conventional medicine

Unicough: Sadly not as good as unicorns.

Another day and another new cough medicine has mysteriously appeared on pharmacy shelves.  It’s called Unicough® (Infirst), and it claims to work by:

addressing the hypersensitivity of the cough reflex, which makes it suitable for dry, tickly and chesty coughs
— http://www.chemistanddruggist.co.uk/news/new-cough-syrup-pharmacy-only#sthash.toAK6A2l.dpuf (subscription required)
source: http://www.infirst.co.uk/were-working-on/unicough

source: http://www.infirst.co.uk/were-working-on/unicough

Riiiight. Regular readers will by now know that most cough medicines are absolute nonsense, with little to no evidence of effectiveness. I’m particularly suspicious of products (like this one and Bronchostop, for example), which claim to be able to work on any type of cough. Chesty and dry coughs happen through different mechanisms, so a product that claims to treat all types seems more likely to not work for any. An exception to this would be a simple demulcent like simple linctus, which acts just by coating the throat for a little while. 

Am I right to be suspicious about this product? Well dear friends, lets take a deep, objective breath and dive into the evidence, hoping beyond hope that maybe this time… this time… it might not be a nonsense product. 

Is it actually a medicine? Or is it just pretending? 

Unlike most new over the counter products which all turn out to be medical devices masquerading as real medicines, this product is actually, genuinely a Real Life Medicine. It even has a Real Life License, for the symptomatic relief of common coughs associated with upper respiratory tract congestion. What larks! What a time to be alive!

This means that the manufacturer will have proven three broad things in order to receive the license: safety, efficacy, and quality. We’re not out of the woods yet, by any means, but this is probably the most promising start to an OTC medicines review I’ve done so far.

It contains diphenhydramine 14 mg (an antihistamine, which as a side effect will make you sleepy), ammonium chloride 135 mg (irritates the airways, therefore is supposed to loosen up any mucus and help you cough it up- aka an expectorant), and levomenthol 1.1mg (minty, therefore feels a bit soothing and cooling). Despite Infirst’s hopes that Unicough will “reshape the approach to acute common coughs”, there are no exciting or revolutionary technologies here. All of these drugs are old as the hills, and very similar products (Benylin Chesty Cough Original) have been widely available for pretty much forever.  

Furthermore, it is a totally irrational combination of drugs. You’ve got an antihistamine, which acts to dry up secretions, nestling up alongside an expectorant, which is supposed to promote loosening up secretions. Those two actions work against each other and cancel each other out, rendering the whole thing pretty darn pointless. 

If it's licensed, that means that there is evidence that it works though, right?

Ummm… no. It seems that it’s managed to get its license on the basis of being exactly the same (save for flavouring) as another product called Histalix®. That product got its license in 1999, seemingly on the basis of thin air. It’s safe to say that back then licensing for OTC products was rather less rigorous than these days, and “but it’s been around for a while now” used to be a legitimate reason to grant a license. Now, I can’t find the information that the manufacturers of Histalix® presented at the time, but I’m guessing it’s probably not a whole suite of robust, well designed trials.

An article about the product in Chemist+Druggist magazine gave some vague details about a trial:

A randomised study of 163 patients co-ordinated by King’s College Hospital, London, found that the cocoa-based formulation was more effective at reducing the frequency of coughs and the disrupted sleep caused by coughs than simple linctus, Infirst Healthcare said
— http://www.chemistanddruggist.co.uk/news/new-cough-syrup-pharmacy-only#sthash.toAK6A2l.dpuf

This trial, however, doesn’t appear to be published anywhere. I contacted the manufacturers asking for more information about it and was, perhaps predictably, met with silence. Without knowing how the trial was designed, and what the results were, we will have to just discount it; it’s the medical equivalent of being told that no, this Rolex watch someone wants to sell you for £20 is definitely not a fake, honest guvnor. It’s worth noting too that the comparator they used, simple linctus, is no better than placebo itself. 

Searches of the medical literature found a great deal of nothing, either. I searched for both Unicough® and Histalix® too, as well as the combination of ingredients, to no avail. Yes, it might help you get to sleep at night thanks to the antihistamine side effects, but I wish they would be honest about that in their marketing. You’ll sleep because you’ve been knocked out by drugs, not because its made any difference to your cough. 

Is it safe? 

On the whole, there probably aren't any major safety concerns here. Drowsiness is going to be the main problem with it, and as with all things that can cause drowsiness there is a possibility of dependence. Other effects could be dry mouth and urinary retention. It can interact with a few different medicines. Of course there is always the potential issue of self-treatment of a persistent cough, and masking of symptoms that could suggest a more malignant cause. 

The practicalities

Any product which causes drowsiness is going to be severely limited in its usefulness through the day. If you drive, work, or even just don’t want to be asleep all day, then you’re going to have to avoid this product, or you might even end up having to buy two lots of pointless medicines; one for day and this one for night. Additionally, antihistamine-induced sleep can often leave you feeling still quite drowsy the next morning, and some people can even feel quite hungover. It’s not going to be ideal if you have to be up early for work, or if you drive early in the morning.

The unique selling point of this product is the taste. It's cocoa-based, which I'm sure is pleasant, but it aint going to make a blind bit of difference to your cough. I even wonder whether a pleasant taste might have a detrimental effect on any placebo effect: if it doesn't taste like medicine, then you might get less of a response. 

Is the cost reasonable?

Whoah, £8.85 for 150 mL? Give over! There is absolutely, categorically no way that this product is worth that amount. 

TL:DR! Is it worth a punt? 

Nope. There’s no evidence it works, and the combination of ingredients in it makes no sense. Save your money and invest in some cheap simple linctus or glycerine, honey and lemon to soothe your throat instead. The best cure for a post-infective cough is time. Look after yourself, rest, drink plenty, and eat well. If your cough doesn’t go away after about three weeks, get yourself checked over. I know that coughs can be awful, annoying, embarrassing, and exhausting, but –and I’m sorry to have to tell you this- nothing will get rid of it instantaneously, or even any quicker than using nothing at all, so you might as well save your pennies. 

A Mahoosive Thank You

Last month, in a drunken moment of possible madness, I decided to set up a Patreon page. I did so hoping that even setting the page up might work as a driver to overcome the writer's block that has been cursing me for too long. I set the target amount as a dollar, and limited paid posts to these OTC product reviews, because I think there is a real gap in the market for them, and ultimately they will hopefully help people save money. 

To my utter astonishment, four kindly patrons stepped up and made pledges. I doff my cap to you and can't thank you enough. 

Shaun Sellars
Alex Brown
Jack Wright
Bevin Flynn

If you enjoy these sorts of posts, find them useful, and have more money than sense, then I'll just leave this here

Literature Search terms:

Embase: unicough (freetext, ti.ab) Histalix (freetext, ti.ab) *Diphenhydramine AND *Menthol AND *Ammonium chloride

References: http://www.infirst.co.uk/were-working-on/unicough https://www.medicines.org.uk/emc/medicine/31365 https://www.medicines.org.uk/emc/medicine/11171 http://www.mhra.gov.uk/home/groups/par/documents/websiteresources/con553668.pdf http://www.mhra.gov.uk/home/groups/spcpil/documents/spcpil/con1445576593772.pdf

Can you really get all medicines for children free in a pharmacy?

The following message has been widely shared on Facebook over the last few days.

It could have been an accidentally wonderful way of spreading the word about minor ailments services- something that pharmacies, CCGs, and PCTs have been struggling to do for years. Sadly, however, it hasn’t quite had that effect- it’s very inaccurate and is likely to lead to a lot of disappointment for patients and pharmacists alike. As with all things, if something sounds too good to be true, then in all likelihood it is.  Hopefully, this post might clear up some of the confusion caused by the original status.

The purpose of a minor ailments service (MAS)

Far from being a free way to stock your medicines cabinet, MAS’s are in place to reduce unnecessary GP appointments. They’re a convenient way to access medicines and advice for those who would otherwise see their GP in order to get free items on prescription as they can’t afford to buy medicines. As such, it’s not about the patient asking for specific medicines. Services are designed so that the pharmacist can sit down with the patient and give them advice about a minor condition. Yes, they can provide some medicines as part of that consultation, but only where the pharmacist deems them necessary in response to symptoms.  Many of the conditions covered are self-limiting, and will go away of their own accord without you having to use any medicine at all.

Local Schemes for Local People

Unless you’re in Scotland or Wales, MASs are commissioned according to local needs, by CCGs. Not all areas with have them, and of those that do, there may be wide differences in how they are run. For example, to access some schemes, you may have to be referred by your GP. Others, you might be able to just pop into your local pharmacy and ask for the service. Some areas may stipulate that only people from that town or county can use the service, whilst others allow it for out-of-townies. There are currently 70 individually commissioned MAS across England, some of which cover multiple areas. They might all have different names and different scopes. 

 

The logo of the Think Pharmacy First scheme,  available in some areas of North East England.

The logo of the Think Pharmacy First scheme,  available in some areas of North East England.

"All" medicines?

Nope. It’s not even available for all minor ailments. There will be a selected list of things that the pharmacist can deal with under the scheme, and again these will change depending on local needs. It might be things like headlice, hay fever, sprains and strains, conjunctivitis etc. The average number of indications covered by each service is 16. 

Even if an ailment is covered by the service, not all medicines will be available under the scheme. Only evidence-based, cost-effective medicines will be available. You won’t be able to get branded medicines (like the Calpol and Piriton bandied about in the original post) because this doesn’t represent a rational use of the service. I was lucky enough to be involved in the setting up of Think Pharmacy First, the minor ailments scheme that originally covered Newcastle and which now also covers quite a few other areas in the North East, and I remember the discussions we had about what we were going to include on the formulary. We checked robust sources for primary care management and made sure to remove anything that we considered irrational or which had no evidence to back it up. The post mentions plasters, but I very much doubt that these will be widely available- it’s a minor ailments scheme, not a first aid service.

Is it just Boots, or is it all pharmacies?

Even within an area with an MAS, not all pharmacies will offer the scheme. The original post seems to suggest that this is something only Boots offer, but in actual fact any pharmacy can participate. 34 MASs require the pharmacist themselves to provide the service. in 29, the pharmacist or an appropriately trained member of staff can undertake it. Some areas will require pharmacies, or individual pharmacists, to be accredited before they can start offering the scheme. So, if you do feel that you could benefit from using an MAS, its best to phone your local pharmacy first to check if they do deliver it.

Anyone can use the scheme, right?

MASs are there primarily to help those with a low income, who struggle to pay for medicines. Depending on the local scheme, others may be entitled to use it too, for example those over 60 or all children, but this is likely to vary. To use my local as an example again, the Think Pharmacy First scheme is available only to adults who are entitled to free prescriptions on the grounds of low income and their children along with all people aged 60 or over.

They very much ARE allowed to advertise it.

I’ve no idea where this nonsense about not advertising comes from. We had four foot, bright yellow and green window stickers made up for the launch of the Think Pharmacy First scheme, and I remember spending about an hour trying to remove air bubbles from it once I put it up. I did local press stints to advertise the scheme widely, with photoshoots and everything. The scheme was advertised in local council newsletters, in schools, and goodness only knows where else. For years, even after I left community pharmacy, I would get annual phone calls from people saying “Hey, I saw you in the paper the other day!” CCG websites and pharmacy websites have plenty of information about the schemes. They aren’t a dirty secret that we pharmacists keep to ourselves because we’re mean. If anything, they help us pharmacists demonstrate our worth, and we have long been campaigning for a good quality, robust national scheme to reduce all these inequalities.

There’s one obvious reason why these schemes probably aren’t that well known, and that’s budget. It’s nothing to do with not being able to advertise, it just comes down to cold hard cash. Some of these schemes are woefully underfunded, and as such they sadly get left to limp along.

It might take a while

We pharmacists tend to be very busy, and we usually have about 30 different things to do that all need doing immediately. An MAS consultation is a lot more in depth than a usual Over the Counter sale- it usually takes 10-15 minutes, in the consultation room, discussing the problem and any possible treatment. The paperwork then takes the pharmacist a good deal of extra time. Therefore, if you do use an MAS service, please do so patiently. If you need a medicine quicker and you aren’t willing to wait for a consultation, or you don’t want to answer any questions, it is probably best to buy a medicine over the counter instead.

Misuse

We’re all constantly bombarded with Daily Mail headlines about prescription fraud and the likes. Now, I don’t buy into any of that overblown rhetoric, but I, and probably any other community pharmacist you will speak to, can reel off many an occasion where people have taken the mickey out of a minor ailments service. Some people seem to go completely wild when they realise they can get something free. I’ve had numerous people ask me to hand them the formulary list so that they can mark all the products they’ve decided they want. Others used to demand to “self-prescribe” themselves whatever they fancied that day, which used to drive me mad and which used to lead to a stern talking to from myself. It’s just not in the spirit of the thing- its about accessing the pharmacist’s expertise and skill in treating minor ailments, rather than a shopping list. I fear the wording of the FB post in question may be leading people to think otherwise.

Overall

It’s a really handy, worthwhile scheme, and more people should definitely know about it and access it when need be. But they also need to know how variable it is and its limitations.

