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A spoonful of nothing

Still practising

Chris Preece

Tuesday, 01 May 2018

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AdobeStock_75768263_homeopathy.jpgSometimes a piece of research comes along that you can’t help but feel confirms what was already abundantly obvious. The recent paper1 examining the correlation between the use of homeopathy and poor prescribing in Primary Care would appear at first glance to be another to go alongside “wearing bad shoes gives you foot pain2 and “kids with TVs in the bedroom are more likely to be fat3. Indeed, the only truly surprising thing in this paper – which showed practices that prescribe homeopathy are also likely to perform poorly on other prescribing quality measures – is that 8.5% of practices were prescribing homeopathy at all.

The case against homeopathy as anything other than placebo has been seemingly established for some time, culminating in the Australian National Health and Medical Research Council’s exhaustive review4 of homeopathy which concluded: “there are no health conditions for which there is reliable evidence that homeopathy is effective.” They advised it should never be used to treat conditions that are “chronic, serious or could become serious”.

Even without the research the plausibility of homeopathy’s central conceit – that things that cause illness in the healthy, can be used to cure it in the sick, but only once diluted to 1 in 1060 and struck multiple times against a suitable surface – seems like it wouldn’t be accepted by anyone with a passing knowledge of medicine.

Yet, there it is, 8.5%.

Or as the Daily Mail puts it: “GPs at one in 12 practices are still prescribing homeopathic treatments for their patients – even though there’s no scientific evidence it works".

It’s genuinely painful for me to record a Daily Mail headline that criticises GPs, that I agree with entirely, but there it is. (Lest this causes you too much distress dear reader, here’s a different Mail article from just two months previously making “The Case For Homeopathy”. Order is restored.)

The Times opted to hit them even harder: “Homeopathy more likely to be used by bad doctors” they stated, pulling no punches whatsoever. It’s a headline that caused me to pause slightly in my own mental disdain for these homeopathic GPs. It would take a whole separate article to debate what exactly constitutes a “bad GP” (makes note to self for the future), but I’m fairly confident that “not always prescribing the most cost effective, high value drugs” wouldn’t constitute the entirety, or even the bulk, of the description.

There are lots of reasons why a doctor, especially a GP, might prescribe something that doesn’t quite sit perfectly with our colleagues in Medicine Management – and most of them result from an understanding of, and compromise with, our patients, in their best interests. Prescribing purely according to the guidelines, without any consideration for the person you’re prescribing for, is a sure fire way to see your prescription wind up in the bin.

Suddenly, I found myself recasting these people as mavericks, not unafraid to go off piste in order to find the real life best option. After all, those homeopathy pills are harmless, and the majority of GPs have issued an “impure placebo” at some point in their careers (for instance knowingly issuing antibiotics for a viral infection). Wouldn’t it be better to ensure the afore mentioned placebo isn’t going to have any negative effects?

Except, of course, it isn’t that simple. Because there is some harm in it (and I don’t simply mean the nocebo effect). The problem with issuing almost any kind of placebo is that you’re reinforcing the notion that the placebo works. If I issue antibiotics for your cold, you’re going to come back for more next time (with the steady march of resistance meaning antibiotics may soon be placebos even for bacterial infections). If I issue a homeopathic drug I’m reinforcing the idea that water really does have magical properties beyond good old-fashioned hydration.

This becomes particularly problematic when homeopathy ventures into the realms that were so sensibly excluded in that Australian review – illnesses that are “chronic, serious, or could be serious”. A recent report in The Guardian identified 120 homeopaths in the UK who were offering “cures” for autism, whilst simultaneously advising against antibiotics for infection and vaccination. This is at best, bad advice, and at worst, dangerous exploitation. Somewhat terrifyingly, in the past the WHO has felt the need to issue statements advising people not to use homeopathic remedies for the prevention or treatment of HIV, TB and malaria.

So maybe The Times was right, maybe those who prescribe these “treatments” really are “bad doctors”.

So, what can these prescribers do instead? Well, preferably, they need to stop prescribing glorified placebos entirely. But if they absolutely must, there is an ethical way to go about it – by clearly stating that what you’re prescribing is just a placebo with absolutely no active ingredients. There’s even some evidence to suggest that when doing just that, taking a placebo still works.5 Now there’s a piece of research that I wouldn’t have predicted an outcome for.

References

  1. Walker AJ, Croker R, Bacon S, et al. Is use of homeopathy associated with poor prescribing in English primary care? A cross-sectional study. Journal of the Royal Society of Medicine, first published online: April 18, 2018. DOI: 10.1177/0141076818765779
  2. Dufour AB, Broe KE, Nguyen UDT, et al. Foot Pain: Is Current or Past Shoewear a Factor? The Framingham Foot Study. Arthritis Rheum. 2009 Oct 15; 61(10): 1352–1358. DOI: 10.1002/art.24733
  3. Heilmann A, Rouxel P, Fitzsimons E, et al. Longitudinal associations between television in the bedroom and body fatness in a UK cohort study. International Journal of Obesity volume 41, pages 1503–1509 (2017). DOI:10.1038/ijo.2017.129
  4. NHMRC Statement on Homeopathy and NHMRC Information Paper - Evidence on the effectiveness of homeopathy for treating health conditions. National Health and Medical Research Council – Australian Government, 2015
  5. Kaptchuk TJ, Friedlander E, Kelley JM. Placebos without Deception: A Randomized Controlled Trial in Irritable Bowel Syndrome. PLOS One, December 22, 2010. DOI: 10.1371/journal.pone.0015591

Author's Image

Chris Preece

Chris has worked as a GP Partner in North Yorkshire since 2004, and still relishes the peculiar challenge of never quite knowing what the next person through the door is going to present with. He was the chair of his local Practice Based Commissioning Group, and when this evolved into a CCG he joined the Governing Body, ultimately leaving in April 2015. He continues to work with the CCG in an advisory capacity. When not being consumed by all things medical, Chris occupies himself by writing, gaming, and indulging the whims of his children. He has previously written and performed in a number of pantomimes and occupied the fourth plinth in Trafalgar Square. Tragically, his patients no longer tell him he looks too young to be a doctor.
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