I fully agree with the scepticism about homoeopathy in the recent Broad spectrum by Terry Maguire and Angela Alexander (PJ, 5 December 2009, p616).
The famous German newspaper Die Zeit recently published an article on another curious example of a homoeopathic remedy. A London pharmacy (Helios Homoeopathy Pharmacy) sells the Berlin wall in dilutions of 6C to 50M as a homeopathic remedy.
The rationale of the product? The blockade of the city of Berlin was overcome by the fall of the wall. So a dilution of the wall might help to overcome mental and emotional blockades of patients!
A nice example of the British sense of humour.
Christiane Staiger
Neu-Isenburg
Germany
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I am happy that Christiane Staiger (PJ, 2/9 January 2010, p11) has enjoyed the humour that homoeopathy can bring. Sometimes I, too, raise a smile at some of the homoeopathic remedy sources which have evolved over the years.
I acknowledge that Berlin Wall is an unusual choice of substance to develop, with an indeterminate chemical composition. In 1994, at the request of a group of homoeopathic practitioners, Berlin Wall was prepared by the lactose trituration method given in the German Homoeopathic Pharmacopeia. This is the standard method for processing insoluble materials homoeopathically.
It was subsequently researched by these homoeopaths and students. They conducted provings to elicit the many symptoms a potentised form of the substance can create and are thus an indication as to its clinical use.
Although rarely used, it is prescribed occasionally, mainly abroad, and, like any pharmacy, we respond to the prescription requests of practitioners and patients. Perhaps some of these prescriptions have helped suffering patients through bouts of depression where antidepressants failed to work.
John Morgan
Managing Director
Helios Homoeopathy Ltd
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Having long regarded the PJ as an organ of impeccable professionalism and high journalistic quality, I am concerned there may have been a lapse from your usual standards.
This is not due to the (albeit regrettable) absence of pasta recipes or Tuscany holiday advice, but because I fear you may have inadvertently permitted a spoof letter through.
How else is one to interpret the contribution from John Morgan (PJ, 16 January 2010, p50) regarding the preparation of Berlin Wall homoeopathic remedy? Surely, the mischievous writer should have waited until 1 April?
Russell Greene
London
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The recent news items and press coverage relating to aristolochia in the context of Chinese medicine revived some early memories of a pharmacognosy course in which, I seem to vaguely remember, that certain processed parts of this plant may have been described as a “substitute or adulterant” of an official drug.
The history and characteristics of members of this genus are described in ‘Textbook of pharmacognosy’ by T. E. Wallace and in ‘A textbook of pharmacognosy’ by E. Trease. Also, there is a short monograph in ‘Martindale: the complete drug reference’.
In Wallace’s book, the monograph is headed “Serpentary rhizome (serpentary root, virginian snakeroot, rhizoma serpentariae)” and, in Trease’s book, it is additionally headed “Texan snakeroot”. In both textbooks, the constituents are described as being a “volatile oil (about 1 per cent), tannin, a bitter principle, apparently an alkaloid crystallising in light yellow needles probably aristolochine”.
In Wallace’s textbook, it is described as having “local and general stimulant and tonic properties closely resembling those of valerian and cascarilla”, while Trease states that “it was formerly used as a snake-bite remedy but is useless for this purpose. It is now mainly employed as an aromatic bitter. In overdoses it produces violent gastrointestinal irritation.”
The Martindale monograph states that “its active ingredient is aristolochic acid and this and its sodium salt have been tried in a number of inflammatory disorders, mainly in folk medicine” and concludes that “there is concern over its use since aristolochic acid has been reported to be carcinogenic in animals”.
It is reported (Merck Index, 12th edition) that it is “one of group of 14 substituted 1-phenanthrenecarboxylic acids in aristolochiaceae and butterflies feeding on these plants”.
Since aristolochic acid (8-methoxy-6-nitrophenanthro[3,4-d]-1,3-dioxole-5-carboxylic acid) is a nitro-polybenzenoid compound, with the potential for bioconversion into highly reactive intermediates, it is hardly surprising that it could possess carcinogenic or pro-carcinogenic properties.
