pharmacy

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

Is SoreFix a sore loser?

Cold sores truly are the devil's work. The pesky little blighters make a habit of cropping up at the worst moment, crushing your self confidence within a mere matter of hours. 

Given that cancelling everything and holing yourself up in a darkened room until it has gone away tends not to be all that practical for most of us, It's no surprise that folk are desperate for something that really works, and fast. I've already written about several other new cold sore products on this here blog, neither of which are the miracle cures they're marketed as. 

Enter Sorefix, a product selling itself as a new all-round product to both treat and prevent cold sores. Interestingly, the manufacturers claim that it even works after the cold sore has come out, which if true would make it a really useful product. 

In case you are too late to prevent a cold sore, SoreFix relieves symptoms such as itching, burning and the blisters on or around the lips and it speeds up the healing process. So prevent feeling embarrassed and choose SoreFix!
— http://www.sorefix.com/sorefix-cold-sore/

Medicine vs Medical Device? 

Once again, this product isn't a medicine. It seems that nearly every new OTC product these days is actually a medical device masquerading as a medicine, and this is no exception. It might look like a medicine, it might be sold in pharmacies, and the manufacturers might even make claims that make it sound like a medicine, but nay, it is in fact a medical device. Essentially, this means that the need for good quality, robust evidence of efficacy before marketing is virtually non-existent. Le sigh.

The evidence   

Usually, the first step in finding evidence for how a product works is to find out what is actually in the product. This is proving quite difficult for Sorefix, as all I can find is some vague statements about "two zinc salts". hmph. Ah well, I shall have to make do with what I can. What i am particularly interested in is the claim that Sorefix can reduce healing times for a cold sore once it is already out. 

The manufacturers themselves don't bother with providing any cursory clinical trial data. This is unusual, and sort of  refreshing in a way; at least they aren't trying to palm off some nonsense animal studies as irrefutable evidence. It does, however, leave me with even less of a start than I normally would have for these sorts of posts. 

A quick Google search found nothing whatsoever, so I delved into the medical literature in a Medline and Embase search to see if there is any studies looking at the effects of zinc on cold sores. As I can't find which exact zinc salts are in the product, I just did a search for zinc. I found a grand total of three results, none of which were relevant. 

I did manage to find some information about the topical use of zinc in a trusted database. It seems that there is some, very limited data which suggests that some specific zinc-containing products, none of which are Sorefix, may reduce the duration of symptoms by a grand total of 1.5 days, and that's only if used within 24 hours of onset. There is also some evidence that zinc isn't effective for recurrent infections, which is probably going to be pretty much everyone. 

So it seems that I can find nothing at all to back up any of the manufacturers claims at this point. I've contacted them to see if they have any further information, and it'll be really interesting to see if I ever get anything back. 

Safety

Safety-wise, it's very difficult to comment on without knowing what exactly is actually in it. The manufacturers say you shouldn't use it if you are very sensitive to any of the ingredients, though of course they don't tell you what they are. Helpful much :S

The practicalities

The key with cold sore treatments is that you need to start using them before they appear, and you need to use them regularly. Despite what the manufacturers seem to be saying, it would appear that this product is no different. It doesn't contain an antiviral, but the limited amount of evidence looking at the effects of zinc for cold sores suggest that it needs to used every two hours in order to have an effect. That's a lot of applications per day, and I think it's unlikely that most people will be able to keep up with it for any reasonable amount of time. It's worth noting that, because cold sores can worsen quickly, this probably does include overnight too.

I really like the idea of having something to use for prevention, but its hard to remember to apply something at the best of times.  Its even harder if you haven't got a throbbing mass of evil reminding you of its presence constantly.  Given the lack of evidence for prevention, there is no specific guidance on how often you are supposed to use it in order to prevent a cold sore, but I suspect its going to have to be very regularly. 

The cost

It costs £7.47 for a jar or tub of this stuff. Although that's quite similar to other new products for cold sores, it's waaay more expensive than generic aciclovir or plain old vaseline. 

So, is it worth a shot? 

At this time, no. I can't see anything to suggest it's any better than existing treatments. I'll be interested to see if I get anything back from the manufacturers, but I can't see any reason why this product would work, and there is certainly no evidence to back up their claims.

