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Homoeopathic remedies were no better than placebo in a recent meta-analysis of randomised controlled trials
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WHO report on homoeopathy
A draft report on homoeopathy prepared by the
department of essential drugs and medicines policy at the World
Health Organization came
under criticism in The Lancet last week (2205;366:705). The report,
entitled “Homoeopathy: review and analysis of reports on
controlled clinical trials”, says that the majority of placebo
controlled clinical trials of homeopathy published over the past
40 years have shown that it is superior to placebo and equivalent
to conventional medicines in the treatment of illnesses in humans
and animals.
However, Professor Ernst told The Lancet that the draft seems "overtly
biased, ie, it is based on data that are positive while ‘forgetting’ the
negative studies and systematic reviews." He added that the
trials cited are not the most recent or the most rigourous.
Xiaorui Zhang, acting team co-ordinator for traditional medicine
at the WHO, said that the reports on traditional medicines are
aimed at improving research approaches and appropriate clinical
studies and should be used only as references, not taken to be
recommendations. The draft report is currently undergoing revision
and its publication date is not known, she added. |
The clinical effects of homoeopathy are placebo effects. This is the
conclusion reached by researchers from Switzerland and the UK following
a meta-analysis of data from placebo controlled homoeopathy and conventional
medicine trials.
The study, published in The Lancet last week, identified 110 trials of
homoeopathic remedies and matched these for disorder and type of outcome
with 110 trials of conventional medicines. The researchers hypothesised
that the effects observed in placebo controlled trials of homoeopathy
could be explained by a combination of methodological deficiencies and
biased reporting and that the same biases could not explain the effects
observed in comparable trials of conventional medicine. Their analysis
indicated that the smaller and lower quality trials showed some benefit
for homoeopathy over placebo. However, when analysis was restricted to
large trials of higher quality they found no significant benefit over
placebo for homoeopathic remedies. The treatment
effect for conventional medicines remained evident (see News p274).
Ongoing debate
The debate on homoeopathy is not a new one. Homoeopathy, with its premise
that like is cured by like, was developed by a German doctor, Samuel
Hahnemann, 250 years ago. Remedies are prepared by serial dilution,
often to the point where none of the original molecules remain. How
homoeopathy works and whether it is effective has proven to be a controversial
issue among health practitioners over the years.
Edzard Ernst, professor of complementary medicine at the Peninsula
Medical School, Exeter, believes that the Lancet study is extremely
well done.
He says: “It conclusively answers the hypothesis that it set out
to test, no less but also no more. In addition to such meta-analytic
evidence we need to consider other data, as long as they are rigorous
and scientific. If we do this, I have to admit that it doesn’t
look too good for homoeopathy.”
An editorial in the same issue of The
Lancet (2005;366:690) says that
for too long a politically correct laissez-faire attitude has existed
towards homoeopathy. The editorial, entitled “The end of homoeopathy”,
makes The Lancet’s views on homoeopathy clear: “Now doctors
need to be bold and honest with their patients about homoeopathy’s
lack of benefit, and with themselves about the failings of modern medicine
to address patients’ needs for personalised care.”
Professor Ernst agrees: “This knowledge now must be conveyed honestly
to patients, consumers and everyone else. There is no
reason why transparency should be an overriding theme in conventional
medicine while in ‘alternative’ or integrated health care
it should be the opposite.” Randomised controlled trials
Lee Kayne, dean of the Faculty of Homeopathy and a community pharmacist,
comments: “Perhaps the most striking fact regarding the Lancet paper is that starting from 110 trials of each type, it was narrowed
down to 21 homoeopathic studies of higher quality. However, only nine
conventional studies were deemed to be of equal quality, which does
not seem compatible with the perception that homoeopathic trials are
poorly designed and executed.”
Many homoeopaths claim that randomised controlled trials are not appropriate
for assessing the effectiveness of homoeopathic remedies. Dr Kayne explains
why. “Primarily, homoeopathy is an individualised therapy — medicines
are prescribed on the basis of a combination of factors including history,
emotional symptoms, physical symptoms, modalities and patient constitutional
type. Therefore it is common to prescribe a different medicine for two
patients presenting with the same superficial condition. For example,
a patient with rheumatism which improves with heat and movement might
be prescribed Rhus Tox while the next patient also with rheumatism may
find that their symptoms, while superficially the same, worsen with heat
and movement — for this patient Rhus Tox would be the wrong medicine
and Bryonia may be more appropriate.”
