Homeopathic “medicines” (as they are registered by the Medicines and Healthcare products Regulatory Agency) are consistently shown to work no better than placebo. The placebo effect is powerful — it can reduce pain and improve mental health. It cannot cure cancer. It cannot vaccinate children against preventable and devastating illnesses. The line between homeopathy and other forms of pseudoscience, such as the anti-vaccination campaign, are blurred.
Pharmacists are scientists and clinicians. They are rightly trusted by their patients. On a daily basis, they dispense and sell medicines with varying levels of efficacy. Alongside these medicines, many pharmacies sell homeopathic remedies.
Current Royal Pharmaceutical Society (RPS) policy states that “there is no evidence to support the clinical efficacy of homeopathic products beyond a placebo effect, and no scientific basis for homeopathy. Pharmacists selling homeopathic products must be competent to do so and be able to discuss with patients the lack of evidence for the efficacy of homeopathic products and their formulation.” At the recent RPS annual conference, delegates came together to discuss whether it is right that pharmacies stock and sell them.
Unsurprisingly, homeopathy practitioner Felicity Lee was an advocate of the medicines, claiming “I’ve treated someone with chronic leukaemia who went into remission before their [sic] planned chemotherapy.” She added: “I am concerned that a body considers itself scientific [the RPS] continues to say there is no evidence for homeopathy.” Perhaps more surprisingly, Lee was on the panel speaking against the idea that they should be sold in pharmacies. She claimed that the medicines only work when prescribed correctly and with a full consultation — she sees her patients for 90 minutes before dispensing.
There was consensus on the value of consultation — RPS English Pharmacy Board member Anthony Cox, who spoke strongly against the sale of homeopathic medicines on the grounds that they do not work, highlighted: “The only thing we do have evidence for … is that the consultation itself in homeopathy has a beneficial effect on patients.”
There were several arguments raised in favour of selling homeopathic remedies from community pharmacies. Tony West, who is a member of the EPB, said: “Would I prefer a patient who needs a homeopathic medicine go to a pharmacy where the supply chain is known, or use the internet? Would I prefer there to be an opportunity for a healthcare professional to talk to the patient about the homeopathic medicine they are about to buy? Yes.” Sibby Buckle, who also sits on the EPB, added: “If the patient wants my professional advice, I will, if necessary, highlight that homeopathic medicines are not clinically proven but may help in certain conditions.”
RPS President Ash Soni also contributed to the argument, suggesting: “It cannot replace conventional medicine. It absolutely must not. However… a number of people we supply medicines to, [the medicines] do not work. Does that mean we stop supplying the medicines? Because the same thing would apply. When we get to fully personalised medicines, where it is absolutely clear that the medicine you are supplying is individualised to that particular patient and it is always going to be effective, then it is easier to make that decision. However, until we reach that point, it is very difficult to base it on the assumptions we are trying to make here. Individual choice is very important.”
However, as Cox pointed out, “It is not necessary for us to get involved in this for patients to have that choice.” People are always able to acquire medicines from elsewhere, for example, ibuprofen (which does contain measurable quantities of active ingredient) can be purchased from petrol stations. He said: “The idea that we have to sell something because it might be sold by other people is not a decent argument. We are actually giving our credibility to these products by stocking them in pharmacies,” adding, “You have a conflict of interest. You are making money out of [these patients]. What you should do is say ‘I am sorry. There is no evidence for homeopathic remedies being effective in the scientific literature. I do not stock them. However, they are available elsewhere.’”
Regarding the evidence that homeopathic medicines do not work, Buckle told the audience: “I do not want to interrogate us this morning on the clinical efficacy of some of the products sold from our pharmacies, nor do I want to discredit us as a profession.” She cited guaifenesin, black cohosh root and vitamin C as examples. For an evidence-based profession, which has aspirations of becoming more clinical, this seems a poor argument to me. Cough remedies and similar products at least have a mode of action that can be understood. Even homeopaths cannot explain the mechanism of action of their medicines. “We are talking about separating magic from the reality of the world,” said Cox.
Perhaps even weaker is that argument that homeopathic medicines do no harm. Lee said: “Because there is nothing there materially, the remedies are inherently safe to use in pregnancy and breast-feeding. In old age, there is no need to worry about poor renal or hepatic function. No antibiotic resistance develops. There is a very low incidence of adverse events.”
However, as West pointed out, in 2012, 10,000 calls were made to poisons centres in the USA to report an overdose of these products — time and money that could be spent on patients who may actually be in danger. Additionally, as one delegate said, these products are sold alongside herbal medicines that do contain active ingredients that may cause harm in some patients or have interactions with some medicines. “The problem that we have got in community pharmacy is distinguishing between homeopathic medicines and herbal remedies. I cannot distinguish between them, so how is a patient going to distinguish between them?” she asked.
With regard to the RPS position on the matter, Buckle said: “it is not the role of the RPS to dictate what should or should not be made available for sale from pharmacies.” Perhaps that is true but, in my opinion, as a professional body, the RPS seems ideally placed to make recommendations, particularly given that it acknowledges in its current statement that the remedies do not work. Additionally, in 2014, the RPS published a statement that read: “The RPS believes e-cigarettes should not currently be sold or advertised from pharmacies.”
The debate was concluded best by community pharmacist Terry Maguire, who said: “This is not about homeopathy. This is about the tension that exists in our profession between the commercialism and the professionalism.”
He added: “There are four Ps in marketing. The price, the place, the product and the promotion. And homeopathy is using pharmacy as a means to sell its product. That is why it is a high-priced product. Although it is cheap as chips, if you are charging a high price, the customer believes it has got some implicit value.
“In terms of the product, they look like pharmaceuticals. That is why they are there — because they are supposed to be pharmaceuticals. And of course they are not. The issue is that when you put it in a pharmacy, it gives it exceptional credence. We are a respected profession. If we are selling these products, they must be good, they must work.”
In summary, Maguire said: “Homeopathic remedies do not work. They are a placebo. That is the issue. I would say that if the RPS, which is a respected organisation, cannot come out with a bold statement that pharmacists should not be selling these products, then I think the professional body is failing in its responsibility to represent a science-based profession. We are the laughing stock of medicine if we continue to do this.”