Unfortunately, when it comes to cold sores, time is the best healer, especially once they are out and proud.  If it hurts, then use painkillers like paracetamol or ibuprofen. If its still at the tingling stage, go for topical aciclovir, but make sure you get a cheap generic version rather than Zoivirax: its exactly the same stuff. It's not going to make much difference once its already taken hold though, and at this point you're better off just using something like vaseline to keep it as supple as possible. 

Hxxx

 

Words are important

This is a guest blog written by the wonderful Cathryn Brown (@cathrynjbrown). Not only is Cathryn is an amazing community pharmacist, she's also involved in teaching pharmacy students at the University of Lancashire. She's smart, brave, honest, and a great friend. It's a pleasure to host her writings here. Hope you enjoy:

We were tidying up the office at home again the other day when I happened across an old Medicines, Ethics and Practice Guide. Flipping through the index, “Addicts” struck me as odd. There was no “see also: Drug misuse, drug misusers, or “people who misuse drugs and other substances.” Instead, a whole, diverse, nebulous group of people and stories, from all sorts of backgrounds, we summed up with one stark word: Addicts.

This got me thinking about how the use of language within pharmacy has changed since I qualified, and how we can make even more positive changes.

I've spent a lot of time over the past few years thinking about how I refer to people and patients. I've carefully avoided labelling people as “asthmatics” or “Epileptics”, preferring “people with asthma” etc instead. I assumed that this people-first language would apply across all groups. But my assumptions were challenged when I happened across an article which suggested that the opposite may be for the best for some autistic people. It made me realise that a blanket approach doesn't work, and that it is important to ask the patient themselves how they would like to be described. (As an aside, I found that article through the Emergency Chat app, which is amazingly helpful for anyone who sometimes feels overwhelmed.)

When I first started teaching on the UCLan MPharm course, we used to ask our students to identify “what a patient might be suffering from” in dispensing classes. Just that one little question presents so many problems. Labelling people as patients, assuming that they are suffering, that their illness defines them. Nowadays, we ask “what might the medicine on this prescription be used to treat?”. My hope is, that by changing the words, we can also change our students' perception about the people they will go on to look after. I'm hoping that they'll start to see people less as suffering patients, and more as fellow people with individual needs.

I also wonder sometimes whether our approach as a profession to patient and public involvement creates a barrier between them and us. Does the way we act cause our students to think of patients as exhibits? “These are the patients we’ve brought you to meet with today, none of the rest of us are patients, oh no…” And do these barriers affect our students, do they see patients as “other” and think that they themselves should never be unwell?

When I refer to my own mental health, I will refer to myself as “bonkers” or “crazy in the head”. That's okay for me to say about myself, but I would hate to think that a health professional would refer to me like that. I know that’s odd, and maybe if we discussed it, then I would let them join in with me, but I would hate to see a consultant’s letter that went to my GP saying “Thank you for referring this bonkers lady to me”. I think it’s easier for me to think about myself as a person with depression, rather than a depressive.

When a friend of mine visited his GP for depression, the doctor described him as “feeling a bit down”. Now, perhaps his Doctor was too scared to use the “D” word. Perhaps he thought he would be resigning the patient to a life of darkness and gloom. But instead, all it did was dismiss the hell he was going through, and on a practical level it also didn't look great on his sick note.

I guess I'd like asking how a person would like to be described to become as ubiquitous a question as “do you take any other medicines?”. Whether someone is gay, trans*, black, a person of colour, a person of faith, Christian, a diabetic, a person living with epilepsy or all of the above, we should be able to ask them who they think they are and respond appropriately. We also need to start being truly patient centred, and let our patients lead the conversations where they want them to go, and if that’s hard to begin with – let’s start a conversation within the profession and see where it goes. Don’t forget there’s lots of help out there, and lots of ways to improve the way we communicate with patients, the public, and other health professionals.


 

Cathryn xx

 

Discussing homeopathy on Rip Off Britain

it's been so long since my last post, for which I apologise. I have had a fairly severe case of Writer's Block. But I figure helping out on a national TV programme is worth a few words, right?

if you go down to i-player today (or within the next 20-odd days), you won't find a teddy bears picnic, but you will find yesterday's episode of Rip-off Britain, featuring one of the smartest, bravest community pharmacists I know. And the subject is our old nemesis, homeopathy. 

