Time to clear homeopathy off the shelves?

Should these be on our shelves?

I was both dismayed and pleased to see the BBC Rip Off Britain episode about the sale of homeopathy in pharmacy.[fast forward to 24 minutes to see the piece & @cathrynjbrown‘s comments – The video will be there for 27 days from now].

Dismay springs from the sampled pharmacies failure to follow existing sensible professional guidance about homeopathy provided by the Royal Pharmaceutical Society. I’m pleased, since the more light that falls on pharmacy’s awkward relationship with this unscientific treatment, the more likely our profession are to be shamed out of supplying it. At present, the continued sale of this nonsense by professionals with a 4 year scientific Master’s degree, to a lower standard than counter staff in Holland and Barrett, means we deserve to be collectively succussed on our collective heads with a large Martindale.

The Society of Homeopaths argued at the end of the programme that pharmacists need to be trained in homeopathy. Yet, the problem seems to be that pharmacies that have better training in homeopathy are the actual problem, as evidenced by their performance (here, here, and in the following video).

What pharmacists need to do, is use their 5 years of scientific clinical training.

I recently spoke at a meeting on homeopathy at the Royal Pharmaceutical Conference arguing that the sale of homeopathic remedies is incompatible with modern pharmacy practice. One of the other panel members was a homeopath, a former senior medicines information pharmacist, who was against homeopathy being sold in pharmacies because pharmacies didn’t provide the detailed consultation process that homeopaths did. This was also one of my arguments, since evidence suggests that it is the consultation process, rather than the ‘activity’ of the remedy , that has the potential of a benefit. (1) This rarely happens in normal pharmacies (or even medical consultations).

My jaw dropped however, when the homeopath started to describe the use of homeopathy in acute lymphoblastic anaemia, asthma, and temporal lobe epilepsy, claiming beneficial results. And this is the problem. Homeopathy is anti-scientific, at odds with the known rules of the universe we live in, never mind lacking in evidence of improved clinical outcomes. And once one believes in homeopathy, other more dangerous cranky views can take hold (skepticism about vaccines or chemotherapeutics being obvious examples). Homeopathy is a ‘gateway drug’ to poor thinking.

Pharmacists are now pitching themselves as experts in medication optimisation. We have huge problems to tackle as part of a multi-disciplinary team to maximise the risk/benefit of medicines, to help patients, reduce waste, and save costs for the NHS. If we are to further develop new clinical roles in community clinical pharmacy practice, our implicit professional endorsement of homeopathy by stocking it in pharmacies is a ball and chain.

If you doubt this, then go and speak to senior negotiators on the Pharmacy contract, and ask them what effect the continued association of community pharmacy with homeopathy has. This tiny financial aspect of pharmacies has a large negative influence on our future as a profession. Ironically, the only circumstances in which homeopathy’s dilution rule actually works.

If you are a member of the Royal Pharmaceutical Society, then we are currently conducting a survey of our members’ views to help inform us about the extent of homeopathy use, and their views on its supply from pharmacy. Please help inform the debate .

1. Brien S,  Lachance L, Prescott P, McDermott C, Lewith G. Homeopathy has clinical benefits in rheumatoid arthritis patients that are attributable to the consultation process but not the homeopathic remedy: a randomized controlled clinical trial. Rheumatology 2010: doi:10.1093/rheumatology/keq234

A synergistic interaction: Clinical Pharmacologists and Pharmacists

Even our BNF is a product of clinical pharmacologists working with pharmacists.

The British Pharmacological Society (BPS) have a new report out calling for a commitment from government to give greater support to clinical pharmacology.

The British Pharmacological Society launched today a new report calling for an increase in the number of clinical pharmacologists across the four UK nations. This medical specialty, the only one focusing on the safe, effective and economic use of medicines, is well placed to help the NHS surmount the biggest financial challenge since its creation.

This has led to some negative reactions from pharmacists on twitter.

I suspect the wording of the BPS “This medical speciality, the only one focusing on the safe, effective and economic use of medicines” is being misread as “Clinical pharmacology is the only profession focusing on the safe effective and economic use of medicines”. That isn’t the claim, the claim is that clinical pharmacology is the only medical speciality focusing on the safe and effective use of medicines. I would argue that clinical pharmacologists are friends of pharmacy and one of our best advocates.

Clinical pharmacology became important in the 1960s, in the wake of concerns about drug safety, yet even in the 1970s there was concern about lack of clinical pharmacology. Here is Professor Owen Wade, a member of the original Committee on the Safety of Drugs, on the importance of clinical pharmacology.[1]

“Medical schools in Britain, with a few exceptions on the Celtic fringe, have recently neglected clinical pharmacology. […] The establishment of full-time chairs in these subjects is an urgent need in any medical schools where they do not already exist. Undergraduate students need instruction on the proper use of drugs, knowledge of their common adverse reactions and appreciation of the dangers of their misuse.”.