If you have any other questions about your local scheme, try having a lookie at your local CCG’s website. If in doubt, ring your local pharmacist and they should be able to tell you what’s available. 

 

 

reference: PSNC briefing 006/15: Analysis of Minor Ailments Services in England, Feb 2015


Is Herpatch Mouth Ulcer Gel worth a shot?

Mouth ulcers can be very unpleasant little blighters. They’re often really painful and can be rather distracting, especially when eating. And, if you ask me, anything that makes eating difficult makes life more miserable. They tend to be self-limiting, but for those most painful moments, there aren’t that many treatment options available over the counter. There’s a new product available in Boots currently called Herpatch mouth ulcer gel, so I thought I’d cast an eye over it to see whether it’s worth spending your hard earned cash on.

What's in a name? Mainly confusion in this case

Its actually been quite hard to find manufacturer’s information on this product due to some brand name issues. It would seem that the Herpatch range is being marketed elsewhere in Europe as two products for cold sores, a preventer and a treatment “serum”. The same manufacturers also market a product called Aphtgel, which is for mouth ulcers.

It seems that in the UK, however, the picture is less clear. From what I’ve managed to cobble together, only two products are being marketed, and they’re both doing so under the Herpatch brand. There is a mouth ulcer gel, which appears to be the same as Aphtgel, as well as the cold sore preventer product. The serum doesn’t appear to be available over here yet. The brand name makes little sense for the mouth ulcer product- there’s no patches, it has nothing to do with herpes, and it ends up sounding gender specific, which is nonsense.

What is it?

Aphtgel Remesense is based on Sylphar’s film forming technology. Upon application, it will form a transparent, thin muco-adhesive film on the mouth ulcer. This film will protect and isolate the injured mouth area affected by the ulcer.
— http://www.sylphar.com/sites/default/files/productfiles/111085Aphtgel_Psheet_UK00.pdf

This actually seems like a very reasonable mode of action. Forming a cover over the ulcer may in theory reduce pain, as well as reducing the likelihood that a secondary bacterial infection can creep in and make itself comfortable. It’s also useful to cover over an ulcer whilst it heals, but its obviously very difficult to stick a plaster in your gob, so a product like this certainly does have an important role, at least in theory. It’s not a new concept, but refreshingly it also doesn’t seem to be marketed as such. A product called Orabase used to do a similar sort of job, though its no longer available.

The main active ingredient is hyaluronic acid, which is naturally abundant in skin and cartilage, along with a few other bits and pieces like xanthan gum and cellulose. Basically, it contains a collection of gloopy, sticky stuff that probably won’t dissolve immediately when in contact with saliva. 

Medicine vs Medical Device?

As with many new Over the Counter products, Herpatch gel isn’t actually a medicine. Instead, it is classed as a medical device- a fact that is fairly difficult to deduce unless you do a fair bit of poking about on the manufacturer’s website. This means that the product doesn’t have to go through the rigorous testing that a medicine would, and it shouldn’t have any direct pharmacological effect- in this case it forms a physical barrier, but isn’t absorbed greatly and doesn’t produce any other effects on the body.

Does it work? 

Wonders will never cease, but it seems that there is actually some half-decent evidence that this product works. There are some actual, real life trials for gingivitis, periodontitis, and a similar product is already licensed for chemotherapy-induced mucositis. There’s not much evidence, admittedly, but the published stuff seems to suggest a decent effect size. It’s worth noting that most trials and evidence include people with recurrent or more severe ulcers, which might skew the results somewhat- most of the folk buying it over the counter will be using it for the occasional ulcer rather than for a more serious, recurrent problem.

Is it safe? 

Evidence seems to suggest that topical hyaluronic acid is well tolerated and there aren’t really any safety concerns that I can see think of with this product. One problem could be indirect harm caused by lengthy self-treatment of an ongoing problem. If an ulcer persists for more than 3 weeks, there’s a possibility that it could be something more suspicious.

The practicalities

Using the product might be a bit onerous. The aforementioned Orabase used to be a claggy, gritty paste which felt pretty unpleasant in your mouth. Being a gel, I’d imagine that Herpatch might feel a bit better, but there’s still a possibility that it might feel weird. You’re supposed to wait for 30 minutes before eating and drinking and avoid rubbing the area with your tongue. That seems… unlikely. We’ve all got that little masochistic streak in us that means you can’t quite leave it alone. I’m therefore not sure how long the barrier will stay in place for.

The cost.

This product isn’t cheap, coming in at £7 a pack. That seems pretty steep to me, especially for something that is self-limiting and will probably resolve in two or three days.

To summarise

Not a medicine as such, but a product that has some prior plausibility and some evidence suggesting it may work. Pretty pricey, but I guess if you’re going out for an important curry or something, you might decide it’s worthwhile. There aren’t that many other options available that aren’t hokum or placebos, so I’d actually-for once- be fairly happy to recommend this product to some patients over the counter.

 

Vicks, Feet, and a whole load of nonsense.

Vicks Vaporub. It's a staple of our medicine cabinet, and we all reach for it at the first sign of sniffles. You may have seen (usually on a poorly made image posted on Facebook) or heard (from a friend who heard from their friend who heard from their aunt's sister's niece's dogsitter) that actually we've all be using it all wrong. 

It's logical to use Vaporub on your chest, pillow, in a steam inhalation. It makes sense, because the vapours will end up in or around your nostrils, which is where it acts. But no- according to this particular internet fraud, it is only by smearing our tootsies with it that we will get the full benefit. 

I'm going to pick apart the standard Facebook post, piece by piece, so you can see my thought processes and logical reasons why I don't believe a word. Even if you do think this works, stick with me and see whether or not you agree with any of my individual points, or if you can come up with a more robust argument for using it on your feet. 

"Some of us have used Vicks Vaporub for years for everything from chapped lips to sore toes and many body parts in between."

 Wait, What? Who uses Vicks Vaporub for chapped lips? I've never heard of anyone do this, ever. Firstly, it would sting lots, and secondly it could be highly toxic, given its essential oil content, and aspiration risk when swallowed due to petroleum. I wouldn't put the stuff anywhere near my mouth.

But I’ve never heard of this. And don’t laugh, it works 100% of the time

100% of the time? Nothing in medicine works 100% of the time, so alarm bells are ringing loudly, unless this is the single most important medical discovery that's ever happened. If a medicine had been truly found to be 100% effective for anything, it would have been ground-breaking, world-changing news- probably not something that's just shared by your cousin on FB. 

 In the interests of research, I actually tried this when I had a troublesome post-infective cough. Needless to say, it did nothing to the frequency of my cough, so we've already disproved that number straight away. Whether or not it works, it most certainly does not work 100% of the time, and if that number isn't true, then why on earth should we believe anything else in this post?

...although the scientists who discovered it aren’t sure why.

 What scientists? What were their names? Where were they working? Where did they receive their funding from? Why aren't their details given? If they aren't sure, do they have any working theories? 

The lack of detail here is really telling. It really suggests that this is a whole load of hokum, especially given that a search (see below) shows no formal records of any "scientists" or research.

To stop night time coughing in a child (or adult as we found out personally), put Vicks Vaporub generously on the bottom of the feet at bedtime, then cover with socks.

Ahh, feet. Feet really are a favourite for peddlers of quackery. I'm not sure why, but from reflexology to detox foot patches, the alt med world seems to be obsessed with them. Any time feet are suggested as therapy for anything going on elsewhere in the body, loud alarm bells start going off. 

The ironic thing is that feet are probably the worst place to apply any medicine. The skin on your feet is miles thicker that elsewhere. Absorption through the skin tends to be low and erratic at the best of times, but if you apply something onto your feet, the chances of absorbing anything useful from it are very low indeed. 

Additionally, your feet, when lying down, are very far away from your airways. The post requests that you put socks on over it. Therefore there is certainly no way that vapour could get to your airways in any clinically relevant amounts.

Even persistent, heavy, deep coughing will stop in about 5 minutes and stay stopped for many, many hours of relief. 

Coughing fits are just that- fits. They're acute- you cough a lot for a little while, then stop, then it all starts again. A more chronic cough will still follow this pattern or stopping and starting. So yes, persistent, heavy deep coughing will usually stop- albeit temporarily- in probably much less than 5 minutes. If you're coughing for longer than that, it's likely you're going to be having severe problems breathing, and you'll need urgent medical care- you wouldn't really be thinking about smearing goo on your feet. You may find that you put Vicks on your feet and your coughing stops shortly after, but the likelihood is that the coughing would have stopped even if you hadn't. This is called regression to the mean, and its one reason why we can't rely on anecdotes for deciding whether a medicine works. We need to scale up and look at robust clinical trials instead.

Works 100% of the time and is more effective in children than even very strong prescription cough medicines. 

That 100% claim raises its improbable head again. To claim that something is more effective than other medicines would suggest the existence of comparative trials, which-spoiler alert- don't actually exist. This is rather a strawman anyway, as there are very few prescription cough medicines on the whole. Even conventional cough medicines don't really work to any great degree, and are based on very shakey evidence. It would be a very, very rare occasion indeed that a doctor would prescribe a cough medicine on prescription for a child. 

 In addition it is extremely soothing and comforting and they will sleep soundly.

I can see how that tingly, cold sort of feeling you get from menthol could be pleasant, though I don't think I'd go as far as to call it soothing. To be honest, you'd have to have perfectly soft skin on your feet to feel anything at all- when I tried it I didn't even feel a tiny tingle, especially since it was covered over with socks. 

Just happened to tune in A.M. Radio and picked up this guy talking about why cough medicines in kids often do more harm than good, due to the chemical makeup of these strong drugs so, I listened.

What guy, and on which radio station? What qualifications does this guy have for making medical recommendations?  Who is even meant to be narrating this post? The only medicines now available for coughs in children in the UK are glycerol and simple linctus paediatric. Both of these essentially work on the basis of being sugary, slightly gloopy water. There's no "strong drugs" here, just some soothing "demulcents" that taste nice and are supposed to leave a soothing lining on the throat, making a cough feel less raw. They're mainly placebos. 

It was a surprise finding and found to be more effective than prescribed medicines for children at bedtime, in addition to have a soothing and calming effect on sick children who then went on to sleep soundly.

 Where is this finding published? What sort of a study was it and how was it designed? How many participants were there? Was there a control group, or a comparator group and if so, what was the comparator? As it happens, all of this is irrelevant really, as no studies exist. These statements come from the head of an internet fraudster, rather than actually being grounded in reality. 

My wife tried it on herself when she had a very deep constant and persistent cough a few weeks ago and it worked 100%! She said that it felt like a warm blanket had enveloped her, coughing stopped in a few minutes and believe me, this was a deep, (incredibly annoying!) every few seconds uncontrollable cough, and she slept cough-free for hours every night that she used it.

 We don't even know who is narrating this thing in the first place, let alone their wife. As I've explained above, this is an anecdote, and we can't derive anything from it. A person, who may or may not be mythical, had a cough, and it went away after they did a thing. It might have gone away anyway, we just can't tell. 

A warm blanket?  far from it. It actually just feels like you have some oily gunk on your feet. At best it might feel a little cold, but for most of us, it'll feel no different at all thanks to our thick skin. 

If you have grandchildren, pass this on. If you end up sick, try it yourself and you will be absolutely amazed at how it works!

Well that's just bizarre. Presumably you don't need to bother if you're simply a parent, only if you're a grandparent? What a load of nonsense. I wasn't left amazed, I was just left feeling a little silly. And I had minty-smelling feet.

So of course I have done a search for the evidence and claims included in the post and have found a grand total of Nothing At All. I will say this though: If I was the manufacturer of Vicks, and someone had done some studies which found my product to be 100% effective, I would sing it loudly from every rooftop I could find. I would be the manufacturer of The Number One Most Effective Medical Product In The World Ever, and I would make sure that I made my millions on the back of that fact, as well as collecting my Nobel prize for Medicine and probably world peace as well. What I probably wouldn't do is ignore the claims, and continue on selling my product and advising that its used in a way which has a less than 100% chance of it working. 

Direct harms from following this advice could include dermatitis and skin reactions. Indirect harms? Well, you've slathered some slippery, oily unguent onto the bottom of your feet. When you take your socks off, you may be slip-sliding all over the place.

The moral of the story is: Very rarely should you believe anything posted on Facebook. Unless its me, posting a link to my blog, of course ;)

Hxxx
 

"I do my own research"

Something that I see a lot in on-line debates about alternative medicine is phrases like “I did my own research” or “people should be allowed to do their own research and make their own decisions”

However, I don’t think that the vast majority of people are able to do their own research. Now, that’s probably a pretty unpopular opinion. It’s patronising, paternalistic, and it flies in the face of patient choice. Who am I to question the intelligence and abilities of other people? Why do I think I'm so clever compared to anyone else out there? Allow me to explain myself.

I've been a pharmacist for a very long time now. From uni, through pre-reg, to my own revision at work, I've been taught critical appraisal skills. Yet to this day, it’s something that I actually find really hard work. It’s a skill that requires continual honing, and every time I use it I feel like I am fighting with my brain. 