A few months ago, I got an e-mail asking if I would be willing to help provide some background information to the show. I jumped at the chance, though I was also a little wary, in case it became a hatchet job for the whole profession.

but I decided the risk was worth it, and so had a conversation with a very nice chap one evening, in which I essentially ranted on for a long time whilst made notes. I gave him the background on how pharmacists are regulated, and the difference in roles between the RPS and GPhc. I told him about how I thought homeopathy breached our professional standards if not sold correctly.I told him about how, if I'm in a pub talking about homeopathy, I'll often collect together various pint glasses in order to better demonstrate the dilution process, and how people are then usually amazed and outraged when they realise that homeopathic medicines contain no active ingredient. Most importantly of all, I told him my theory that most pharmacists who sell homeopathy badly do so because of a lack of knowledge, rather than a willful way of exhorting money from poorly customers. 

Then came the dreaded question: would I be willing to appear on camera to say all of this? Yes. Yes I would. I would absolutely adore to, in part because it is the scariest thing I could ever think to do and I haven't been so good at challenging myself of late.  But my workplace would no doubt see it differently, as they have done before. But luckily, I knew exactly who to ask to do it in my place though, and she's done me and the profession proud. 

in the programme, the undercover journalist actually received the best advice from Holland and Barrett. Let's just let that sink in for a bit, shall we? Holland and Barrett gave better advice that several registered pharmacies. Yes, it's a small sample, and the chap in this particular Holland and Barrett is likely an outlier, but if ever something should make our profession hang our heads in shame, it is that. 

There is a mistake in the programme too. They referred to the Faculty of Homeopathy as regulating homeopaths, but that's nonsense. Homeopaths don't have to be a member of the Faculty, and it seems that they do very little in the way of regulation anyway. Homeopaths can do what they please, with no one to slap their wrists when they harm people, unlike real healthcare professionals. 

The researchers contacted Nelson's, who said that they were disappointed that pharmacists weren't giving the right advice. They offered to provide more training, but I certainly do not think that's the sort of thing the profession needs. We need to be better able to distinguish between homeopathy and herbal medicines, and we need to make sure that we are honest with our patients. We need to know that "a lot of people buy it" is NOT the same thing as "it works", and we need to find better ways of connecting community pharmacists with good quality evidence. 

Thank you, Cathryn. You've done us proud. 

Hxxx

  

  

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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
 

The beauty of disagreement

If this skepticism lark has taught me anything, its that disagreeing is a beautiful thing. Disagreeing with someone is a hard thing to do, in any context. Yet as humans, health care professionals, and as skeptics, its one of our keenest tools. Its only by being able to step into disagreement that we can understand our topic, our audience, and hopefully steer hearts and minds away from those willing to mislead.

I recently attended a panel about daring to disagree, which mainly focused on religious debates over Twitter and the like. I'm guilty of wiling away hours of my life arguing with homeopaths over twitter, and I'm often asked why, as I'm never going to change their minds. The short, and most noble answer is that someone undecided might spectate, and I might be able to make some impact into how they think about the subject. The more self-serving version is that its good practice to hone my skills in identifying fallacies and flaws, finding workarounds and ways of wording things, and to understand an argument in advance of the next time. In these types of arguments, the people who you are speaking to are removed from yourself, perhaps not anonymous as such but they tend to be used to arguing. Their position is usually on the defensive in the first place because their chosen subject has usually been the butt of skeptical inquiry for years.

But what of those closer to home? Sticking out heads up above the parapet in other situations is one of the hardest things in life to do. Most of us instinctively see disagreement as a threat and a personal attack, and we react accordingly. Even now, despite all I've learnt about constructing arguments and debates, with all of this practice, I certainly still get physical reactions when someone disagrees with me. My heart will pound, my mouth with become dry, and I'll want to curl up in fear because my body and brain immediately leap to the conclusion that no one likes me, that I'm so insignificant that I must automatically be wrong. I'm thankful to skepticism in that I'm able to take a deep breath and overcome those initial few moments, then can try to reassess my position. Am I actually right, but there are some good points to take away from the other stance? Or actually, is my reasoning flawed? In which case, why? Where could I have found more information, what is the other person bringing to it? Whichever way it goes, I, and the other person, end up learning more. Ultimately, we're not here to be right or wrong- we're hear to learn more, and that's the important bit.