Since the products of the plant and the oil obtained from it have such doubtful therapeutic value, could the term “snake oil” have been derived from this source?
J. W. Clitherow
Sawbridgeworth, Hertfordshire
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Your News stories (PJ, 27 February 2010, p205) made for interesting reading. First, we have the headline “MPs condemn homoeopathy licensing and funding”, with quotes stating “The committee believes that evidence shows homoeopathy does not work beyond the placebo effect … [and] the Government should not endorse the use of placebo treatments”.
The next news headline on the same page states “Pharmacists’ interactions with patients may exert placebo effect”. However, we have just learnt the Government does not endorse or fund placebos. So, is pharmacy next for the withdrawal of funding since we are now simply quartermasters paid for our supply function?
But, all is not lost. The story goes on to state placebo effects “are genuine psychobiological events”; such effects should be harnessed; and more research could lead to the ethical use of placebo mechanisms in routine clinical care and encourage the use of treatments that stimulate placebo effects.
So, pharmacy appears to be safe and, if these suggestions are true, can we have homoeopathy back?
John Thompson
Inverkeithing, Fife
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I was delighted to see that David Needleman has received a well deserved four-year appointment to the Medicines and Healthcare products Regulatory Agency’s Advisory Board on the Registration of Homoeopathic Products (PJ, 20 March 2010, p284).
Clearly, though, those ministers in charge of our health need to make up their minds as to whether homoeopathy is to be embraced or farcically condemned, as pointed out by John Thompson in his letter (ibid, p288).
Can we have any confidence that the Department of Health has any idea what it is doing?
Adrian Korsner
London
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As widely reported in the UK press, a parliamentary committee has recently recommended that homoeopathy should not be available on the NHS (PJ, 27 February 2010, p205).
The MPs questioned several experts from both sides of the homoeopathic divide, including Paul Bennett, professional standards director for Boots. Talking about homoeopathic remedies, he told the committee: “I have no evidence to suggest they are efficacious.”
Consumers of Boots are confronted by shelves full of “alternative” medicines. Consumers may therefore well assume: “If it is sold by this trusted pharmacist chain, it must work.” But does it?
Boots even offers its own brand of homoeopathic remedies. These homoeopathic remedies are so highly diluted that they contain no active ingredients at all. This is precisely why scientists argue they are implausible nonsense. Today, there are about 200 clinical trials of homoeopathy. Collectively, they fail to provide good evidence that homoeopathy is anything more than an elaborate “make-believe”.
Bach Flower remedies are produced by dropping a few flowers into a tank full of water. This water is then mixed with alcohol to increase the stability of the product. Subsequently, the liquid is filled into little bottles and sold dearly. To assume that they do anything other than reducing the cash in the buyer’s pocket is far-fetched. What is more, all the rigorous trials of Bach Flower Remedies have shown that they are pure placebos.
Therapists like to call aromatherapy oils “essentials” oils, which implies we cannot do without them. The evidence, however, tells a different story. Aromatherapy consists of a soothing massage, which clearly is pleasant, but pleasant does not mean healthy. In fact, there is no good evidence that the oils sold in Boots pharmacies make any difference at all.
Herbal extracts can, of course, contain pharmacologically active ingredients. This means they can both kill and cure. Several herbal medicines are demonstrably effective. For instance, St John’s wort alleviates depression, devil’s claw reduces pain and horse chestnut seed extract improves the symptoms of varicose veins.
Other popular herbal medicines, by contrast, have been shown to be fairly useless: evening primrose oil, bilberry and goldenseal might be good examples for this category. Others, again, may actually be harmful: borage, black seed oil or comfrey, for instance.
Why are so many placebos for sale at Boots and other pharmacy outlets? Are pharmacists shop-keepers only out to make a profit or are they healthcare professionals who are keen to improve public health?
Several pharmacists have tried to tackle this thorny issue, not least because their code of ethics leaves them no real choice. It states in no uncertain terms that pharmacists must provide their customers with relevant information regarding “alternative” medicines.