Even in the last two weeks, I've been revisiting my critical appraisal skills to make sure they are up to date. I've done some in-house work, three on-line courses, and a one to one training session. Yet I still find myself sat here at my desk for several hours, if not days, looking over the same study with a furrowed brow, desperately trying to make the numbers and statistics tell me their story.  If I find it so hard, then how on earth is someone without any medical background or critical appraisal training supposed to do any of it? 

There’s hazard ratios, odds ratios, confidence intervals, numbers needed to treat, event rates, absolute risks and other confuddling terms to deal with. I naturally struggle with numbers at the best of times; like most people, I much prefer narratives. That means that I have to constantly argue with myself to keep looking at the results page, rather than just flicking to the discussion. Because if I did that, I'd be relying on what the authors, with all of their possible biases and agendas, say their numbers say. Then, when I eventually manage to squeeze the swimming mass of figures into some sort of order in my head, I find out that these numbers aren't the full story, and I need to dig even deeper into other analyses of the same figures to find out what’s really going on.* 

A quick and very simplistic visualisation of all the layers of interpretation that might lead to information found on your common or garden health information website. That's a whole lot of bias.

A quick and very simplistic visualisation of all the layers of interpretation that might lead to information found on your common or garden health information website. That's a whole lot of bias.

It’s not a pleasant task by any stretch of the imagination. It really does feel like a mental marathon. I often question whether I am even up to the task- I can end up feeling stupid, and confused. But in order to really figure out whether or not a drug works I need to strip away all the levels of other peoples’ interpretation and start from scratch, with the cold, hard, impersonal numbers. That way I can build my own narrative, uninfluenced by what the study’s authors or sponsors want me to think, by what newspapers want me to believe, by what campaigners want me to know. The only way to know the truth is to start right at the bottom, in a dark dank pit of statistics, then to slowly start building yourself a ladder until you emerge, blinking, into the pleasant knowledge that you've worked out what on earth is going on.

This sort of raw data is not only extremely hard to deal with once it’s in front of you, but its also pretty difficult to come by. Finding it in the first place includes searching multiple medical databases- and these things aren't just a quick free text search like you would do on Google. Constructing a search can in itself take an hour or so, and then you have to trawl through the results to decide which are relevant to what you are specifically looking for. For me, most of the time, a question is structured like this:

What is the evidence that [drug/ group of drugs] works for [disease] in [patient group

 So, in my poorly drawn Venn diagram below, I need to find those holy grail papers that reside in the pink area:

I am truly terrible at MS paint, but you get the idea.

I am truly terrible at MS paint, but you get the idea.

What a typical EMBASE search looks like. This is for a new drug with few synonyms so its a fairly straightforward one. Others can have forty odd lines of searches.

What a typical EMBASE search looks like. This is for a new drug with few synonyms so its a fairly straightforward one. Others can have forty odd lines of searches.

Some of these papers might be pay-walled, so it’ll take me a week or so to get my hands on them. Some of them might initially look promising, but once you start to dig down into the figures you see that there might actually be problems with how they were undertaken or reported, or they might turn out to not quite fit in some way- perhaps the dose they used in the trial is different to the licensed dose in the UK, or the people enrolled into the trial don’t quite fit the population you want to know about, or perhaps the trial just didn't recruit enough people so any results from it are invalidated.

I've been doing this job for years, and I really do still struggle with all of this stuff. That’s not because I'm poor at my job, or because I'm stupid, or because I haven’t put the effort in to understand it. It’s because, when it comes down to it, this stuff is really bloody hard. It’s time-consuming, boring, and unintuitive.

People might well feel like they've done their own research. They might spend several hours digging about on the internet and feel empowered by any decisions that they make. But what they don’t realise is that what they've been researching isn't just the information- it’s the information with many, many layers of interpretation (and therefore bias) added. For a choice to be truly informed, you need to go right back to the start, to those terrifying tables of numbers and statistics. That’s simply not realistic for the majority of people.

Far better, then, to learn how to decide on whose interpretation you’re going to rely on. Will it be those that take the media reports at face value, or who have an agenda or a product to sell you? Or will you go with those that have years of training in how to pull apart complicated data and disseminate it in understandable ways?

Hxxx

*I thought I’d give you a quick real life example here, but I thought it best to asterisk it because I've probably bored you enough already. I'm currently looking at a drug called edoxaban and its use in reducing the risk of stroke in patients with atrial fibrillation. It’s the newest in a series of novel oral anticoagulant drug- they’re supposedly like warfarin, but less faffy. So I find and look at the main trial, and spend days unpicking the stats. It looks like both strengths used in the trial are no worse than warfarin, and the higher dose might even be a little better. Great, right?

Well, that’s not quite the end of the story. Because it turns out- and this isn't reported in the trial at all, but instead is contained in the FDA’s briefing document- that in people with fully working kidneys, edoxaban is actually worse than plain old warfarin. In people whose kidney’s aren't quite at full capacity though, it might work better than warfarin. So the overall trial results are kind of skewed, and if we didn't dig deeper, we might have been giving a whole group of people a more expensive drug with worse outcomes than warfarin. Even the FDA findings are borderline- some of what they describe doesn't reach statistical significance.

It's time to reclaim holism

Holistic. It's one of those words that's sure to set any skeptic’s teeth on edge. It's basically a codename for woo, bandied about by supporters and pushers of all sorts of magic, unicorn tears, and snake oil.

But should it be? Is it time for the medical profession to reclaim the label holistic as its own, and start shouting from the rooftops about how we are holistic practitioners? I think it is, and here’s why.

holistic

həʊˈlɪstɪk,hɒ-/

adjective

Philosophy

adjective: holistic

characterized by the belief that the parts of something are intimately interconnected and explicable only by reference to the whole.

Medicine

characterized by the treatment of the whole person, taking into account mental and social factors, rather than just the symptoms of a disease.

There is a general perception, gleefully pushed by proponents of alternative healthcare,  that somehow conventional healthcare and holism are at odds with each other. The image of an uncaring, white-coated medical professionals hell-bent on simply treating that one particular symptom, with no regard for the fact that a patient is attached to that symptom seems pervasive.

We don’t help ourselves, I suppose. With a limited time on GP appointments, for example, its easy to feel like you’re being rushed through the system. Some surgeries ask that you book one appointment per ailment. Our health care professionals tend to specialise in one particular type of illness, and you can start to get the impression that they only care about that particular bit of your life, despite the fact that it’s very often all interconnected. You can feel passed from pillar to post, one day an appointment with a diabetes nurse, the next day an appointment with someone else for your arthritis, and two days later an appointment with a mental health specialist. So I do understand that it can seem like, as healthcare professional, we only care about your symptoms. 

But, even at the most basic level, it is impossible and really quite dangerous  to practice healthcare without looking at the patient as a whole. We’re all trained to do it, and its become so second nature to us that we have all sort of forgotten to be proud of it. As a result, we've lost control of the word holistic and we’re allowing unscrupulous charlatans to creep in to the public’s consciousness on the back of it. Of course, there are improvements to be made, but I think on the whole we do bloody well in the NHS, given the knowledge, funding and time constraints we’re lumbered with.

Now, in my day job as a medicines information pharmacist, I actually have no direct contact with patients. But I still, fundamentally, operate as a holistic practitioner. Here’s a basic example of what I mean:

GP: “Ah, hi there, I’m just wondering if there are any interactions between Champix and CellCept?”

In this sort of seemingly simple interaction enquiry, it is imperative that I look at the patient as a whole, rather than simply as two drugs out there on their own. 

  • Champix®▼(varenicline) is a drug used to help patients stop smoking
  • CellCept® (mycophenolate mofetil) is an immunosuppressive drug used to stop organ rejection in transplant patients. 

If I were to look at interactions of these two drugs,  I wouldn't find any,So fine, we’re good to go, right? I mean, I’ve answered the question, done my job, and all is well, yes? 

No, not at all. If I’m going to safely answer this question, I need to look at the patient as a whole. I need to acknowledge that they’re not simply a smoking machine that needs to stop but they’re a living, breathing complicated human.  I need to look at the patient holistically, not just as some isolated drugs.

So our patient is in his mid-forties, using the mycophenolate mofetil because he has previously had a heart transplant. He has a history of depression (understandable really, given how ill he has been in the past), and takes a couple of other medicines too (no major interactions on checking). He wants to stop smoking, which is great, a really positive step for him, but he’s failed a few attempts already whilst using nicotine replacement therapies. He's found these failed attempts frustrating in the past,which has then triggered bouts of depression. His liver and kidneys are working just fine.

So, looking at the patient as a whole, I need to think about how using varenicline will impact him as a person. Some of my thoughts go thus:

  • Stopping smoking itself might affect some drugs, as there are chemicals in cigarette smoke which can affect the enzymes that metabolise some drugs. Is this the case with any of these drugs?

  • Quitting smoking itself can be a trigger for depression or suicidal ideation. 

  • There is also an association between varenicline and changes in behaviour and thinking, including depression and suicidal ideation. Given this patient’s history, this will need to be discussed with him and he’ll need to be monitored carefully.

  • Certain cardiovascular events were reported more frequently with varenicline than placebo in trials: we need to bear that in mind and monitor him for any adverse reactions, especially given his heart transplant

  • Not succeeding in giving up smoking has made him depressed in the past. Continuing to smoke increases his cardiovascular risks. A good old risk vs benefit decision needs to be made.

So I discuss all this with the Dr, and her response is:

“Ah that's great. Yep, I knew about the depression stuff but to be honest I hadn't really thought about the cardiovascular risks. I'll discuss it all with him, and I think we'll go ahead and prescribe it but I'll make sure to keep him closely monitored”

By looking at the patient holistically, his Dr and I have made sure that he will know to look out for any cardiac effects and to report it as soon as possible if he does experience any side effects. We can make sure that he's also prepared for the fact that his mood might change, and knows to report any of that too. He’s willing to take these risks for the sake of stopping smoking, so we’re helping him to take a really positive step in his life, aimed with all the information he needs to do it safely.

That’s just a small example of how I practice holistic medicine in my daily life. All over the NHS, at every level, other healthcare professionals are doing the same thing in their practice. We don’t declare ourselves to be holistic, because its such second nature that we don’t even realise we’re doing it. Maybe its time to start reminding people-and ourselves- that conventional medicine does, fundamentally, mean holistic medicine. 

Hxxx

 

A comparison between medical and homeopathic information sources

Recently, I’ve been delving back into the world of homeopathy, and all of the nonsense that it entails.

Part of my research and preparation has been consulting homeopathic texts- materia medica and repertories that are still in use by modern homeopaths.

One thing that I have been repeatedly struck by is the stark differences in the quality of these information sources compared to those used in modern medicine. Let’s take a look at some of those differences.

Up To Date?

Part of my day job’s role is resource management. This means that I need to make sure that all of the resources that we use and have access to are present and up to date. Whenever I use a book as part of my work, I document which edition I have used. If I use a website, I make sure to include when it was last updated. When we get a new book in the office, I find the old copy and cover it in stickers saying “Out of date- do not use”.

I don’t do these things because I am weird, or because I enjoy it. I do it to ensure that I give the most accurate, up to date information so that the patient gets the best care. What we know about medicines is constantly evolving- new medicines, new safety information, and new evidence is emerging daily. What might have been correct to the best of our knowledge last year may now have been subsumed by more recent experiments, and so the information sources I use change accordingly. So, for example, I can reach for a copy of the British National Formulary from 2005, and find information that recommends sibutramine as a weight loss aid in certain patients. However, if I look at the current version, I won’t see it in there, as it has since been withdrawn for safety reasons. If I were to have used the 2005 copy to advise a patient, I might have given them the wrong advice, in the context of what we know today.

How up to date is the information used by homeopaths? According to The Homeopathic Pharmacy (Kayne, S. 2nd Edition, published in 2006 by Elsevier Churchill Livingstone, page 192- I did warn you about the documentation): ‘The most well known are Boericke’s Materia Medica with repertory and Kent’s Repertory of the Homeopathic Materia Medica’. Sadly, the author of this book doesn’t see fit to bother telling us when these were published. Neither does the online version of it, although there is a bit of a hint in that the “Preface to the ninth edition” on there is signed off by William Boericke in 1927.

Nineteen Twenty Seven. Medicine and healthcare is a pretty fast-paced industry, with new innovations and information coming out at an overwhelming rate. So much has happened in medicine since 1927 that there is no way that anyone should accept health care advice based on something written from that time. I know I certainly wouldn’t be too happy if my GP gave me health advice from a dusty tome, or if I went to the dentist’s to find them using equipment from the 1920’s.

Maybe Kent’s Repertory will be more up to date? A Quick look at the website gives us no clues. This time, the preface contains no date at all. The closest thing that we have to a publishing date is the fact that the website is copyright 1998, and appears to have been formatted by a default-font loving child in the early nineties.

Political Correctness

Over the years, medical terminology has changed and evolved along with society and scientific discoveries, and rightly so. In some cases, words that used to be considered as perfectly legitimate scientific terminology (such as ‘Mongol’, or ‘Mongoloid Idiocy’, used to describe a person with Down syndrome) are now considered downright offensive. Even whole swathes of what is now considered normal society (such as gay people) were once declared as illnesses- and of course we know better by now, or at least we should do, and if you don’t- grow the hell up, will you. We generally don’t refer to people as “hysterical”, or “insane” anymore, as we know a lot more about such conditions, so are able to categorise people more helpfully and professionally.

