, in actual fact. Whilst it has few side effects with normal, recommended use, it's horribly toxic in overdose.

Overdose? Lets have a think about that word. It immediately brings to mind suicide attempts, right? So that wouldn't apply to most people, right? Very much wrong. In the last few weeks and months (it being the cold season and all), I've noticed a few of my friends on social media rather jokingly saying things like how they've taken a few extra doses of paracetamol, or they're taking lots of Lemsips because they like the taste, or they're combining a branded cold and flu product with paracetamol tablets, and I've felt the need to intervene and ask them to be careful about the amounts that they are taking. Would they consider themselves to be taking "overdoses"? I fear not. I also don't think they're taking me seriously, to be honest, and I think they think "what's a few extra doses going to do, it's just paracetamol after all". What they don't realise is that this sort of therapeutic excess or staggered overdose scenario can be just as-if not more-serious than a classsic, acute self-harm attempt-type of overdose. And the sort of toxicity that happens is not pleasant, and ultimately, in the worst case scenario could mean a slow, painful death, or a liver transplant. The antidote to paracetamol poisoning (although its not always able to be used, particularly in these sorts of cases) isn't a walk in the park either. It's a lengthy course of an IV drug (in the UK, anyway) which could mean at least a few days hospital stay.

Unfortunately, its easy to accidentally take too much paracetamol. There's so many branded products that require a fair amount of package-reading before you work out that they contain paracetamol.  I think its also easy for people to feel blase about the way they're using it, because if its available everywhere and its "just paracetamol" its safe to take more than is directed. Maybe people think taking extra paracetamol "proves" that their pain is more severe than other people's pain, who knows. I think many of us would agree that we've heard anecdotal reports of parents putting Calpol in babies' bottles, or leaving the bottle with a child to self-administer overnight, or giving their child Calpol "to make them sleep" (it would have no direct effects to promote sleep).It's just so pervasive that it's almost become like vitamins or a foodstuff in some peoples' mind, or so it would seem.

Just because a drug is as old as the hills, and its safe in everyday use, and it works, doesn't mean that its innocuous and we can throw caution to the wind when we're using it and have as much as we like, whenever we like.

Why am I on about this? Well, part of my day job involves advising on management of poisoning cases, and as a result I see a lot of these types of cases. And it can be really sad and frustrating and sometimes scary to hear of how commonly this sort of thing happens, and the variety of reasons for it.

So my point is: if you're taking paracetamol, please take no more than 4 grams per 24 hour period, and please check for other sources of paracetamol in cold remedies or other branded products first.

H xxx