Problems arise though because often our instincts take hold. I can't describe the number of times its all gone tits up. I can spend ages agonising over whether or not to disagree. Once I've decided to do so, I write and rewrite my argument so that it is as objective as possible, structured clearly, evidence based etc., only to have the response be “Eurgh why are you being so mean?! I thought we were friends!” or similar. I've tried all sorts of ways to word things, and I haven't quite come up with an answer on how best to avoid this response. Its not just Facebook etc. where this is a problem- we all hear in the news about irrevocable breakdowns in the doctor-patient relationship (Ashya King, as an example). We've all encountered the patient at the pharmacy counter who believes a random person waiting in the queue over our own expert advice. No one learns anything from these sort of exchanges, and that's a real missed opportunity.

So the question is, how do we go about promoting disagreement as a positive thing that we all need in our lives? How do we turn the tables on the thousands of years of evolution that make us shut down arguments as soon as they begin? Well I think the answer has to initially come from example. I believe the skeptical movement is extremely well placed to start this tidal change in thought, but we all have to practise the heck out of it every single day if we're ever going to get anywhere. We have to start being known synonymously as folk who are really, really good at disagreeing respectfully, and that has to start from within. Its clear that the skeptical community in the UK and beyond occasionally falls short in this regard, and that's a real shame as it appears to be driving good people away.

We need to recognise that we might agree with someone on one thing, but not the other. We can't see a person as synonymous with one of their opinions, and put people in good or bad boxes based on that. We shouldn't be labelling people as anti-this, or anti-that, and then refusing to engage further. We should be experts at digging deeper than that, looking behind the headlines to search for shared humanity underneath. We need to lead the way in disagreeing without bullying, and we should never, ever let up on that. We put ourselves in a position that could so easily be mashed up together with bullying by the general population when we dare to disagree, and we need to be relentlessly exemplary in our behaviour to prove that we aren't. We need to be the type of people who, even if faced with a mutant hybrid of Nigel Farage and Piers Morgan, would manage to keep their cool and be polite.

But then again, feel free to disagree ;)

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.

Why I'm not currently a member of the RPS

Since there's a whole load of people tweeting their reasons for why they've renewed their membership, it seems like a really good time to discuss my reasons for not renewing.

Historically, membership of the Royal Pharmaceutical Society of Great Britain was mandatory, as they acted as both a professional body and a regulator. Their fees were huge- £400+, and they had a reputation for being very meek and for being a bit of an Old Boys Club. Then the split occurred, and now we pharmacists have to pay the regulator, the General Pharmaceutical Council, but we can choose whether or not we want to fork out for RPS membership. When I was working towards being a pharmacist, I was so excited and proud to be part of a professional body. I'd love to still feel that way today, but there are a few things standing in my way. Some of these reasons are very personal to me, whilst others I think may resonate with many. I can but hope that if they are read by anyone at the RPS, my comments are taken as they are meant- constructively, and with a hopeful heart that one day I will be convinced enough to renew my membership with them after a long hiatus.

Cold, Hard Cash

Membership of the Society costs £192. That's a lot of money. Surprisingly, that's not a popular opinion- whenever I say so on Twitter I am hounded by comments like "It's only the price of a pint of beer per week" or "just give up your morning coffee!". The inference is that my priorities are all wrong, and I must be mad to not join for such a reasonable price.

A few years ago, I really was in financial trouble. It was a combination of things, including a divorce, that got me to that point. Some of those things were my fault, some weren't, but none of that mattered when I had ran out of my overdraft and an enormous bill was overdue. I'm now at a much more stable point in life, but that time is still fresh enough in my memory that £192 is still a lot of money for something non-essential. 

Attitude towards poverty and Other Snark

There have been a few occasions when I have mentioned that I can't justify the cost on Twitter, and as mentioned above the response has been rather eye opening, sometimes from RPS staff. It would appear that there is a complete lack of understanding of financial difficulties from some quarters. You try to explain that yes, it might just be the price of a pint per week, but if you haven't got the price of a pint in the first place it makes no difference, but that concept just does not appear to compute. Some of these conversations got so bad that I had people DMing me to check that I was okay.