As a result, we healthcare professionals are very aware of how crucial the use of clear, concise, professional communication is, including the information in our resources. No self-respecting modern medical text would ever dream of using out-dated, offensive terms, and if it did, there would be an outcry.

Let’s have a look at the sort of thing that Boericke’s Repertory wants to help us to treat. There are things like “Brain-Fag”, “Cretinism”, “Masturbatic dementia”, “Fears of syphilis”, “hysteria”, “insanity”, “weak memory from sexual abuse”, “Haughty”, “Stupid”, and many others. These were just taken from the “Mind” section, but there are many other examples in the other sections too. These terms are just too outdated and are wholly inappropriate to be used in today’s society.

Having looked through various other Materia Medica entries too, I’ve found statements that are sexist, bigoted, and occasionally racist. Nice eh? You don’t find that sort of thing in an up-to-date copy of Martindale: The Complete Drug Reference.

Clarity

Good, modern medical resources are all about clarity. They need to be- after all if someone gives the wrong medical advice because they have interpreted something incorrectly, patients could be at risk.

Jargon is sometimes necessary, but nowadays medical jargon tends to use standardized, accepted terminology which keeps the risks of misinterpretation to a minimum.

Homeopathic repertories and material medica, on the other hand, are full of vague, odd terms which are massively open to interpretation. What, pray tell, is a “voluptuous, tingling female genitalia” when it is at home? (and I wonder whether Ann Summers offers free delivery on such a thing?). What does “expectoration, taste, herbaceous” mean clinically? How is one supposed to diagnose “Taedium vitae”? When would you class a person as “Obscene, amative”, and when would they be considered as merely “gay, frolicsome, hilarious”?

In Conclusion

Our health is arguably the most important asset that we have. Why would we entrust it to sources which are terribly out of date, inaccurate, and in some cases, offensive?

Homeopaths like to paint themselves as a caring, human alternative to the more business-like, clinical world of real health-care professionals. But when this alternative categorises people as being “stupid”, or “cretinous”, and is happy to use criminally out of date resources which can risk peoples’ health, I wonder just how caring and ethical it really can be.  

I've said this before, and I'll say it again: why would you continue to use an abacus when calculators exist, and are proven to have a better record at getting the right answer?

 

Does XLS Medical Fat Binder weigh up?

Oh Omega Pharma. Once again you provide me with some juicy blog fodder.

XLS-Medical Fat Binder has been on my radar for some time, but I haven't really gotten round to writing a blog post on it or taking a proper look at the evidence. However, prompted by a bit of real-life work I've just been doing, I've been doing some digging.

So what is it? Well, it contains something called litramine, which appears to be a cactus extract. It supposedly binds onto dietary fat and stops it being absorbed. Sounds suspiciously similar in action to orlistat, a licensed medicine. However, XLS- Medical Fat Binder is instead marketed as a medical device.

Here's what the company have to say on the matter:


  
"What is a medical device and how does it differ from traditional medicine? 
  • A medical device is designed to work on or inside the body - either temporarily or permanently. Its main aim is to prevent, diagnose, monitor or treat diseases. 
  • The key difference compared to traditional medicines is that medical devices work mechanically as opposed to pharmacologically. So it works alongside or with your body rather than affecting the chemistry of the human cells."

 

I think what they've missed out here is this: "If we sell this product as a medical device we just need to fill in a form and send it to the MHRA rather than actually having to bother proving that it works so YAY LETS JUST DO THAT!!." It would seem pretty bizarre that orlistat, which is also not absorbed from the GI tract and which also prevents absorption of fat from the diet is regulated as a medicine whereas this product isn't. 

What of the evidence? Well, Omega Pharma once again provide us with a list of the most vague references ever seen, making it virtually impossible to find anything to back up the results they are shouting about. As references go, just writing: "In vivo, 2-armed, randomised, placebo-controlled, double-blind study, conducted in Germany, 2009" is, as someone so succinctly put it on Twitter, the equivalent of saying "This one time, at Band Camp...". These studies don't appear to be published in any peer-reviewed medical journals, so there is no way to verify the results from them. Oh dear.

Of course, not one to rely on the manufacturers alone, I performed a literature review to see if there was anything else out there. And there is: all of one study. And to be honest, the results are promising. Whilst there is a link to this bit of evidence on the XLS Medical website, its hidden away in the tiniest of tiny footnotes, which seems a bit odd really, given it seems to show that Litramine actually works. The trial appears well desgined (double-blind, randomized, placebo-controlled), and whilst not massive (n=123), it isn't as tiny as the usual sort of guff that can be purported as evidence. Patients who used Litramine lost an average of 3.8kg (+/- 1.8) compared to 1.4kg (+/- 2.6) in the placebo group (p<0.001), which actually seems rather encouraging. 

Hang on though, let's not all jump for joy and throw away the salad leaves just yet. Patients in the trial had a hypocaloric diet plan and exercise regimes. The trial only lasted for 12 weeks, so is pretty short- term. and of course its still quite small, and the results would need to be replicated in further, larger, well-designed trials before we could know for sure.

And here's the big problem with it. the study medication is described as:

"Litramine IQP G-002AS is a natural fiber complex derived from Opuntia ficus-indica, enriched with additional soluble fiber from Acacia spp.IQPG-002AS is standardized for its lipophilic activity and has been shown to reduce the dietary fat absorption through GI fat binding." 

- Grube B, Chong P, Lau K, and Orzechoski H. A Natural fiber complex reduces body weight in the overwieght and obese: A double blind, randomised placebo controlled study. Obesity 2013. 21: 58-64

 

The study participants were given 500mg tablets three times a day. However I can't see anywhere on the XLS-Medical website that actually tells me how much litramine is in the tablets- it could be 5mg or 500mg. . So whether or not we can apply these promising results to XLS-Medical, we simply can't say.  

 

And wahoosa are these things are expensive. £39.99 for a months supply? That's six and a half hour's work at minimum wage.

 

Hxxx

Common Community Pharmacy Annoyances

It's funny how variable working in a community pharmacy can be. Nowadays, I locum here and there, and I tend to really enjoy it. I usually do evening shifts, so you have an hour or two of bedlam, followed by several hours of blissful calm and quiet, where you get to sort out all the outstanding things, do lots of other bits and pieces like checking owings, controlled drug stock levels, and cleaning. I usually also end up having bizarrely deep and meaningful conversations about life, love and philosophy with whoever I am working with. Usually when I leave a pharmacy it is as clean and tidy as possible, I've sorted out what I can, and have left notes for anything that I haven't been able to deal with fully.

I say all this because I lately did one of *those* locum shifts. The ones where it is constantly busy, no prescription is straightforward, the fax machine isn't working, and you seem to have to deal with every problem under the sun. On this particular locum shift, I think my colleagues and I encountered every single type of category of impolite customer possible in a 4 hour shift.

So, because the only way that we can cope with such things is to laugh about them, and because I fancy a self-indulgent rant, here is my compilation of the things in pharmacy that annoy me and that happened in that locum shift.

The Mythical Taxi

Some people do get a taxi to their local supermarket. I have done it myself. But it would appear that taxi companies must have an amazingly lucrative trade in ferrying people to and from pharmacies if the frequency of use of the phrase "Can you do it quickly please, I've got a taxi waiting" is anything to go by. These are not, as far as I am aware, magic words that will somehow warp the time-space continuum so that I am able to dispense and check a twenty item prescription in a mere matter of seconds. Whether or not you actually have a taxi waiting will simply mean that your prescription gets put in the queue in the same place it would have done anyway, and you will wait the same amount of time as you would have done anyway. Needless to say, I suspect that many of these taxis don't actually exist, but merely a tactic used by some people to attempt to "hurry their prescriptions along".

The Dry Chesty Cough

"What sort of a cough is it?" "Well, its a dry, chesty cough."
No, no it isn't. It's either dry or its chesty, its not both. And either way, there is little point buying anything for it given that there is no evidence that any cough medicines work.

The Evil Eyes

Glaring at me continuously for the entire time that I am dispensing your prescription will not in any way speed up my work, and in fact may have the opposite effect as I am more likely to lumber around in a sloth-like manner just to annoy.

"I Need To Be Somewhere"

At 6:05pm, a woman handed in her prescription of 4 items. At 6:07pm, having spent all of two minutes repeatedly sighing and tapping her feet, she asked to speak to the pharmacist. Off I went, leaving a prescription half-dispensed. She demanded to know how long her prescription was going to be (the one I left to go and speak to her), because she needed to be somewhere. I gave her an estimation, told her I was doing it now, then went off to complete it. She then asked to speak to me a further three times to find out how long it was going to be, each time meaning it would take a little longer. "But I need to be somewhere at 6:15!!" she told me each time. I handed her the prescription at 6:12pm, thanking her for her patience. She then proceeded to rant for several minutes about how long the prescription had taken and how it meant she was going to be late and she had to be somewhere at 6:15. She eventually stopped complaining at exactly 6.15, and I returned to the dispensary, whereupon I noticed out of the corner of my eye that she had taken the time to hang around to complain about how long it had taken her to get her prescription to some of her friends who she just happened to bump into in the shop. Goodness only knows what time she actually left.

Invading Privacy

If you have ever picked up a prescription from a pharmacy, you will have probably been asked to confirm your address. This is so that we can make sure that you actually get the correct prescription. This is not because we are evil assassins or because we want to sit in a bush outside your house and spy on you- we really don't- and you're address is written on the prescription so if we wanted to we could anyway. On this locum shift, however, we were accused of invading someone's privacy for asking for this information. "I don't need to give you that information!" he declared. The counter assistant advised him that this is a routine question to ensure that we give out the correct prescription. But this wasn't good enough, and he wanted to speak to someone in charge. Off I went into the breach. I told him that he could come into the consultation room to give us his address so no one could overhear, but this was "an inconvenience", apparently.

By this time, he was shouting and other people in the queue were staring at him.

Again, I advised that we routinely confirm the address to ensure that the correct prescription is given out.

He decided to prove that the prescription was his instead by giving out his name, date of birth, and by telling me every item that was on the script. Loudly. One of which was sildenafil (Viagra).

Magicking Up Medicine

Me: "I'm sorry, we don't have that item in stock. There is a manufacturing problem on it, so we can't get it from our suppliers"
Patient: "But I need it" 
Me (in head): "Oh I see. Well if you can hold on a few minutes, I'll just nip round the back into our large pharmaceutical manufacturing factory, dig out the raw materials, and whip you up a batch right now then" 
Me (in real-life): "I understand, but I'm really sorry, we can't get any in at the moment."
Patient: "But I need it."
Me: "Where is the nearest wall please, so that I can bash my head against it repeatedly?"

The Expert Customer

I'm advising a patient about how to manage their child's teething problems. Another customer waiting in the queue decides to chip in with "Those Nelsons Teetha sachets are really good." (Nelsons Teetha sachets are homeopathic, therefore contain nothing of use and have no pharmacological effect). From then on, I (and my many years of training and experience) might as well not exist, as nothing I say can steer the patient away from believing that Nelsons Teetha are simply THE best thing since sliced bread, and in her eyes I'm obviously a terrible pharmacist for not recommending them immediately.

Impatient Patient Questioning

You ask the patient all the usual questions. They're all answered with a loud sigh, vacant eyes, and a disinterested "yes" or "no" at all the bits that they think are right. I could be asking anything, and I'd get the same response. So sometimes, I like to mix it up a bit and throw in a question they're not expecting. If its something like Nytol or a codeine containing medicine, I'll ask "Do you take it regularly?" to which the response is usually a bored yes. In which case, I advise them that I can't sell them any, then swiftly duck for cover when they inevitably throw things at me.

A variant You ask the patient if they are taking any other medications, to which they sigh and say "no". It's only when they're about to hand over their money that they a) ask what would happen if they were taking medicines, then confess, or b) whip out an inhaler and proceed to take a couple of puffs right in front of you after they have just told you that they don't have asthma or COPD.

Specifics

The patient can inexplicably only take one or two brands of generics for a product. You are, of course, expected to telepathically know this and dispense the right one, and woe betide anyone who doesn't. Now, I am entirely understanding of cases where a patient has specific requirements for one type of product- maybe an allergy to an excipient, say. But when there is not reason for it, and the patient is shouting at you for not giving them "the right medicine" despite them at no point telling you what "the right" one is, then I tend to feel a bit put out.

Mobile Misery

Now I am known for being attached to my mobile phone. However, one of the most annoying things when working in retail is having to deal with customers who refuse to hang up theirs whilst you are trying to have a conversation with them. Over a pharmacy counter, we often need to give detailed counselling, and of course we need to ask a lot of questions. I can't really do that if you are also listening to so-and-so discussing who was drunkest down the pub the other night. At this particular locum shift, I had to attempt to explain that there was an item owing on a prescription to a chap who was having just such a conversation. The icing on the cake was when he said to his phone-based friend "Hang on, I can't hear you, this stupid woman keeps talking about something and wont give me my prescription". Needless to say, despite me explaining the owing and handing him an owing slip, he returned a few minutes later demanding to know where the missing item was. This "stupid woman" then had to patiently and politely re-explain everything I had already told him.