Christine Glover, a pharmacist and licensed member of the Faculty of
Homeopathy, agrees. “The gold standard for acceptability in the
world of science currently is a double blind randomised controlled trial.
This is not an appropriate paradigm to use for homoeopathy, which is
usually tailored for individual use. A meta-analysis of a series of RCTs
is almost bound to have an unsatisfactory outcome for homoeopathy.”
She adds: “Homoeopathy is difficult to come to terms with — especially
if you have a rigid approach to life. If it was ‘all in the mind’ it
would not have survived for 250 years and still be flourishing.”
James Semple, chairman of the Scottish Pharmaceutical Federation, takes
a different view of homoeopathy’s longevity. “Homoeopaths
have had over 200 years to provide a single reproducible and methodologically
robust experiment that proves their remedies work. Hardly a tall order
given the claims they continually make but, as this review confirms,
they still have not managed it,” he says.
“What interests me is the lesson 200 years of homoeopathy teaches us about
the placebo effect. Not just the mysterious ability of the human body
to repair itself in response to perceived but physically non-existent
interventions but, more commonly, the susceptibility of the human mind
to see patterns of therapy and response where none actually exist — both
in the mind of the patient and in the mind of the therapist. It is no
surprise that homoeopaths tend to claim success in those conditions that
normally spontaneously resolve, those that have a natural ebb and flow,
or either of the aforementioned but involving babies or animals.” Patient choice
Ray Sturgess, is a pharmacist and freelance medical writer. Although
he is not surprised by the researcher’s findings, he says there
could be a place for homoeopathy in pharmacies. He told The Journal: “The
finding that homoeopathy is no more effective than placebos is to be
expected since … homoeopathy and the other complementary therapies
are placebos.”
However, he adds: “It should be borne in mind that placebo or belief
effects are significant and it could be argued that pharmacists should
continue to supply homoeopathic preparations on the grounds that some
people taking homoeopathic remedies do experience benefits for minor
conditions and that the products, being highly diluted, are safe.”
Mrs Glover agrees that patient choice is important. “If a patient
chooses to use a homoeopathic remedy and they get better, they should
have that choice. What is important is that the patient’s
condition improves — this is at low cost to the NHS and without
the risk of adverse drug reactions.”
However, she does not believe that the effects of homoeopathy can be
explained by placebo effects. “The placebo effect needs much more
research and we need a greater understanding of how the effect works.
However, it does not explain homoeopathy, which has been shown to work
for animals and babies where the placebo effect cannot be applied.”
In contrast, Mr Semple believes that there is no place for homoeopathic
remedies on pharmacy shelves. “I believe that pharmacy should have
the courage to cast this quackery into the wilderness where it belongs.
Snake-oil remedies — even where they themselves do not harm — have
the potential to cause harm by discouraging patients from using proven
effective treatments. It is time we stopped pussy-footing around this
huge edifice of nonsense, however entrenched it has become, and sent
a clear message to the public which confirms our role as impartial advocates
of their health and well-being.” Availability on the NHS
The Prince of Wales has commissioned an economist to write a report
on the benefits of complementary medicines to see how much the NHS could
save if they were more widely available. The Times reported last week
that the draft document claims up to £480m could be cut from
the prescription drugs bill if 10 per cent of GPs offered homoeopathy
as an alternative to conventional drugs.
Dr Kayne explains that homoeopathy is available on the NHS and any
doctor is able to prescribe a homoeopathic medicine or refer a patient
to an
NHS homoeopathic hospital. He suggests that a limiting factor to doctors
prescribing homoeopathically could be education. “Although it has
been estimated that 25 per cent of all GPs in Scotland have undergone
some degree of training in homoeopathy, this figure falls sharply when
viewed as a UK whole.” He adds that the Faculty of Homeopathy was
established by an Act of Parliament in 1950 to provide education in homoeopathy
for pharmacists, doctors, dentists, veterinary surgeons, etc, and remains
active in this field, offering courses around the UK.
With such strong opinions being voiced on both sides, it seems likely
that the homoeopathy debate will continue for another 250 years. |
The
Pharmaceutical Journal