I've been made to feel ashamed and belittled. This may not have been intended, but this general conception that pharmacists- presumably because they get paid fairly well- must never have real money worries is really concerning to me. A good wage is brilliant, but it doesnt 100% guarantee such financial security that £192 seems like a throwaway amount. Sometimes life just steps in and mucks everything up. As health care professionals, empathy is an extremely important skill, and there have been a few occasions were that seems to have been lacking. If folk can be so dismissive of financial hardships, what else could they be similarly judgemental about?

Additionally, I did see another, unrelated snarky tweet by a very prominent member of RPS staff to a tweeter who had dared to ask for evidence. This may be a very minor thing, but to me its a big no-no, since I'm so passionate about evidence based medicine. 

I wish I had screenshots of all of these conversations, but they happened a long time ago and I'm too tired to try to hunt them out. I know this might all sound super petty, but for an organisation with professionalism at its very heart, I think such seemingly small things add up.

 Evidence of Value for Money.

The RPS certainly does some very good work. And I can honestly say that I hugely admire their improvement over the years that I've been a pharmacist. They're a lot more visible these days, a lot more proactive. I've admired their stance on things like social media, homeopathy, and e-cigarettes. I love that they've collaborated with Sense About Science. But, despite all of these advances, I'm still not entirely convinced that membership would make enough difference to my daily life to justify a cost of £192. How do I know, if I'm not a member? well, I know this isn't particularly robust, but from my own n=1 experience of previously being a member compared to now, I see no difference.

I've never had a patient look at my credentials and say "Here, you're missing an R and an S from your MPharm, you must be a rubbish pharmacist.

Money=Professionalism

This is a concept which I simply cannot abide, but which is creeping more and more into the forefront. It seems that organisations are starting to equate RPS membership with professionalism, and this is very simply not the case. Throwing money about does not, under any costs, make someone more professional. I know some really terrible, unethical pharmacists who are members. Homeopathic pharmacists who repeatedly endanger peoples' lives, in spite of the RPS stance on homeopathy, appear to be members. Then there's me, who works bloody hard to be a good pharmacist, to promote safe and effective healthcare, and who spends sleepless nights worrying about my patients.

What of those of us who work our asses off, day by day, to help our customers, pay our bills and maybe, if we're lucky go on a little holiday? The implication that people who cannot afford membership are somehow less professional really, really drives me mad, and far from making me rush to hand over my cash, it instead distances me further.

Previous personal letdowns

I've written previously about a complaint against me when I was newly qualified, which was handled by the  RPSGB. Although they no longer deal with complaints, I was left with a lasting sour taste in my mouth following that experience. I spent a lot of time with the inspector, talking about the substandard working conditions I was being forced to work in at the time. I was assured that the RPS would fight to improve those standards, and that they would be taken into account. Of course there was no mention of that conversation in the report i later received.

I know this is anecdotal, and I know its unfair to tar the current RPS with the same brush as I did their predecessors. But it does mean that to me personally, they need to work a little harder than usual to win back my trust.

My Joining Threshold

I'm not entirely sure of what would convince me to join as of yet. This is still, despite all of these years, pretty nebulous and shifts occasionally. Some of my admittedly vague suggestions where there is room for improvement are:

  • Guiding a sea-change in the profession to embrace evidence-based medicine. 

  • Speaking up about the amount of unprofessional quackery for sale over pharmacy counters. 

  • Truly standing up for everyman: acknowledging the importance of every pharmacist out there with aching feet and a headache who hasn't had a proper lunch break in years. 

  • Shaking off the traditional top-down culture of the profession and finding creative new ways to really listen to those of us working at the front line- those of us who can't get the time off work to attend meetings in London and who are too exhausted at the end of our 16 hour shifts to spend hours reading consultations .

  • Making some really meaningful steps towards changing poor workplace conditions for pharmacists.

  • Constructively engaging with non-members in order to raise the profile of the profession cohesively, rather than creating a false, unhelpful two tier system

  • Working towards breaking through mental health stigmatism both for patients and within the profession. 

The other important factor for myself is of course financial stability. I'm getting there. I'm not ashamed to say that at the moment, though, I'd rather prioritise that pint per week over membership. My social life is extremely important to me- its what has gotten me through the hard times, and I can see a clear benefit to my life from it. At the moment, sadly, I can't quite say the same about RPS membership, though hopefully in time I will be persuaded otherwise.