And who would argue that it is not relevant for consumers to know that homoeopathic remedies, for instance, are biologically implausible and scientifically unproven?
Sadly, the Royal Pharmaceutical Society has so far tended to side with commercial interests rather than with scientific truth. In my view, we should continue to question this position.
Edzard Ernst
Peninsula Medical School
Exeter
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From Paul Bennett, professional standards director and superintendent pharmacist, Boots UK
Homoeopathy is recognised by the NHS and many health professionals, and our customers choose to use homoeopathy. Boots UK is committed to providing our customers with a wide range of healthcare products to suit their individual needs.
We know that many people believe in the benefits of complementary medicines and we aim to offer the products we know our customers want.
Our pharmacists are trained healthcare professionals and are on hand to offer advice on the safe use of complementary medicines.
The Royal Pharmaceutical Society issues guidance to pharmacists on the correct selling of homoeopathy, which our pharmacists adhere to.
We would support the call for scientific research and evidence gathering on the efficacy of homoeopathic medicines. This would help our patients and customers make informed choices about using homoeopathic medicines.
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Paul Bennett - that's exactly the corporate dilly-dallying you espoused at the evidence check to which Prof. Ernst is referring and is what got dragged Boots personally into the fray with the 1023 homoeopathy campaign and made your pharmacists into targets for protesters.
As it was ineffective at convincing the assembled MP's of the legitimacy of homeoepathy, one wonders why you would think it worthy of repetition here.
I think you are confusing consumer choice with patient-centred care. The two are very different.
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Correct this situation
From Professor E. Ernst, MD
Terry Maguire’s Broad spectrum (PJ, 5 December 2009, p616) should send a shiver down the spine of every pharmacist.
Are UK pharmacists shop-keepers or healthcare practitioners? Currently, the former seems to be the case.
Professional organisations must now take urgent measures to correct this situation. If not, patients may be seriously harmed.
E. Ernst
Director, Complementary Medicine
Peninsula Medical School
Exeter, Devon
Berlin Wall at 30C
From Dr C. Staiger, MRPharmS
I fully agree with the scepticism about homoeopathy in the recent Broad spectrum by Terry Maguire and Angela Alexander (PJ, 5 December 2009, p616).
The famous German newspaper Die Zeit recently published an article on another curious example of a homoeopathic remedy. A London pharmacy (Helios Homoeopathy Pharmacy) sells the Berlin wall in dilutions of 6C to 50M as a homeopathic remedy.
The rationale of the product? The blockade of the city of Berlin was overcome by the fall of the wall. So a dilution of the wall might help to overcome mental and emotional blockades of patients!
A nice example of the British sense of humour.
Christiane Staiger
Neu-Isenburg
Germany
Berlin Wall rarely used
From Mr J. Morgan, MRPharmS
I am happy that Christiane Staiger (PJ, 2/9 January 2010, p11) has enjoyed the humour that homoeopathy can bring. Sometimes I, too, raise a smile at some of the homoeopathic remedy sources which have evolved over the years.
I acknowledge that Berlin Wall is an unusual choice of substance to develop, with an indeterminate chemical composition. In 1994, at the request of a group of homoeopathic practitioners, Berlin Wall was prepared by the lactose trituration method given in the German Homoeopathic Pharmacopeia. This is the standard method for processing insoluble materials homoeopathically.
It was subsequently researched by these homoeopaths and students. They conducted provings to elicit the many symptoms a potentised form of the substance can create and are thus an indication as to its clinical use.
Although rarely used, it is prescribed occasionally, mainly abroad, and, like any pharmacy, we respond to the prescription requests of practitioners and patients. Perhaps some of these prescriptions have helped suffering patients through bouts of depression where antidepressants failed to work.
John Morgan
Managing Director
Helios Homoeopathy Ltd
Should have waited until April Fool’s Day
From Dr R. J. Greene, MRPharmS
Having long regarded the PJ as an organ of impeccable professionalism and high journalistic quality, I am concerned there may have been a lapse from your usual standards.
