Houston we have a problem!

Elizabeth Thompson, consultant homeopathic physician, Bristol

Tuesday, 9 March 2010

Some of you may have been pleased to see the recent call to remove homeopathy, a Complementary and Alternative Medicine (CAM), from the NHS, agreeing that it has been an irrelevancy within healthcare since it was introduced by statute of parliament in 1948. The Science and Technology committee Evidence Check into homeopathy has concluded that homeopathy is a placebo and placebos are not justified in the NHS. This view seems to have been heavily weighted by the opinions of Edzard Ernst Professor of CAM from Exeter University who has written extensively in the media calling for homeopathy to be removed from the NHS. In the science report he is quoted as saying “placebos are unreliable and there is lots of data to show that placebo effects are notoriously unreliable; somebody who responds today may not respond tomorrow; responses are not large in effect size and they are not usually long-lasting”.

... the transcripts of Evan Harris interviewing those people who presented evidence for homeopathy does not inspire one that the process was balanced... 

However some large pieces of observational data from Europe and the UK, which were dismissed disparagingly as patient satisfaction surveys (which they were not but have been carried out separately in our department), suggest that homeopathy can indeed contribute to health gain and improvements in well being and quality of life in the long term ^1-4. Also firmly concluding that homeopathy is a placebo does not reflect the evidence presented. The balance of the meta analyses done thus far, even those confining trials to high quality trials, suggest that we cannot conclude that homeopathy is just a placebo⁵. In some condition specific research for example in fibromyalgia two placebo controlled trials have shown positive results⁶. Condition specific research has been lacking and there have been only 200 RCTs across the whole breadth of medicine as CAM funding has been significantly under supported despite a flurry of funding from the Department of Health in 2000 to build the research infrastructure which then petered out. One member of the committee is said to have abstained because the process did not appear balanced and reading the transcripts of Evan Harris interviewing those people who presented evidence for homeopathy does not inspire one that the process was balanced with Harris demonstrating preconceived ideas and a mocking attitude.

Although the chair Mr Willis is quoted as saying "there seems to be a little confusion about the nature of the work that we are doing, this is not an inquiry into whether homeopathy works or not. This is an inquiry which follows a series of evidence checks across a number of government departments to see whether in fact there was any evidence to support the Government's policy towards homeopathy."

 EBM cannot gather all its data from randomised controlled trials (RCTs) as sometimes this is not an appropriate way to gather evidence

Yet the lines of questioning, by the Chair and in particular by Dr Evan Harris focused entirely on the issue of whether homeopathy works or not, in the narrow world of RCTs and meta-analyses. They focused entirely on efficacy in artificial trials, rather than on effectiveness in the real world. EBM cannot gather all its data from randomised controlled trials (RCTs) as sometimes this is not an appropriate way to gather evidence. I have had particular interest in whether homeopathy can help with symptom control in the cancer patient and the management of treatment side effects and began inquiring into this area using observational models moving on to a randomised placebo controlled trial. Ernst co-authored a review of homeopathy in the cancer setting and suggested results from RCTs were promising and more research was needed in this important area⁷.

Just this week a piece of research was published demonstrating four ultra-diluted remedies (Carcinosin, Phytolacca, Conium and Thuja) exerted preferential cytotoxic effects against two breast cancer cell lines, causing cell cycle delay/arrest and apoptosis⁸. Again basic science was dismissed as evidence within the report as was any qualitative research which assesses the patient experience of CAM use. Many clinicians take a more pragmatic view of evidence faced with the daily challenge of helping the person in front of them. About 50% of referrals to the complementary cancer care service at the Bristol Homeopathic Hospital come directly from oncologists and specialist nurses. These clinicians may be sceptical about how homeopathy works but they know their patients are in a tight squeeze with limited conventional treatments and they see good results coming from the clinics.

...if other areas of care are dealt with in the same way we could be significantly reducing our therapeutic options in many clinical settings and thereby reducing choices to clinician and patient

So is my journey to a brave new world of NHS integrative care, which I envisaged ten years ago as a senior registrar in palliative medicine combining the best of conventional and complementary approaches, looking like it is being aborted by the science committee report. I had expected that the UK, led by Ernst and others would now have a very active research initiative up and running looking at a number of CAM treatments across a broad array of chronic diseases using a mixed methodology of placebo controlled, pragmatic and qualitative trials to gain an understanding of specific and non-specific effects within a healthcare interaction. This research would have, where appropriate, linked to increasing integration of holistic approaches that offer an in-depth approach to illness and the suffering it brings and a longer term perspective for things that might need to change to restore health. Many CAMs offer an acknowledgement of complexity and as many are non-toxic do no harm in the process of waiting for change.

Having recently experienced an illness for which I was advised a certain drug I then found side effects meant that I could not increase the dose so keeping the dose low and using acupuncture, meditation and homeopathy alongside I am making a good recovery. I could afford these treatments privately but many of the patients I see could not. Is it not understandable that I would want to offer to others what I would want from the health service myself? Although it looks for the present that viewing homeopathy through the narrow lens of EBM is our problem, if other areas of care are dealt with in the same way we could be significantly reducing our therapeutic options in many clinical settings and thereby reducing choices to clinician and patient. Houston we do have a problem but it is shared across the clinical arena and it has only just begun.

Reference

1. Witt CM, Ludtke R, Baur R, Willich SN. Homeopathic medical practice: long-term results of a cohort study with 3981 patients. BMC Public Health 2005 Nov 3;5:115.:115.
2. Witt C, Keil T, Selim D, Roll S, Vance W, Wegscheider K, et al. Outcome and costs of homoeopathic and conventional treatment strategies: a comparative cohort study in patients with chronic disorders. Complement Ther Med 2005 Jun;13(2):79-86.
3. Spence DS, Thompson EA, Barron SJ. Homeopathic treatment for chronic disease: a 6-year, university-hospital outpatient observational study. J Altern Complement Med 2005 Oct;11(5):793-8.
4. Thompson EA, Mathie RT, Baitson ES, Barron SJ, Berkovitz SR, Brands M, et al. Towards standard setting for patient-reported outcomes in the NHS homeopathic hospitals. Homeopathy 2008 Jul;97(3):114-21.
5. Ludtke R, Rutten AL. The conclusions on the effectiveness of homeopathy highly depend on the set of analyzed trials. J Clin Epidemiol 2008 Dec;61(12):1197-204.
6. Bell IR, Lewis DA, Brooks AJ, Schwartz GE, Lewis SE, Walsh BT, et al. Improved clinical status in fibromyalgia patients treated with individualized homeopathic remedies versus placebo. Rheumatology (Oxford) 2004 May;43(5):577-82.
7. Milazzo S, Russell N, Ernst E. Efficacy of homeopathic therapy in cancer treatment. Eur J Cancer 2006 Feb;42(3):282-9.
8. Frenkel M, Mishra BM, Sen S, Yang P, Pawlus A, Vence L, et al. Cytotoxic effects of ultra-diluted remedies on breast cancer cells. Int J Oncol 2010 Feb;36(2):395-403.