Hxxx

Special Investigation: Is Santa really a pharmacist?

Despite him being one of the most famous people on the planet, we know a suspiciously small amount about Santa Claus's background. I've had the suspicion for some time that he may in fact be a pharmacist throughout the rest of the year. 

A quick check of the GPhC register brings up no S. Claus’s, though of course that only rules out pharmacy practice in theUK. Unfortunately it would seem thatLapland does not have a similarly searchable pharmacist register, so we are unable to confirm his registration status in his home country. However, if Santa were to be working overseas, it would seem that Your Family Pharmacy, 15 N Kringle Place, Santa Claus, Indiana would be his first choice, especially given its prime location near to Lake RudolphCamping Park. (honestly, this place exists)

Santa is, of course, most famous for operating a highly efficient free delivery service. No doubt these skills have been honed throughout the rest of the year, as he organises a prescription collection and free delivery service to his patients.

As the song goes: “He’s making a list, he’s checking it twice”, demonstrating that Santa is following robust self-checking procedures. It is clear that he has the sort of attention to detail that is required by pharmacists. It’s also clear from this song that he is aware of NICE guidelines.

It seems clear that Santa’s system of working, is synonymous of that in a community pharmacy. He works alongside a team of highly skilled and well trained elves, though retaining legal responsibility for all that goes on in his workshop. One assumes that, on visiting the workshop, his Responsible Father Christmas sign is clearly displayed.

Perhaps the most convincing evidence is that of his links with the Coca Cola company. Santa has a long history of advertising the product, adding a splash of red and a liberal helping of fur to his usual pharmacy white coat. Its good to see that Santa is so devoted to advertising the invention of  fellow pharmacist John Pemberton, who originally invented the drink as a cure for his own morphine addiction. Santa is clearly interested in harm reduction and no doubt works closely with local drug and alcohol teams during the rest of the year to dispense opioid replacement therapies for patients.

Santa Claus, however, does have some flaws as a pharmacist. As discussed in the BMJ, he appears to pose a number of public health risks, including as a vector for infectious diseases, and in the promotion of drink-driving. It would seem that he would benefit from a visit to his nearest Healthy Living Pharmacy, where he can access advice on reducing his weight and brandy intake. It is good to note that he successfully quite smoking and seems to have remained abstinent.

Hxxx

Advert Annoyances Vol 1: Senokot

Welcome to the first installment in what is likely to be a very sporadic series. As you've probably guessed by now, I have a tendency to be irrationally annoyed by small things, especially when it comes to medicines. Adverts for OTC meds can be a prolific  source of cringes. Even leaving aside the requests for "you know, that one on the telly, where there is a guy and a dog and its a blue box", there will occasionally be a little phrase or image used in these adverts that makes me stop and seethe a little.

The current one at the moment, is Senokot. I can't find a link to the new advert, but when I do, I shall pop it in here so you can see for yourself.

There's all sorts of naturalistic fallacies going on, but that's not what annoys me the most. It's the phrase " works in harmony with your body" that i'm finding hard to stomach (geddit?)

Put simply, senna works by irritating your bowel. Your bowel notices that it is being hurt by something, therefore starts contracting and producing secretions to hastily get rid of the thing hurting it.  This then might make you poo, but from your bowel's point of view that's a side issue- its just trying to protect itself from harm.

That doesn't really sound to me like "working in harmony". You might as well say that fire works in harmony with human skin to make you walk faster- in actual fact, one is just out to hurt the other, meaning something else happens as an unintended- but sometimes useful- consequence. 

Hxxx

 

It's thyme to Bronchostop this nonsense

I’m sorry, I just could not resist that headline.

Whilst working a locum shift the other week, I noticed a couple of new products had leapt their way to the pharmacy shelves. “Bronchostop”. Sounds interesting, I thought, until I moved a bit closer and noticed that they are, in actual fact, a herbal cough remedy, and my vague excitement was replaced with a bit of my soul dying. Then I saw the price tag, and the anger kicked in.

Brought to us by our old friends at Omega Pharma, Bronchostop syrup contains thyme extract and marshmallow root, whilst the lozenges just contain thyme extract. Omega claim that it “relieves any type of cough”, and that it “takes the hassle out of choosing a solution”. Well, I must say, I’m pleased to hear that, because I find one of the main stressors in my life is choosing which cough remedy to use. I mean, it’s just so complicated to decide if you have a dry or a chesty cough, then realise that it makes no difference anyway as most cough medicines don't work, so you then just by a cheapo honey and lemon thing to make yourself feel placebo-ey better. 