This is not due to the (albeit regrettable) absence of pasta recipes or Tuscany holiday advice, but because I fear you may have inadvertently permitted a spoof letter through.
How else is one to interpret the contribution from John Morgan (PJ, 16 January 2010, p50) regarding the preparation of Berlin Wall homoeopathic remedy? Surely, the mischievous writer should have waited until 1 April?
Russell Greene
London
Snake oil
From Dr J. W. Clitherow, FRPharmS
The recent news items and press coverage relating to aristolochia in the context of Chinese medicine revived some early memories of a pharmacognosy course in which, I seem to vaguely remember, that certain processed parts of this plant may have been described as a “substitute or adulterant” of an official drug.
The history and characteristics of members of this genus are described in ‘Textbook of pharmacognosy’ by T. E. Wallace and in ‘A textbook of pharmacognosy’ by E. Trease. Also, there is a short monograph in ‘Martindale: the complete drug reference’.
In Wallace’s book, the monograph is headed “Serpentary rhizome (serpentary root, virginian snakeroot, rhizoma serpentariae)” and, in Trease’s book, it is additionally headed “Texan snakeroot”. In both textbooks, the constituents are described as being a “volatile oil (about 1 per cent), tannin, a bitter principle, apparently an alkaloid crystallising in light yellow needles probably aristolochine”.
In Wallace’s textbook, it is described as having “local and general stimulant and tonic properties closely resembling those of valerian and cascarilla”, while Trease states that “it was formerly used as a snake-bite remedy but is useless for this purpose. It is now mainly employed as an aromatic bitter. In overdoses it produces violent gastrointestinal irritation.”
The Martindale monograph states that “its active ingredient is aristolochic acid and this and its sodium salt have been tried in a number of inflammatory disorders, mainly in folk medicine” and concludes that “there is concern over its use since aristolochic acid has been reported to be carcinogenic in animals”.
It is reported (Merck Index, 12th edition) that it is “one of group of 14 substituted 1-phenanthrenecarboxylic acids in aristolochiaceae and butterflies feeding on these plants”.
Since aristolochic acid (8-methoxy-6-nitrophenanthro[3,4-d]-1,3-dioxole-5-carboxylic acid) is a nitro-polybenzenoid compound, with the potential for bioconversion into highly reactive intermediates, it is hardly surprising that it could possess carcinogenic or pro-carcinogenic properties.
Since the products of the plant and the oil obtained from it have such doubtful therapeutic value, could the term “snake oil” have been derived from this source?
J. W. Clitherow
Sawbridgeworth, Hertfordshire
Is pharmacy next in line for funding withdrawal?
From Mr J. G. Thompson, MRPharmS
Your News stories (PJ, 27 February 2010, p205) made for interesting reading. First, we have the headline “MPs condemn homoeopathy licensing and funding”, with quotes stating “The committee believes that evidence shows homoeopathy does not work beyond the placebo effect … [and] the Government should not endorse the use of placebo treatments”.
The next news headline on the same page states “Pharmacists’ interactions with patients may exert placebo effect”. However, we have just learnt the Government does not endorse or fund placebos. So, is pharmacy next for the withdrawal of funding since we are now simply quartermasters paid for our supply function?
But, all is not lost. The story goes on to state placebo effects “are genuine psychobiological events”; such effects should be harnessed; and more research could lead to the ethical use of placebo mechanisms in routine clinical care and encourage the use of treatments that stimulate placebo effects.
So, pharmacy appears to be safe and, if these suggestions are true, can we have homoeopathy back?
John Thompson
Inverkeithing, Fife
Ministers need to make up their minds
From Mr A. R. Korsner, MRPharmS
I was delighted to see that David Needleman has received a well deserved four-year appointment to the Medicines and Healthcare products Regulatory Agency’s Advisory Board on the Registration of Homoeopathic Products (PJ, 20 March 2010, p284).
Clearly, though, those ministers in charge of our health need to make up their minds as to whether homoeopathy is to be embraced or farcically condemned, as pointed out by John Thompson in his letter (ibid, p288).
Can we have any confidence that the Department of Health has any idea what it is doing?