How do I deal with situations like this? Politely, professionally, and with a smile on my face. I might have a bit of a rant and a laugh about it later in the back of the pharmacy, but outwardly in these situations I remain as calm as possible and attempt to be as helpful as I can. I've had many years of practice. The worst thing about this shift was that I was working with a new counter assistant and a newly qualified pharmacist, and I could see their morale slipping minute by minute. Their shoulders slumped, their smiles became more forced, and I found myself desperately trying to reassure them that this is just how some days go. Of course, we pharmacy types do make mistakes on occasion, and inconveniences do happen. I can understand that, when it comes to health, people can be scared and anxious, and that can come across as aggression. It is my firm belief, however, that a little bit of kindness and manners get you everywhere, and I am always much more likely to respond positively to calm and polite customers than those who default to outright rudeness, although I will do what I can to ensure that I help them all.

Hxxx

 

To self-monitor blood glucose, or not?

Today's news greets us with a story about "rationing" of diabetes glucose test strips. Diabetes UK, in a survey of about 2,200 people, found that 39% of people with diabetes have had their prescriptions refused or restricted. Meanwhile, politicians are wading in stating that restrictions are unacceptable. 

Now, this sounds bad. But when you start applying some skeptical principles to this area, it all becomes slightly less clear. Here are some brief points to consider about self monitoring of blood glucose (SMBG) to put today's news into context:
 

Test strips are expensive. 

Spending on test strips in the UK is pretty high, and has been rising year on year since 2008. In 2010/2011, a whopping £158.4 million was spent on testing in England alone. These things are expensive, and a lot of them are being prescribed. Historically, they have been over-prescribed, and this has been a priority area for the NHS to attempt to prescribe more rationally. (NB: rationally does not necessarily mean rationing, it just means using resources more effectively.)

The UK Guidelines are clear that SMBG has an established place in the management of diabetes controlled by insulin, whether this is type one or type two. Its also accepted in the guidelines that it is useful for patients with type 2 diabetes who are at risk of hypoglycaemia. Reports such as this one from the NHS Diabetes Working Group are also clear that rationing should not be undertaken in patients who are deriving benefit from SMBG. 
 

SMBG doesn't actually do anything to control diabetes.

 It isn't an intervention, it's a testing tool. The only way it can have a positive impact on diabetes treatment is if the results are used to guide treatment or behavioural choices. So its useful for insulin dosing, for example, as it is variable and needs to be responsive to what you have eaten that day. However, if you take a twice daily dose of metformin 500mg, say, SMBG isn't going to really help anything. I think this point isn't quite as clear as it should be to some patients, carers, and even healthcare professionals.  

It only gives you a result for one pinpoint in time. It doesn't tell you anything at all about more long term control. This limits how useful it is in assessing lifestyle changes, such as exercise and longer term changes in diet.


Studies have found that some patients are not using SMBG to guide treatment changes or choices

...so they are essentially testing for no gain at all. If this is the case, then it is clear that the SMBG can be discontinued with no impact on the patient's overall care- in fact its an all-round win situation, as the NHS saves some cash and the patient no longer has to bother doing a painful test.

Its not a no risk option. Apart from the obvious discomfort of testing, there is some (although limited) evidence that some patients can feel more depressed, anxious, and even obsessive if they are using SMBG.
 

The evidence that SMBG works is very limited, 

and is confounded by lots of different factors. You can find more detailed information on the evidence base in this Medicines Q&A. The technology of SMBG was welcomed with open arms by patients and healthcare professionals alike, and it was widely accepted before there was robust evidence that it worked to improve outcomes. In these sorts of situations, where people are used to using a technology or drug etc, it becomes quite difficult to start being rational about it, without people feeling that they are having something taken away from them. If you really want to have a good look at the evidence, you can have a look at this Health Technology Asessment by Clar et al. It's only 156 pages long (!) but it is a really good quality summary of the evidence. 
 

The evidence that SMBG is cost effective is even more limited.

We simply don't know if it represents good value for money for the NHS. Meanwhile, there are interventions which we do know are cost-effective. So doesn't it make sense to limit spending on the unknown, and to put funds into the interventions that we know work instead?

Its a real shame if these sorts of issues have been ignored in favour of rationing. Rationing test strips for patients who are insulin treated isn't rational prescribing, its just daft. But there is a serious issue of overuse and over dependence on SMBG, which blanket rationing makes more difficult to address. The UK guidance makes a lot of sense given the state of the evidence we have access to at the moment, and I would be very sorry to see it being misused in some patients, whilst others are fruitlessly undertaking a needless task at a potential cost to their quality of life and the NHS. 

Hxxx

Nelson's: Suggesting that your kids need mood stabilisers from two years old.

You know of Rescue Remedy, right? You probably had an aunt who would constantly swig a drop for her nerves, or might have even taken some before a driving test or exam.

Rescue Remedy has become a pretty well known brand- so well known, in fact, that most people don't bother finding out whats in it, or what principles its based on. You wouldn't want to know the recipe of Coca-Cola before you take a refreshing swig- you'd just assume that because its a well known brand, its probably going to work.

Rescue Remedy is, however, a whole load of woo nonsense. Sorry, but there's no other way of putting it. Some dude called Edward Bach decided- apropos of nothing- a good few years ago that some flowers, if left out in the sun and dissolved in alcohol,  will be able to balance physical and emotional distress. This is interesting, really, given that its taken the entire fields of neuroscience, psychiatry, and psychology many, many years to get to a point where there are still a vast amount of unknowns regarding mood disorders.

Science is getting there- slowly- when it comes to understanding things like depression. It's a vastly complicated subject. There's no perfect cure-all drug out there for treating such things- mainly because we don't yet understand it that well yet. So forgive me if I am skeptical that some random guy years ago has just randomly (without any basis in science) decided that, for example, mustard flower:

 "is the remedy for deep gloom and depression that descends for no apparent reason out of a clear blue sky. People in this state often list all the reasons they have to feel happy and contented, but still everything looks black and hopeless to them. The remedy helps to dispel the clouds so that we can once again appreciate the joy and peace in our lives."

Rescue Remedy is a blend of some of Dr Bach's made up flower remedies, diluted in brandy. You're supposed to reach for it in times of anxiety, as a soother. Funnily enough, brandy, being alcohol and all, it might make you feel a little bit better, but similarly to homeopathic remedies, they are dilutes such that very little or no levels of active ingredient are likely to remain. So even if Dr Bach were right about the flowers (despite evidence and science suggesting otherwise), there wouldnt be enough flower-stuff in a drop of it anyway to make a difference.

I can't quite get away from the fact that this is a cynical product which Dr Bach made up in an attempt to target wealthy women ("ooh! pretty flowers!") in the days where women were considered "hysterical" and many were labelled as having "problems with their nerves" based entirely on their sex.

Anyway, why am I on about Nelsons, and why am I on about children? Well, because the Bach Rescue Remedy brand- in all of its many, varying, and just-as-cynically money-grabbing-as-Big-Pharma- forms- is sold via Nelson's homeopathic brand. That's Nelson's who the FDA discovered weren't putting magic woo water in all of their magic woo water pills, but were happy enough to put particles of glass in there. That's Nelson's who are all "ooh, we care about you and your healthcare unlike those big meanie pharmaceutical companies who only care about money" all the time.

Well, I happened to stumble across this product of theirs today. Rescue Remedy Gummy Stars- aimed at children from 2 years and onwards. According to Nelsons:


"The first day back at school is a big day so parents should have a secret weapon against tiny tears on standby in the school run bag. RESCUE® Gummy stars - The latest addition to the RESCUE brand come in fun star shapes to help turn a frown upside down at the school gates and each Gummy Star contains four drops of RESCUE, the famous soothing combination of five flower essences."

What's wrong with that? The fact the Nelsons are attempting to medicalise a perfectly normal part of childhood purely for their profit, that's what. Being nervous on your first day of school is entirely normal, especially for a little one. What they need to do is to develop normal coping mechanisms to deal with their anxiety. What they don't need to feel is that their anxiety is abnormal and something which only a medicine can fix.

When encountering the world of complementary or alternative medicine, I often like to stop for a moment and replace the names of the companies with those of Big Pharma. It gives a good indication of whether or not there really is a difference in practices between the two camps, and whether people's reactions would be different

"The first day back at school is a big day so parents should have a secret weapon against tiny tears on standby in the school run bag. PROZAC® Gummy stars - The latest addition to the PROZAC brand come in fun star shapes to help turn a frown upside down at the school gates and each Gummy Star contains 10mg of PROZAC, the famous soothing antidepressant fluoxetine."

Icky, right?

Hxxx

Prescription exemptions and the bloody Mail on Sunday.

Today, I feel ranty. So ranty, in fact, that I can't even think of a clever title for this post.

Why? because the Mail on Sunday has riled me up with this story about how pharmacies are failing to check exemption statuses of patients. I have been weak, dear readers, and I have allowed the Mail to affect my emotions.

As a pharmacist, my job is to make sure that patients get the right medicines, can use them safely, and have all the information that they need. My ultimate goal is to make sure that my patients stay as healthy as they can for as long as they can, and to improve their quality of life.

My role is not as a fraud investigator, but as a healthcare professional. Its up to the patient to ensure that their exemption is correct and up to date, and its up to me to ask to see proof of exemption, and to train my staff to do likewise. So that's what I- and many, many other pharmacies- do, day in, day out.

What if a patient says they don't have any proof of exemption? I go right ahead and give them their prescription anyway. What am I supposed to do? Say no, sorry, you can't have this inhaler until you go home and get your exemption certificate and bring it back to me. And then what happens when the patient has an asthma attack on the way back to the pharmacy, and without their medication dies? Funnily enough, I suspect newspapers like the Mail on Sunday would just as gleefully report on my failure as a pharmacist to supply life- saving medicine to a patient, and how I was just being evil and money-grabbing instead of thinking about patient care. So we are literally damned if we do, and damned if we don't.

Of course, we can cross the box on the back of the prescription, which means that a small, random selection of prescriptions may be investigated. But this process is pretty murky, and the details of it are unclear to the majority of patients, pharmacists, and pharmacy staff. We get little to no feedback of any cases which are identified as fraud through this method, so it ends up seeming pretty pointless. You spend years and years of dutifully crossing the box, and you never see it making any difference. Perhaps if this process were clearer, and we could more clearly see some results from it, this would spur pharmacists on to continue with the box ticking exercise.

Ever tried to confront someone about the fact that they may be committing fraud? Ever tried to do so over a counter, when you're working on your own and have a queue of about twenty people behind the person you are accusing? A pharmacy is certainly not the correct place for such things to happen in- the personal security of the staff, the workload, and the potential for a patient to have to go without their medicines all mean that its practically something that we cannot do well, without a massive overhaul of staffing and how pharmacies are designed.

I suspect the reporters at the Mail on Sunday haven't ever had to stand on one side of a pharmacy counter whilst a patient asks which of their medicines is the most important because they can't afford to buy all of them. I have, and its heart breaking. Prescription medicines in the UK are £7.85 right now. We're currently in a time when Atos are merrily declaring- sometimes on very shaky grounds- that people who are crippled by a variety of medical and psychiatric problems are fit for work, and are stopping their benefits. There are people out there who cannot afford to pay £7.85 per prescription item, through no fault of their own, and these are the people who are likely to be taking a variety of different medicines. Do I therefore withhold their prescription, or tell them which is the most important drug for them to take and send them off on their way with a sub-therapeutic drug regime that is going to make them even less able to work and find means of paying for their medicines? I can't imagine the hurt and shame that a patient must have to go through to admit that they can't afford their medicines, but I know I don't want to have to put an already unwell patient through that.

I've had a friend worry how he was going to pay for his prescriptions because of problems with his benefits, problems that he had no control over and were to do with mistakes at Atos. Do you know what I told him? Go to your usual pharmacy, tick the box, and don't say anything. I know that's wrong, but given the options: he becomes very unwell vs a small risk he gets a fine of £100 at a later date when he would hopefully be able to pay it, I'm sorry dear readers, but I'm always going to opt for the former. That may be, as the Mail so charmingly puts it "scandalously careless" of me, but it doesn't feel like it. It feels like I am caring for my friend's health, and that's my job, and my personality. What would feel "scandalously careless" would be to force someone with no income through no fault of their own to choose between food or essential drugs. 

Forgive me if I would rather give patients their drugs and keep them as healthy as I can. Do forgive me if I put the quality of my patients' lives ahead of the fear of prescription fraud, which I can do very little about anyway.

This whole system of exemptions and payment is outdated and needs an overhaul. In the meantime, branding pharmacists as lazy debt collectors and desperate patients as robbing prescription cheats doesn't help. As a healthcare professional, my need to provide vital medicines to my patients transcends petty demonisation by a scaremongering newspaper. 

