The Pharmaceutical Journal
Vol 268 No 7189 p360-364
16 March 2002

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Letters to the Editor

Baddy chemists (5 letters)

Individualised trials possible

From Dr B. L. Furman, FRPharmS

There is nothing like a debate on homoeopathy to stimulate me to write to the The Journal.

Although homoeopathy, like other complementary approaches, is a system based on a holistic approach, this does not place homoeopathic preparations beyond evaluation by the gold standard: a randomised, double-blind, placebo controlled trial.

Patients could be subjected to a normal consultation with a homoeopathic practitioner who would then write an individualised prescription. A second, independent person would then randomly allocate the patients to receive the prescribed item as written or a placebo. The patients and the physicians who assess the patients would be blind to the treatments. Thus, all patients would be assessed and treated holistically and the only difference would be that one group received one of a number of individualised homoeopathic remedies for their particular condition, whereas the other group received placebo. The null hypothesis then would be, "There is no difference between placebo and the homoeopathic treatment regimen".

As with any clinical trial there would be defined inclusion and exclusion criteria. Patients would continue with their usual medication and, of course, the trial would have to be sufficiently powered to detect the desired differences.

The role of the holistic approach per se in treatment effectiveness is much more difficult to evaluate scientifically and, as suggested by Professor Ernst (PJ, 9 March, p325), the "placebo effect" may contribute to the success of conventional therapy as well as to that of complementary therapy. In a study of the credibility of various acupuncture techniques Choi and Tweed¹ found that the holistic acupuncturist was rated significantly more attractive, expert and trustworthy compared with non-holistic practitioners. Cassell² stated that "suffering is experienced by persons, not merely by bodies, and has its source in challenges that threaten the intactness of the person as a complex social and psychological entity". In the same article Cassell also states that "physicians' failure to understand the nature of suffering can result in medical intervention that (though technically adequate) not only fails to relieve suffering but becomes a source of suffering itself".

Brian Furman
Glasgow

Amusing but in places wrong

From Professor E. Ernst, FRCP

I would like to thank Simon Whitaker for his most amusing piece on "quack cures" (PJ, 2 March, p288). It was amusing but in several aspects wrong. He states for instance that "herbal preparations ... lack any credible evidence base". Little does he know that there are hundreds of good quality randomised controlled trials demonstrating the efficacy of some (not all) herbal medicinal products. Many are even backed up by positive systematic reviews or meta-analyses of RCTs.¹ I agree with Mr Whitaker that health care professionals have a "responsibility for giving correct and appropriate advice". But surely this also includes a responsibility for being adequately informed.

Edzard Ernst
Department of Complementary Medicine,
University of Exeter

Valuable babies thrown out with the bathwater

From Professor P. J. Houghton, FRPharmS

I agree with the general thrust of Simon Whitaker's remarks (PJ, 2 March, p288) about the lamentable triumph of commercial over scientific considerations in much community pharmacy. However, I fear that he has thrown out some valuable babies with the bathwater in dismissing herbal remedies as quackery and lacking scientific evidence.

I would admit that there is much to be done in establishing a sound evidence base for some herbal remedies. I would also stress that, for many common herbal remedies now available, there is an increasing volume of pharmacological and clinical studies that confirm their traditional uses. The recent draft directive from the European Union proposing a new category of licensing for "medicines with a traditional use" emphasises that these products are viewed as having some value.

The department of pharmacy at King's College London is proud of its heritage of the scientific study of plant-based medicines and of its pharmacognosy courses. We strive to give our students the basic tools to be able to evaluate the scientific credentials of the herbs about which they will be asked questions in their later professional lives.

Although I cannot vouch for the infallibility of my memory, I cannot remember Simon Whitaker as one of our undergraduates. His apparent lack of knowledge of the current "state of play" regarding the scientific base of herbal remedies is therefore excusable. It is to be hoped that the new indicative syllabus will give every pharmacy student in the United Kingdom the benefits that graduates of King's enjoy.

Peter Houghton
Professor of Pharmacognosy
King's College London

The Society's position on homoeopathy is quite clear

From Mr J. R. Sharp, HonMRPharmS

Predictably, Simon Whitaker's article on quack cures and "Baddy Chemists" (PJ, 2 March, p288) has brought forth the standard outraged cries from the proponents of homoeopathy (letters, PJ, 9 March). Just as predictably, none of your correspondents is able to present any real scientific evidence for the efficacy of homoeopathic "remedies". It is difficult, for example, to believe that Lawrence Collin's citing of a 1900 report of the treatment of cholera "using camphor homoeopathically" in Russia in 1830 is a significant result derived from a properly controlled scientific trial.

It is just as difficult to understand the persistence of this argument that continues, from time to time, to rear its hoary head in your columns. The Royal Pharmaceutical Society's policy on this issue is quite clear, and should surely be the final word on this subject. It is:

"The Council of the Pharmaceutical Society of Great Britain recognises that the essence of homoeopathy involves a thorough and lengthy consultation with a homoeopathic practitioner, which takes into the account the whole condition of the patient. There are many reports that such consultations are beneficial. The consultation may include, in addition to advice, the prescription of a homoeopathic remedy.

"With regard to the actual composition of the "homoeopathic remedies, there is no scientific evidence for their efficacy, only anecdotal and subjective reports.

"It is unlikely that the benefits attributed to homoeopathy could extend to over-the-counter recommendation or self-selection sale.

"The Council of the Society therefore recommends members to inform any persons seeking advice on homoeopathic products that there is no scientific evidence for their efficacy, beyond that to be expected from a placebo response." (PJ, 14 June 1986, p770.)

If, however, I may be permitted a postscript, it is interesting to note that in the same issue in which the pro-homoeopathy letters were published there appeared a report of a controlled trial which demonstrated that "homoeopathic potencies of house dust mite" were ineffective against asthma (PJ, 9 March, p313). The homoeopath's riposte to this finding is, apparently, that the treatment was not "individualised" and this "individualisation" is "the hallmark of homoeopathy". This is a very neat response, since "individualisation" would render invalid any attempt at a double-blind cross-over clinical trial. It does, however, call into question how "individualised" are all the hundreds (thousands even) of homoeopathic "remedies" that are freely available, self-select and self-serve, in pharmacies across the country.

And, can anyone tell me, please, how does one go about diluting a house dust mite?

John Sharp
Woodley, Berkshire

Is the sale of homeopathic products ethical?

From Mr W. J. Pugh, MRPharmS

Predictably, poor old Simon Whitaker (PJ, 2 March, p288) has incurred the wrath of the homoeopaths (letters, PJ, 9 March, pp325–326). What he has to realise is that, to its disciples, homoeopathy has many characteristics of a religion. The fact that it is undisprovable is the bedrock of their belief. I once knew someone who believed that Jesus's father was an astronaut from deep space. "You prove I'm wrong" was the reply to anyone questioning this conclusion. Why bother? The underlying question is "Is the sale of homoeopathic products ethical?" There are (at least) two answers to this. If the pharmacist truly believes in homoeopathy then the answer is "yes". He is no more a quack than the vicar who promotes belief in God. Whether he is a nitwit is a separate question. If he does not, he has all the ethical standing of Donald Duck. It is, of course, difficult for the Royal Pharmaceutical Society to distinguish motive, and it seems to lack the motivation — although I recall the Statutory Committee warned that pharmacists who promoted Spagyric therapy could expect to be struck off (PJ,16 August 1997, p250).

W. John Pugh
Welsh School of Pharmacy
Cardiff

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