These concerns have continued. Despite increasing governmental focus on drug safety in the past 10-15 years, clinical pharmacology has continued to diminish with 68 specialists in the UK in 2003. A 79% increase in medical specialists from 1993-2003, could be contrasted with a 24% fall in Clinical pharmacologists.[2] There have been recruitment difficulties, and careers were more likely to be found in the industry, rather than into academic medicine. Some of this loss was also due to the high value placed on clinical pharmacologists into organisations such as NICE and the MHRA, but clinical pharmacology has also been hit by a target driven NHS, the rise of cardiology and primary care in cardiovascular management, and changes in undergraduate medicine (around an integrated curriculum) that have damaged some disciplines (in particular the teaching of prescribing to undergraduates).[2] The BPS report highlights that there are now only 77 clinical pharmacologists in the UK.

The British Pharmacological Society, and their members, have for a number of years been concerned about this decline, and the effects on prescribing safety in particular. In recent years there has been a fight back, with the creation of the Prescribing Safety Assessment for undergraduates. Prior to this localised schemes were developed to assess competency in prescribing, and these have always drawn on pharmacists. Locally, I have been involved in OSCE assessments of prescribing competence, as have a number of other pharmacists. Clinical Pharmacologists and pharmacists working together to improve patient safety. A model that we ought to bear in mind.

I’ve worked with clinical pharmacologists for about 14 years, firstly on wards, where they were often the clinicians most likely to want a pharmacist on their ward round. [See note at end] Indeed, one was even a qualified pharmacist as well. Then as a pharmacist in a Yellow Card Centre, where the Director was a clinical pharmacologist. Wherever I have seen clinical pharmacologists work they have been a key ally of pharmacy in the medical arena, helping pharmacy push through Drug and Therapeutic committee decisions, and not anti-pharmacy at all. Senior academic clinical pharmacologists have been nurturing towards pharmacists, often encouraging pharmacists to develop their academic side, getting them involved in research, and in many cases setting pharmacists off on a course to obtain a PhD helping to develop the pharmacy workforce. Certainly, the Yellow Card Centres across the UK are one area where this can be seen, which are centres of excellence in terms of pharmacists working with clinical pharmacologists. I know I am not alone in seeing this synergism.

The BPS provides a quote from Roger Walker on the role clinical pharmacologists play with pharmacists, and gives an example of pharmacists working together with clinical pharmacologists:

The All Wales Therapeutic and Toxicology Centre (AWTTC), a partnership led by clinical pharmacologists working together with pharmacists in Wales was able to provide resources and training to support prescribers in Wales in reducing primary care prescribing costs in three main areas.

I am part of a team that obtained a grant to develop Safe Prescriber a website about prescribing safety for F1 doctors, that is now being rolled out nation wide for other prescribers. That team consists of clinical pharmacologists and pharmacists from the start. The main editor is a pharmacist. From the start modules have been largely co-developed with a medical and pharmacist contributor. In my main job as a Programme Director on an undergraduate pharmacy course, the clinical pharmacologists are an essential resource.

Clinical pharmacologists are not a threat to clinical pharmacy, nor do they devalue pharmacy. Why would they put a quote from a pharmacist in their own report to back-up their own importance if they felt pharmacists were not valued? Practically, there are not enough pharmacologists to deal at ground level with the tsunami of drug-related harm that patients experience, they need pharmacists as a partner.

I am a member both of the BPS and the Royal Pharmaceutical Society. These organisers work together, for one example see here. I hope we continue to do so, and I would hope that we can support the clinical pharmacologists in their call to re-envigorate their speciality.

The swamp of medicine-related problems is vast. Neither pharmacy and or clinical pharmacology is going to drain it alone, but we can at least work together to fix the parts we can.

  1. Wade OL. Adverse Reactions to Drugs. 1st ed. London: William Heinemann Medical Books Ltd, 1970
  2. Maxwell RJ, Webb DJ. Clinical pharmacology – too young to die? The Lancet 2006;367(9513):799-800

Additional note: Rather than focusing on a non-existent threat from clinical pharmacology pharmacy ought to concentrate on its own profession. There are a number of threats to clinical pharmacy services in the UK, such as re-banding and redundancy pressures on senior experienced clinical pharmacists in the NHS. Additionally, ward rounds, anecdotally, appear to be contracting as hospital pharmacy starts to focus on process driven targets, rather than clinical care in its widest sense. We ought to start a discussion about how we can insure that pharmacists become part of clinical teams, to ensure that the clinical aspects of their expertise that cannot be measured with targets continues to be valued. Why not speak to your clinical pharmacology colleagues to see how you can work together?

Let’s have some over-the-counter evidence

I have an editorial in The Pharmaceutical Journal on over the counter medicines and pharmacists relationship with them. Here’s part of it:

While the secret shopper work carried out by the consumer watchdog Which? in 2013 investigated[1] the quality of advice on OTC medicines given in pharmacies at the point of sale, an earlier report[2] in Which? published in 2012 focused on OTC products themselves. Among the products that were judged to be below par were sub-therapeutic doses of drugs, dubious herbal slimming tablets, oils that allegedly reduce scarring and some highly implausible alternative remedies. A pharmacist drawing up a local formulary of prescription drugs for a GP would take into account evidence of effectiveness, advice from evidence-based guidelines and a positive risk-benefit ratio. How many OTC products would reach the required standard?

Read more…