Here's an extract of the Mail on Sunday's report:

 

"Dr Clare Gerada, chairman of the Royal College of GPs, called for a ‘fundamental review of prescriptions’. But a spokesman for the Royal College of Pharmacists said it was ‘not their job to police the Government’s prescription exemption system’, adding: ‘Guidance is very clear that pharmacists must put the clinical needs of a patient first, and not deny someone access to lifesaving medicines because they haven’t got proof of exemption."

Interesting, really, given that the "Royal College of Pharmacists" doesn't actually exist. This is lazy, crappy reporting, if they don't even bother to get the Royal Pharmaceutical Society's name right. You can read how the RPS have responded to this article here. Its a perfectly reasonable response, and in my opinion reflects what actually happens in daily practice.

Hxxx

Self Selecting P-meds: searching for the evidence

The other week, the lovely folks at The Pharmacy Show Community (they are really lovely, my flattery of them is nothing whatsoever to do with the fact that they are linking to and publishing bits of my blog) held a tweet chat all about the self-selection of P meds, led by the mysterious and always entertaining @MrDispenser.

There are a few concerns that I- and it seems many other pharmacists share about the self-selection of P-meds. I've covered some of my concerns here, but the tweet chat threw up many others too. Other pharmacists have also shared their concerns, and you can find some of them in the links below:

Right now I want to look at the evidence that self-selection works. The theory is that allowing patients to choose their own medicines leads to greater adherence. As the patient feels they have more ownership over their healthcare decisions, they might use the drugs more effectively for a better outcome. But is there any cold, hard evidence that this is the case when it comes to over the counter medicines? 

As a skeptic, the words "Where's the evidence?" are often found escaping from my mouth. Sometimes the need for evidence is countered by the risk averse pharmacist side of me, where the theoretical likelihood of a risk outweighs the need for evidence. As with all things in healthcare, a balance needs to be taken into account: what are the risks vs what are the benefits?  In this case of self selection, I can see there being a real risk of fatalities. Any evidence of benefit to patients needs to be robust in order to outweigh the risks, in my opinion.

So I've made a start by looking at Embase and Medline. I've also had a look at NHS Evidence and have even googled. And I've been able to find very, very little on the subject. I found one Dutch paper about self-selection in the pharmacy, but that has no abstract.

I found this World Self-Medication Industry website which states:

"A study done in the United Kingdom showed that consumers welcome the opportunity to self-select medicines in that country's pharmacy class. Three out of four of the British consumers in the study felt that re-configured pharmacies with easier access to non-prescription medicines was a good idea, half because it would save their own time or that of their doctor, and the remainder because it offered greater choice."

But this doesn't appear to be referenced, so I can't find the study to see how reliable it is.

Have I missed anything? If you're aware of any evidence for the efficacy of self-selection of P-meds, please do let me know by dropping me an e-mail at healthydoseofskepticism@gmail.com. I would be particularly interested in any evidence that could be provided by the GPhC, and might drop them a line to see what they have to say on the matter. 

In contrast, I stumbled across a study from New Zealand, which concludes that, when purchasing a pharmacy medicine for the first time, in 62.2% of cases the sale was influence by pharmacy staff. This study has its limitations of course, but if true (and from my personal experience of many years of community pharmacy work it would appear about right), it would seem a shame to eliminate this from the medicines buying experience. 

There is also some evidence that patients who approach the pharmacy counter with a specific product in mind are given poorer advice than those who ask for a recommendation based on their symptoms- again something I have experienced both as a pharmacist and a customer. 

Of course patients can still ask for the expertise of pharmacy staff, but how many of them will know to ask, and how many will simply pick the nearest thing and hope for the best?

I'm going to hopefully write another post about my concerns about how the patient experience will be affected. If you have any thoughts on this, again do get in touch. If you're a customer in a pharmacy, I would love to know whether you think self-selection of Over-The-Counter medicines would be good for you. 

Antidepressants in pregnancy

This morning BBC News are running with this rather terrifying looking story about the dangers of antidepressants in pregnancy. This is an area that I deal with pretty commonly, so I thought you may be interested in my assessment of the situation. 

First thing to note: things can go wrong in even a normal, healthy pregnancy. There is always a risk of malformations or miscarriage, and unfortunately these things can happen for reasons that we dont understand. The risks are usually low, but are increased by things like increased age, obesity, illnesses etc.

One of those illnesses can be uncontrolled depression. "But how can feeling a bit sad harm an unborn baby?" I hear you ask. Well firstly, depression can be a very serious illness which should be taken seriously. It may even be terminal. Pregnancy is a time of massive changes, and as a consequence is a high risk time where someone's mental health can destabilise. If you have depression, you may not be looking after yourself properly: you might not be eating well, you might be avoiding exercise etc. In the worst, most tragic cases, suicide attempts might happen. We don't have enough data to put figures on how much of an increase in risk this all adds up to, but we do know that it can increase risks in a pregnancy if not sufficiently controlled.

Of course, this doesn't even take into account the more nebulous risks to both the child and mother- how will having a depressed mum impact psychologically on the child, how will the bond be affected, and what are the long term effects of this?  

So what of the SSRIs, the most commonly used type of antidepressants in pregnancy? Looking at the risk of cardiac malformations,, the BBC article claims that:

"Currently, prescription guidelines for doctors only warn specifically against taking the SSRI, paroxetine, in early pregnancy."

 It used to be the case that we were aware of the possibility of a cardiac malformation risk with paroxetine. Up until, oh, about 2010, when a large review was published whichsuggested that the increase in risk, if it exists, may be a class effect. The UK Teratology Information Service's Guidance was changed accordingly to be more practical, to remove a heirachy of one particular SSRI, and to make the drug of choice that which is the best for the individual patient (please note that UKTIS are a service for healthcare professionals only, and pateints should not ring them directly). The fact that NICE guidelines haven't yet been updated probably says more about NICE's workload and update schedule than any evil big pharma cover up. 

As an aside, you will notice that there are a lot of words in this post which suggest uncertainty. That is because there is a lot of uncertainty in teratology: because we cant do large robust trials on pregnant women because of ethical concerns, we have to scrape together what we can and make the best of it. There are few certainties in this area.

Strange then, that the BBC are quoting a Prof Pilling from NICE:

"He says the risk of any baby being born with a heart defect is around two in 100; but the evidence suggests if the mother took an SSRI in early pregnancy that risk increases to around four in 100."

I'd love to know where these figures came from. The current status of data on the risks of SSRIs is pregnancy is as follows:

  • There is lots of data, which has had various statistical analysis methods applied to it. 

  • Some of this data suggests no increase in risk

  • Some of it suggests a small increase in risk.

So, with some data saying there isn't an increase and with some saying there is, it is virtually impossible to say for certain if there is an increase. The only thing we can say for certain at this point is that we can't say anything for certain. But given that we have lots of data, and SSRIs are commonly taken in pregnancy, I think we can say that if there is a large increase in risk, we would have known about it by now. So any increase in risk, if it is there, will be low.

Of course the BBC are reporting the relative risk, which sounds more impressive: a doubled risk sounds much more sensational than a small absolute risk. But I'm not even sure where this figure has come from, given the conflicting state of the evidence at the moment. Needless to say, research is oretty much constantly ongoing. 

All of this is a very long winded way of saying: we dont know at the moment. But the fact that we don't know, in the face of how commonly used these drugs are in pregnancy, could be seen as reassuring.

As with all things in healthcare, this is a balance. A balance between the risks of uncontrolled depression and destabilising a mother's mental health during pregnancy, compared with the -as yet unknown but likely to be small- risks of SSRI antidepressants. Of course some women with minor depression might be taking antidepressants unnecessarily, but in cases where it is required, we need to look at the bigger picture. Just focusing on a drug's teratogenic potential is not enough: we need to consider the teratogenic potential of the illness itself, and the impact on everyone's lives that might happen if treatment is withheld. 


The bottom line is, if women are thinking of becoming pregnant or are already pregnant whilst taking an SSRI, and they are worried, they shouldn't stop it of their own accord, but should make an appointment with their GP to have a discussion about their concerns. 

Hxxx

UPDATE: I've been thinking about this 4 in 100 figure for cardiac malformations, and last night tried to find the reference source from it.

I've tweeted @bbcpanorama asking to know where this figure has come from, as have a few others. I've also tweeted @shelleyjofre, the journalist who has mad ethe programme, and have been met with a stony silence. This is really unfortunate, given that to be able to deal effectively with any enquiries from patients relating to this programme, I -and all the other health care professionals dealing with worried mums to be- need to be able to see and appraise the evidence for ourselves.

I have managed to find this document from the MHRA, which does mention a 4 in 100 figure. However, I sincerely hope that this isn't the source in question, given that:

  • The document refers to paroxetine alone, not the whole class of SSRIs

  • There is no date on the document, meaning we have no way of knowing how up to date these figures are.

  • the 4 in 100 figure cited refers to the risk of ALL malformations, not just cardiac ones.

  • the risk cited for cardiac malformations is 2 in 100. Half that which the BBC and Professor Pilling are quoting.

  • The background risk of all malformations cited is 3 in 100, and the background rate of cardiac malformations is 1 in 100. So yes, the relative risk is doubled, but the overal risk remains very low. 

As I say, I really do hope that this isn't the source, and that @bbpanorama or @shelleyjofre are able to provide me with the reference soon.  

Needless to say, I never heard back.

 

In which the title of pharmacist makes a real difference.

Here is a little story of something that made me proud to be a pharmacist. It works as a sort of counterpoint to all the talk of pharmacy as a quack profession, the sort of bad experiences I have recently had as a customer in a pharmacy, and the Which? Report. 

It happened now behind a pharmacy counter, or in my office, but instead at one of my last phototherapy sessions. Because they were three times a week for 10 weeks, you sort of start to get to know the other folk who go there, and of course I got chatting with a few. I had mentioned offhand to one of them during a bout of small talk that I was a pharmacist.

The next time I saw her, she was eager to talk to me "I've been thinking, and I have a question for you, although I hope you don't mind me asking." She had had very severe psoriasis for many years, and it was having a real, tangible impact on her life. It had been suggested to her that she could try methotrexate, but she had been resistant to this treatment strategy "Because I'm just so terrified of all the side effects"

Her question to me was simple: Would I, as a pharmacist myself, take methotrexate if I was in her position? What a great question. And how amazing that someone I don't know at all thinks enough about my opinion, simply because of my job description, to ask me it.  And so, shivering slightly in our hospital gowns in the clinical white of the dermatology changing rooms, we had a really good chat about the benefits and risks of all drug treatments, about how methotrexate works ("someone told me its like chemotherapy!"), about her fears of the medicine ("I've had a look on the internet and the side effects are terrifying") and her fears of the psoriasis ("I sometimes think other people think psoriasis is something that isn't serious enough to warrant a drug like methotrexate, when it's also used to treat cancer and things. But it really is ruining my life."), about the sort of monitoring she could expect. and some of the things to look out for if she did decide to take it. 

My bottom line answer was that yes, I would take it if my psoriasis was as severe as hers, and having the impacts on her life that she was experiencing. I explained that I too would be scared of the side effects, but not everyone gets them, and because you're quite closely monitored whilst you're on it, the most serious side effects should be pretty easily picked up and with some careful dosing, along with folic acid, could hopefully be minimized. 

"Eeee, well thank you. You've really put my mind at rest." she said, and off she padded to receive her few minutes on the NHS sunbed whilst I attempted to put my clothes on the right way round for the second time that day- no mean feat when you're me and you haven't yet had your first cup of tea or coffee yet. I don't know whether or not she was definitely going to start taking the methotrexate, but I get the feeling that I had given her a few things to consider that she hadn't thought about, and that I had provided some reassurance that the horror stories on the internet are not the full story. 

This just goes to show the sort of esteem we pharmacists have the privilege of in the eyes of some. Its a privilege we should honour by doing all we can to ensure our advice is good quality and evidence-based. Being a Good Pharmacist doesn't stop the moment we extract ourselves from behind the counter, or out of our office or wards. Our words are more trusted, more weighted than many of us probably realise, because to some (but not enough) people "Pharmacist" really does mean "expert in medicine", and we need to ensure that we don't take advantage of that to sell products that don't have a good evidence-base just for profit. Our integrity as medicines experts can and should shine through, even when you're standing in a cubicle failing to rock the hospital chic look, bleary eyed and in need of caffeine.

Hxxx

Dermalex: a superficial skin miracle?

I've written before about the guttate psoriasis which suddenly appeared at the start of this year and the impact it has had on my life.

I'm pleased to report that, after 9 weeks of phototherapy, it is much better. It has virtually gone on my top half, but the plaques on my legs are still stubbornly visible, although much better. The fact that it hasn't gone away entirely yet means its probably not going to clear up. Without wanting to sound over-dramatic, it actually feels like quite a bit to deal with- I've never had any long-term health conditions before, and although I've become slightly more confident, I'm still really conscious and nervous of having to expose any affected skin.

A while ago, my Mum rang me. "There's this new product out that says its for psoriasis, shall I buy you it so you can try it and see if it works?". To be honest, it was tempting, but when she told me the price £29.99 for just 150g, I declined. Skin diseases really can have an enormous impact on your life, and leave you desperate to try anything to find that one miracle that will get rid of it once and for all. Since then, I've seen it prominently displayed in quite a few pharmacies, hailed on shelf-edges as a 'breakthrough in psoriasis treatment'. So the big question is, is there any evidence that it works?