Adrian Korsner
London
Are pharmacists shopkeepers out to make a profit?
From Professor E. Ernst, FRCP
As widely reported in the UK press, a parliamentary committee has recently recommended that homoeopathy should not be available on the NHS (PJ, 27 February 2010, p205).
The MPs questioned several experts from both sides of the homoeopathic divide, including Paul Bennett, professional standards director for Boots. Talking about homoeopathic remedies, he told the committee: “I have no evidence to suggest they are efficacious.”
Consumers of Boots are confronted by shelves full of “alternative” medicines. Consumers may therefore well assume: “If it is sold by this trusted pharmacist chain, it must work.” But does it?
Boots even offers its own brand of homoeopathic remedies. These homoeopathic remedies are so highly diluted that they contain no active ingredients at all. This is precisely why scientists argue they are implausible nonsense. Today, there are about 200 clinical trials of homoeopathy. Collectively, they fail to provide good evidence that homoeopathy is anything more than an elaborate “make-believe”.
Bach Flower remedies are produced by dropping a few flowers into a tank full of water. This water is then mixed with alcohol to increase the stability of the product. Subsequently, the liquid is filled into little bottles and sold dearly. To assume that they do anything other than reducing the cash in the buyer’s pocket is far-fetched. What is more, all the rigorous trials of Bach Flower Remedies have shown that they are pure placebos.
Therapists like to call aromatherapy oils “essentials” oils, which implies we cannot do without them. The evidence, however, tells a different story. Aromatherapy consists of a soothing massage, which clearly is pleasant, but pleasant does not mean healthy. In fact, there is no good evidence that the oils sold in Boots pharmacies make any difference at all.
Herbal extracts can, of course, contain pharmacologically active ingredients. This means they can both kill and cure. Several herbal medicines are demonstrably effective. For instance, St John’s wort alleviates depression, devil’s claw reduces pain and horse chestnut seed extract improves the symptoms of varicose veins.
Other popular herbal medicines, by contrast, have been shown to be fairly useless: evening primrose oil, bilberry and goldenseal might be good examples for this category. Others, again, may actually be harmful: borage, black seed oil or comfrey, for instance.
Why are so many placebos for sale at Boots and other pharmacy outlets? Are pharmacists shop-keepers only out to make a profit or are they healthcare professionals who are keen to improve public health?
Several pharmacists have tried to tackle this thorny issue, not least because their code of ethics leaves them no real choice. It states in no uncertain terms that pharmacists must provide their customers with relevant information regarding “alternative” medicines.
And who would argue that it is not relevant for consumers to know that homoeopathic remedies, for instance, are biologically implausible and scientifically unproven?
Sadly, the Royal Pharmaceutical Society has so far tended to side with commercial interests rather than with scientific truth. In my view, we should continue to question this position.
Edzard Ernst
Peninsula Medical School
Exeter
Boots UK responds
From Paul Bennett, professional standards director and superintendent pharmacist, Boots UK
Homoeopathy is recognised by the NHS and many health professionals, and our customers choose to use homoeopathy. Boots UK is committed to providing our customers with a wide range of healthcare products to suit their individual needs.
We know that many people believe in the benefits of complementary medicines and we aim to offer the products we know our customers want.
Our pharmacists are trained healthcare professionals and are on hand to offer advice on the safe use of complementary medicines.
The Royal Pharmaceutical Society issues guidance to pharmacists on the correct selling of homoeopathy, which our pharmacists adhere to.
We would support the call for scientific research and evidence gathering on the efficacy of homoeopathic medicines. This would help our patients and customers make informed choices about using homoeopathic medicines.
Paul Bennett - that's
Paul Bennett - that's exactly the corporate dilly-dallying you espoused at the evidence check to which Prof. Ernst is referring and is what got dragged Boots personally into the fray with the 1023 homoeopathy campaign and made your pharmacists into targets for protesters.
As it was ineffective at convincing the assembled MP's of the legitimacy of homeoepathy, one wonders why you would think it worthy of repetition here.
I think you are confusing consumer choice with patient-centred care. The two are very different.