This poor chap obviously has some practical joker friends who like to write words of skin conditions in his sun tan lotion when he is sleeping in the sun.

This poor chap obviously has some practical joker friends who like to write words of skin conditions in his sun tan lotion when he is sleeping in the sun.

The product is Dermalex, and it is made by Omega Pharma. If their name sounds familiar to you, that may be because they also produce Prevalin, the overpriced, overcomplicated, under-evidenced Vaseline substitute for hayfever. This leaves me with a slight prickling of my skepticism, but lets keep an open mind for now.

How is it supposed to work? Well, the fact that the website itself titles this section "How its works?" (sic) begins to worry me slightly. I know this blog is liberally sprinkled with typos and spelling errors, but at least I have the courtesy of being shameful about it. In a professional website selling a quality medicinal product, I don't think spelling errors are acceptable, and there are a few dotted around the whole website. Nowhere on the website does it actually tell you what is in the product. Its said to: 

  • "Reduce Psoriasis symptoms by: Normalising skin cell production and Acceleration of the recovery of the skin barrier"
  • "Fortify the skin barrier through: The creation of a protective shield on the skin by means of Alumino silicates against outside to inside insults (bacterial superantigens & toxins) through the non-intact skin barrier."
  • "Providing a barrier to water loss"

This is helpfully illustrated by a diagram of the skin, which has labels that don't correspond to any numbers at all- either they're deliberately trying to make it look all science-like and confusing, to make the patient think "this is too complicated for me, so it must work", or its just sloppy oversight. Either way is bad enough.

Some labels on those numbers would be nice. Unless there really are little blue circles with random number in them floating about in the layers of our skin.

Some labels on those numbers would be nice. Unless there really are little blue circles with random number in them floating about in the layers of our skin.

We can pretty much entirely discount the claims for "fortifying the skin barrier". All this means is moisturising the skin, and a plain old (cheaper) emollient will do just as good a job at that. Once again, this seems to be Omega Pharma reinventing the Vaseline-greased wheel. As for the former claims, well, I need to see some evidence to corroborate them and decide if they are reasonable or not. So let's have a little lookie, shall we?

Having had a bit of a dig about on the website, I could see no clinical evidence. So of course I emailled the manufacturers, and got back a curt response after several days telling me to look at this page for references. So, here it is, the grand total of the evidence that Dermalex Psoriasis works:


"PASI based clinical efficacy study of Dermalex Psoriasis cream for the treatment of Psoriasis Vulgaris symptoms in a mono application therapy, Józsefváros Health Center, Budapest, Hungary; Open Label Clinical Study into the overall efficacy of Dermalex Psoriasis Cream, 2008, Dermatology and Psoriasis Clinics Laudau and Kandel, Germany"

For some reason, Omega Pharma seem to want to throw away the usual format of referencing- the one that is accepted and good enough for use in the rest of the medical profession. These references do not give me enough information to find the original studies, so what use are they? I've emailled them back to ask for standard reference formats, including where the studies are published, and have been greeted with a loud silence. I've tried googling the titles, and this brings up nothing, suggesting that they haven't even been published.

Why isn't the evidence published anywhere? How many patients were involved? What are the study designs? What were the results, and the statistical analysis of the results? Without answers to any of these questions, all I can do is discount this as evidence at the moment. 

Of course I didn't just leave my research there, in the hands of the manufacturers. I've also had a look myself at the medical literature. And could I find anything at all for whether Dermalex works for psoriasis? Not a sausage. 

You're supposed to apply this stuff  three times a day. 150 grams will not last you long at that rate. That makes this a whoppingly expensive product. The national minimum wage in the UK is £6.31, meaning one pack would be equivalent to just under 5 hours work. Isimply don't think that a couple of unpublished trials that may or may not say it works is a good enough reason to justify the expense. They're either being deliberately evasive about the evidence, or remarkably blase with people's hard earned cash.   

They say beauty is only skin deep. It would seem that the evidence that Dermalex is even more shallow than that. 

Hxxx

Update: I was contacted by the manufacturers of Dermalex, who promised to provide me with the references I asked for above. Here is the response I've gotten, with my response to the points they have raised below. . 

Thank you for your enquiry regarding Dermalex.
As you may be aware, the Dermalex range contains a number of different products to treat the following conditions; atopic eczema, contact eczema, psoriasis, rosacea, atopic eczema for babies and children. Please rest assured that all Omega Pharma products have been produced under strict guidelines and regulations.
range of proprietary studies have been conducted across the Dermalex product portfolio and as medical devices, these products have undergone statutory trials to ensure they meet the safety and efficacy standards required by regulatory bodies to demonstrate an impact on skin pathologies.
Medical devices are designed, engineered and formulated, in compliance with the UNI EN ISO 14971:2009 and 13485 guidelines. This means that each step of development and marketing has been strictly regulated to ensure the safety and efficacy of the products.  All testing is carried out by medical device status certified organizations, which include leading dermatology research centres. In addition, all studies were conducted by practicing clinicians. Please note that these studies include varying number of participants and study designs.
The research behind the Dermalex range is ongoing - we are working towards publishing data on the product range this year to ensure we are able to communicate the efficacy and safety of these products to healthcare professionals. We are working closely with the University of Amsterdam and are looking to publish the first set of results in theInternational Journal of Contact Eczema. We will also be presenting this data at the upcoming conference on ‘impaired skin barrier in the pathogenesis of atopic and contact dermatitis’ in Amsterdam in June.
To date, we have conducted six trials across the product portfolio involving nearly 200 patients. The products have also been used in in Belgium, France, The Netherlands, UK, Italy, Portugal, Austria, Switzerland, Ukraine, Czech Republic, Slovakia, Turkey and Australia, among nearly 3 million sufferers.
All Dermalex products are well tolerated and have been clinically proven to work. In summary, the trials showed:
  •  Dermalex Contact Eczema produces symptom improvement comparable to prescription drug treatments
  •  Dermalex Atopic Eczema (Babies & Children and Adult formulations) effectively relieves both objective and subjective symptoms of contact or atopic eczema
  •  Dermalex Psoriasis is effective against objective and subjective symptoms of psoriasis
  • Dermalex Rosacea & Couperose is effective against objective and subjective symptoms of rosacea
We hope that this information is useful and thank you for taking the time to contact us."

Firstly: I was aware that Dermalex is being sold as a medical device, but only because of those tell-tale words "Clinically proven!" and based on knowledge of Omega Pharma's other product, Prevalin. the fact it is classed as a medical device (and therefore not subject to the rigorous clinical testing of a real medicine) is even less prominent on the Dermalex website than it is on the Prevalin website.  

The rest of the e-mail appears to be a lengthy way of saying "We don't have any trials published yet, and no, you can't have any results in order to make up your own mind whether or not it works, you'll just have to take our word for it.". 

What's particularly interesting is that the International Journal of Contact Eczema doesn't appear to actually exist, as nothing at all is coming up for it on a Google search.

They say they have conducted six trials, which initially sounds reasonable. But this is across the product range, which includes at least four products and also children's versions. 200 people over six trials is not a lot- if shared equally that is only 33 patients per trial, and assuming they're placebo controlled, that would only mean that 16 patients per trial are actually exposed to the product- nowhere near enough to claim clinical significance of any results. Stating that the product has been used in other countries is meaningless, unless it is backed up by good, robust clinical trials. Its a logical fallacy- an appeal to popularity. Just being used doesn't mean it works- people might just try it once, or use it on the basis of advertising alone, but the product could still be ineffective.

So here's my main problem. How do Dermalex justify charging such an enormous price for a product before they have proven its efficacy. If good quality research had been undertaken prior to marketing, and robust results said that it worked, then that's one thing. But charging people £29.99 for "We think it might work, but we don't know yet because we're still doing research now, and the trials we've done so far that haven't been published yet in a non-existent journal are too small to decide" is, to my mind, entirely unjustified. 

Bad Pharmacy

This morning, I needed to go and buy some medicines.

So, on my way into work, I popped into the nearest pharmacy to my route into work: a branch of a very large chain of chemists. Here's what I bought:


This turned out to be a particularly disappointing example of what I wrote about in my last post- a very lackadaisical, dangerous attitude to OTC sales. And this comes merely a few weeks after publication of the latest Which? report into pharmacy, and about a week after pharmacy was referred to, by Ben Goldacre and Andy Lewis no less, as a "quack profession".

Now, I'm demonstrably not a parent, but you know when you tell off a child for doing something naughty? The usual response is to stop doing the naughty thing, and act extra-specially well-behaved for a period of time until the original naughty thing is forgotten about, then you start doing it again. On second thought, I know some adults that exactly the same thing applies to. The pharmacy profession as a whole should be in that well-behaved phase right now. We should be pulling together, and ensuring that everyone involved- including counter staff- pulls their socks up, shakes off bad habits, and works to the highest quality, to prove a point, but also just because this is how we should be operating all the time.

So, this morning I shuffled into this particular pharmacy (which I'm sure you have no idea which one it is, given I have so cleverly covered the brand in the picture) and asked for "Some Piriton and some co-codamol". The lady who served me appeared to be an experienced member of the pharmacy counter-staff. Here's how the conversation went:



Pharmacy Lady: "Do you want a pack of 30 or 60 Piriton?
Me: 30
Her: And you wanted paracetamol?
Me: No, co-codamol.
Her: Soluble?
Me: No.
Her: have you got a loyalty card? 
Me: No
Her: that'll be £5.34
Me: *pays and leaves* 

Here is how the conversation *should* have gone, as a bare minimum:

Pharmacy Lady: "Do you want a pack of 30 or 60 Piriton?"
Me: 30
Her: We've got a cheaper generic version, if you want that?"
Me: "lovely, yes please"
Her: "These can cause drowsiness, mind, so make sure you don't drive or anything when you've taken them"
Me: okay, I wont.
Her: And you said you wanted co-codamol?
Me: Yes.
Her: soluble or tablets?
Me: just tablets is fine
Her: Have you used these before? Do you take them regularly
Me: No, just when i have a headache now and again.
Her: Because of the codeine content, they should be used for no more than 3 days at a time. If you feel you still need to use them after that, see your doctor. They also contain paracetamol, so make sure you don't take any other paracetamol products with them, and no more than 8 tablets in a day.
Me: okay
Her: Do you take any other medication at all?
Me: no, just the contraceptive pill
Her: have you got a loyalty card? 
Me: No
Her: That'll be £5.34
Me: *pays and leaves* 

That extra counselling would have added on about 20 extra seconds, which might have seemed like a minor inconvenience to myself, but lets have a look at the theoretical consequences of not saying them:

Piriton: Causes drowsiness. I take one, get in my car, fall asleep at the wheel, and have an accident.
Co-codamol: I don't realise it has paracetamol in, and take 2 co-codamol tablets and 2 paracetamol tablets four times a day for a while. I get liver failure, and die a slow, painful, unpleasant death because a suitable liver isn't available for transplant.
Also: I take co-codamol regularly for a week. I then try to stop taking co-codamol, and start getting headaches, and generally feeling awful, so I restart taking it. I am now dependent on the codeine content of it. 

Yes, I am a pharmacist, so I already know the potential risks and consequences of taking these drugs. But I wasn't wearing an "I'm a pharmacist" T-shirt this morning, so its not like the member of staff knew this. Just because I asked for the products by name does not instantly mean that I know all about them and do not require full counselling on how to use them appropriately. And yes, I do also know that there is no good evidence that co-codamol is more effective than paracetamol alone, and I know I'm daft to be buying them, before anyone starts with the "aren't you supposed to be a skeptical pharmacist?"- sometimes even skeptical pharmacists like to utilize the placebo effect the promise of a tiny opioid hit provides.

Any of these theoretical problems can-and do- happen to people. We simply cannot go on providing such poor service over the counter and yet at the same time expecting the profession to be taken seriously. This is not safe selling of medicines- this is irresponsible and dangerous, and unacceptable. It makes me pretty angry because it not only gives a bad name to myself, and all the other great, conscientious pharmacists I know, but more importantly because it endangers patients on a minute-by-minute basis. 

MMR: The blame hot potato

I shouldn't be having to write this blog. We shouldn't still be having to see news stories about measles outbreaks in 2013. We have an effective, relatively safe vaccine which should have massively reduced the incidence of this potentially fatal or life-changing disease. But no, here we are in the midst of an outbreak which is starting to reach scary levels. The first fatality has been reported, in 25 year old man, although it hasn't yet been confirmed that measles is the reason for his death.

So why is it still one of the main topics of conversation at the moment? Well I'm pretty sure you're aware of the truly awful, entirely discredited research by the now-struck-off the register Andrew Wakefield. If anyone is unsure about whether or not its unfair to think of Wakefield as a nasty piece of work, remember that he was struck off because of 4 counts of dishonesty and 12- yes, 12-counts of the abuse of developmentally challenged children. Its been 15 years since the publication of his "elaborately fraudulent" paper which suggested a link between the MMR vaccine and autism- and yet still to this day a dark cloud of fear surrounds the big scary needle that evil big pharma and nasty doctors want to inject into innocent children.

A quick history of events goes thus: Wakefield's paper is published in The Lancet---> Wakefield's paper is picked up by the media---> all hell breaks loose---> Children aren't vaccinated---> Wakefield's paper is discredited---> media continues panic-mongering--->Children still aren't vaccinated--->Other research says MMR isnt associated with autism---> media continues panic mongering---> Children still aren't vaccinated---> Measles outbreak---> media continues panic mongering ---> Wakefield denies responsibility ---> media denies responsibility. And that pretty much brings us back up to date.

So, are the media right to deny any responsibility? Are they hell, and there's evidence to prove it. Anecdotally, I found myself a few months ago having a lengthy, in-depth conversation with a customer about whether or not his first child should be vaccinated. "I thought it was all sorted out and was rubbish" he said. "But then I read about it in theDaily Mail and they said it was proven." Luckily it was quiet, and I had a chance to spend some time with him, discussing the problems with the Daily Mail report, the original research, and the risks of not being vaccinated. "Oh", he said: "we hadn't thought of the fact that measles might be dangerous." He left hopefully feeling reassured, but concerned that his girlfriend still wouldn't believe him and wouldn't want to vaccinate their child. One of my best friends isn't vaccinated, because his Mum read the seemingly terrifying stories in the press and refused to allow him to have the vaccine. As a result he caught measles, and german measles, (and whooping cough too), bless him. This got me wondering about whether or not there is good, hard evidence that the media is to blame.

In short, the answer is yes, a bit. In a telephone survey of the parents of 177 children who hadn't had the MMR vaccine, fear of side effects was the most common reason given, and the most common source of information was the media. Another study found that parents were more influenced by the fear of harm from the vaccine than fear of harm from measles itself. In another, parents seem to have thought that the information on vaccines given to them by healthcare professionals was poor. A qualitative study again found that parents did not rate science or evidence as important factors when making a decision about whether or not to vaccinate their child.

All of this leaves us with an unfortunate dichotomy. We healthcare professionals usually deal in science and evidence- and so we should, as this provides us with the safest and most objective method of treating patients. But it seems like this is a currency that the general public not only don't often deal in, but on occasion actively reject.

Yes, vaccines have risks associated with them, but these risks are nowhere near as bad as the risks of the disease itself- its a simple case of harm reduction.  If your teenager is going to have a drink, would you rather that they had one glass of wine at the dinner table, in your house where they are safe, or a bottle of vodka on a street corner in an area surrounded by drug dealers and murderers? Wouldn't you rather give a small, highly controlled dose of a disease in a vaccine than take the risk of your child getting the whole, dirty, nasty disease itself? It does seem that the potential for harm of the disease itself can be forgotten in the decision making process.

So how do we go about changing this? I have no idea, to be honest. Its amazing to me, and quite mystifying, that one utterly rubbish- and rather cruel-piece of research can still- 15 years later- hold so much weight over the safety of children. Is it the misguided fear of a poorly understood condition in autism, or the terror of  big pharma, or an unquestioning faith in what the papers say? It seems to me that all we can do, as health care professionals, is continue to attempt as much as we can to give rational, evidence-based advice to our patients. We can improve our communication skills, but i'm not convinced that we will ever be able to truly "win" the good fight if the media continues on with such atrocious health and science reporting. 15 years on and some of the newspapers still insist on calling him "Dr" Andrew Wakefield, when he is very demonstrably no longer a doctor. They use scary photos of massive needles, and continue to give space to the idea that MMR can cause autism, when all of science and rationality disagrees. They reach for emotional language at any opportunity, pitting devastated parents against the picture of a cold, uncaring healthcare profession that they paint. We can try as much as we like to convince our patients on a one-to-one basis, but its like trying to take a drink from a firehose with such irresponsible reporting reaching millions of people every day.

The short answer here is that the blame for the current measles outbreaks lies in all sorts of places. ITs a comedy of errors, but not a very funny one. But, it seems clear to me that the media in particular needs to sit up and realise the harm that it is reaping on a daily basis.

Hxxx

Homeopathic Harms Vol 7: Professional Ethics

In February 2013, my friend @EBMScientist and I delivered a Newcastle Skeptics in the Pub talk entitled Homeopathy: Where's The Harm? As a follow up to this, we decided to write a series of blog posts expanding on a number of points we covered in the talk:

"Ethics is the science of morals, or moral philosophy. The principles, written or unwritten, that are accepted in any profession as the basis for proper behaviour are the ethics of the profession" -Dale and Appelbe's Pharmacy Law and Ethics

As you'll know by now, I'm a pharmacist. And as such, I have to be registered with the General Pharmaceutical Council (GPhC) to practice in the UK. I'm therefore governed by the GPhC, and in particular their code of conduct, ethics and performance, which has seven main points:

  1. Make patients your first concern

  2. Use your professional judgement in the interests of patients and the public

  3. Show respect for others

  4. Encourage patients and the public to participate in decisions about their care

  5. Develop your professional knowledge and competence

  6. Be honest and trustworthy

  7. Take responsibility for your working practices.

If I-or any of my colleagues- were to act against this code of ethics, we could be held to account by our regulator and reprimanded accordingly. Other healthcare professionals- Doctors, nurses etc- all have similar codes of conduct produced by their regulatory bodies. They all have one thing in common- that the patient is central to everything you do, and if a member steps outside this code of conduct, there is a clear and organized route through which complaints or concerns can be raised. This is as it should be: healthcare professionals have the lives of patients in their hands, and need to be held to account if anything goes wrong. As I've written before in this series, homeopaths don't have to register with a regulatory body and anyone can set themselves up as a homeopath with no training whatsoever. Whilst some 'professional' bodies exist in the UK, they have no regulatory powers so are unable to reprimand anyone if they receive a complaint.

Health care professionals who also practice homeopathy still have a duty to ensure that they abide by their regulatory body's code of ethics. In my opinion, however, it is very difficult to reconcile some of the clear guidance with homeopathic principles. Let's take a look at what I mean, using some selected points from the  the first two standards of the  GPhC's Code of Ethics July 2012 as a guide. (I'll cover the rest of the points in another post)

1. Make Patients Your First Concern
Under this heading, the GPhC states that we must "Make sure the services you provide are safe and of acceptable quality". Given the lack of high quality information that homeopathy works, we are unable to guarantee that such a service is of acceptable quality. You'll also know if you've read the rest of this series of blog posts that there is a lack of evidence regarding the harms- both direct and indirect- of homeopathy- so how could we guarantee that it is safe?

2. Use Your Professional Judgement In the Interests of Patients and The Public
There are a couple of relevant points here. firstly we are told that we need to make sure that professional judgement is not affected by personal or organizational interests or incentives. If you're going to charge for a homeopathic service on the side of your usual practice, then there is already a clear personal incentive to promote homeopathy.  We can minimize the possibility of such things affecting our professional judgement by making sure that we use evidence to guide treatment decisions wherever we can: evidence-based medicine is not perfect, but its the most objective method we have at the moment. And, as you'll know, there is no good evidence at all that homeopathy works. 

We are also advised to:

 "Be prepared to challenge the judgement of your colleagues and other professionals if you have reason to believe that their decisions could affect the safety or care of others"

I myself-and other pharmacists-have done this: I've spoken out about Tony Pinkus, for example, a pharmacist who endangers patients' lives by promoting unlicensed homeopathic vaccines or sugar pills to prevent malaria. In Nancy's latest blog post, she covered some of this, and I know Adam at Dianthus Med has also been discussing this point on twitter and his blog lately. Its clear-from our own professional guidance-that where patient safety is in danger, we do not protect our own- we need to report, speak out, and denounce those amongst our colleagues who let the profession down.

Homeopaths, on the other hand, seem to have no such obligation. We've been struggling to think of one single example of where homeopaths have spoken out against other homeopaths where patient safety has been endangered. In a conversation on twitter, for example, no homeopath would say that it was inappropriate for a homeopath to have said that a homeopathic remedy could have saved someone who died due to injuries sustained in a horrific gang-rape and disembowelment.  I recently asked some homeopaths on Twitter whether they would speak out against a colleague who put patients in danger. The answer I received from one was shocking:

"When its so easy 2 wink at 1's own sins, seems impossible 2 find judge orjury before whom 2arraign the 1st law breaker. KENT" (sic)- @22VenkateshN

Admittedly this particular homeopath that responded (he was the only one) has a reputation for obfuscation, but this reply seems to suggest that no, he wouldn't report, in case someone did similar to him. I tried to clarify : "so to clarify: you wouldn't speak out in case someone else did the same to you? A yes or no would suffice, thank you". The reply:

"some questions can't be replied with a simple 'yes or no'. for example_ 'are you still mad ?'"- @22VenkateshN


I'm not sure what he is trying to imply by asking about being mad, but we'll give him the benefit of the doubt and ignore any insinuations he might have been trying to make. What is staggering is the reluctance to admit that he would put patient care first and report a fellow homeopath in a situation. As a health care professional-and a good person- the code of ethics  becomes deeply ingrained in your being. Its second nature- and pretty obvious- that you would put the needs of a patient first. I persisted further,  trying to make it easy for him to agree that you would report a colleague: "It's very easy, if you work under clear ethical guidance. homeopaths do have that, right?: patient safety comes first: therefore yes, you would report and denounce a colleague who endangered it." Again, the reply astounds:

"Its not that easy, every one accusing everyone else would result. That's why I tweeted the appropriate observations of Kent"- @22VenkateshN

Wow. So it would seem- on the basis of this sort of conversation and the complete radio silence from any other homeopaths- that no, they wouldn't report or denounce a fellow homeopath because some sort of petty slanging match would ensue. Instead of a clear referral process to deal with complaints, accusations would be flying all over the shop- and one very, very important aspect gets forgotten: patient safety. 

I'd love to be proved wrong here. I'd love to think that medical homeopaths or pharmacists who also practice homeopathy would do otherwise, in accordance with their code of ethics. But I'm currently deafened by their silence. If I were one of the more professional, caring homeopaths who really did want to do the best for their patients, I would be utterly horrified and disgusted by some of the claims and actions of others, and I'd want to-nay I'd feel obliged to- speak out against them for the good of my own practice. I'd be embarrassed to be associated with them.

So here's your chance, homeopaths. Speak up against bad practice and drown out the previous deafening silence. Go right ahead: I'm listening intently. And while you're at it, please do take a few minutes out to respond to Adam's Challenge to the Society of Homeopaths too

 

Take all of it, every scrap

There are many things in life that are not black and white. There are many arguments in which I can see where all sides are coming from, and I can understand the root of why people would disagree with me. Yet there is one area which is consistently contentious, and yet my brain can genuinely not comprehend the other side of the debate.

I'm talking about organ donation.

The news yesterday was good: there has been a 50% increase in organ donation since 2008. And yet there is still a long, long way to go.

"Last year, 125 families overruled an individual's intention to donate."- BBC News

I really, really struggle to understand why anyone would object to organ donation. I just cannot get my head round it. And overturning an individual's decision to donate their organs seems particularly bizarre to me. I understand that in the acutely shocking and devastating situation of a death you might not be thinking clearly, but... I really just don't get it. 

Maybe its my atheism. Maybe its the fact that I see death as just that and no more. I don't see it as the start of a new journey into the afterlife, or the first step on my way to meeting my maker. You just die and that's that. So I suppose its easy for me to disassociate myself from the shell that's left. I don't feel creepy about the idea that there could be bits of me in other people: in fact I feel positively proud that I might be able to help in any way.

Religions offer us a legacy. They give us the promise of a new beginning after our death, and so go some way to assuage the fear of nothingness that might follow. But it's a legacy that, in my opinion, is pretty useless. It might be comforting to our loved ones, but in the long term view of things on this planet, that doesn't mean a great deal when there are people whose lives could be made better by a chunk of my flesh being implanted into them when its no longer any use to me.

Not that I think every objection to organ donation is on religious grounds, but I suspect it may be a fairly important part of it for some people. Atheists are often told that we're evil, that we have no morals, and that we are going to hell, but to me it seems that organ donation is clearly the more morally good choice when the alternative is wanting to keep a dead person intact for ceremonial reasons. 

Some people just think its icky: the idea that a bit of you will be in someone else. I had an ex-boyfriend who thought organ donation was wrong "because its just weird" (he's an ex for a number of very definite reasons, and this is quite a prominent one). Well, I think a lot of things are icky, but they still get done because they have to be done. I can think of more pleasant things than having a smear test, for example, but I do it because it is a necessary evil. And, one has to remember a key point: you're dead. Things don't seem so icky or weird to you any more because you no longer exist. 

Fig 1. Handy flow chart for deciding whether to sign&nbsp;up for organ donation

Fig 1. Handy flow chart for deciding whether to sign up for organ donation

urely there is no better legacy than giving parts of ourselves to allow other people to go on living healthier, longer lives.  

And so, your homework is to (if you haven't already), think about it, speak to your loved ones about it, and sign up to the Organ Donation Register 

Hxxx