So, given that the great all-consuming cough medicine dilemma of my life has now been sorted out by Omega, I can spend some quality time looking up the evidence to see if it works.

It turns out that there are some preliminary trials which suggest thyme might improve cough symptoms. However, these all use specific cough syrups with different combinations of ingredients compared to Bronchostop, so they’re not very helpful. Because the product is being sold as a traditional herbal remedy, the manufacturers don’t need to bother collecting any evidence that it works before it goes on sale- their claims are based entirely on “traditional use”, which means nothing at all scientifically.

One attempt at a clinical trial compared thyme syrup with a “real” expectorant, bromhexine, and found no difference over a five day period. There are a number of problems with this though- firstly, bromhexine isn’t commonly used in cough medicines. Secondly, there’s little to no good evidence that expectorants work anyway, so we’re comparing something that may or may not work with something that doesn’t.

Worryingly, the website www.bronchostop.co.uk contains absolutely no safety information whatsoever. It doesn’t tell you who can’t use it, who needs to be careful using it, or what any of the side effects might be.

What side effects could it possibly have, you’re wondering. After all, its just a herb. We eat it, so it can’t be that bad, right? Well, sort of. The amounts used in food tend to be a lot lower than when it is used as a herbal medicine.

On the whole, thyme is well tolerated, but occasional gastrointestinal effects can occur. Uncommonly, and more seriously, people can have allergic reactions to it. It can interact with drugs, including those that thin the blood, those used in Parkinson’s disease, those with anticholinergic or cholinergic effects, oestrogens (research suggests it may decrease the effects of HRT, but theoretically also the contraceptive pill), and non-steroidal anti-inflammatory drugs. It may cause problems in people with bleeding disorders, who are undergoing surgery, or who have hormone sensitive cancers. We have no idea of the effects that medicinal amounts of thyme can have in pregnant or lactating women.

It seems to me, however, that its main adverse effect will be on your bank balance. This stuff is £8.99 for a 200ml bottle or £4.99 for 20 pastilles- that’s a whole lot more than simple linctus, which is about £1.50 and which will probably do just as good a job.

Hxxx

Is pharmacy a good career choice right now?

I always wanted to be an archaeologist, growing up. I knew, however, that this was probably a pipedream- partly because I dislike creepy crawlies, but mostly because I was pretty sure in my childhood brain that everything interesting would have been dug up already by the time I was old enough to work.

Turns out I was wrong about that, but I’m still really proud of the profession I ended up in. I remember wandering up to the local shops with my Mum when I was little. We were talking vaguely about the future, when we had a little nose around the local chemist’s shop, cooing at the colourful bubblebaths and hairgrips that they had in stock.

“I know”, Mum said. “Why don’t you become a pharmacist?”

“What’s one of those?”, I asked. As far as I was concerned, the chemist’s shop was a place to buy cheap make-up and bath salts.

“Well, they stand in the back and mix up the medicines”. That’s it, I was hooked. I had images of brewing potions, mixing up gloopy ointments, and all sorts of stuff that, it turns out, in real life you only actually get to do for a couple of hours as an undergraduate. But my decision was made, and all the rest of my life I knew I was going to be a pharmacist.

As I got older, and I started telling people what I wanted to do, I used to hear nothing but positive things. I worked as a counter assistant in my local super market, and locums always used to tell me “You’ll never be out of work. Everyone is always desperate for pharmacists.”

At the time I graduated (2006), it still hadn’t been that long since the Great Pharmacist Shortage. This happened because the old style three year degree now became a four year Masters degree- so there was one year where no newly qualified pharmacists came on the scene. Everywhere you looked, people were crying out for a full time pharmacist to work for them. Whatever happened, you always knew that you could locum as a back up, and earn a good wage doing so.

As university went on, and I started applying for pre-reg places, I got worried. Not because I didn’t think I would get a place- in actual fact I was being courted by several companies, all of whom were clamouring to fill their pre-reg spots. I think I did maybe 10 interviews, and I got job offers from every one of them (and believe me, some of those interviews I was really quite atrocious in). No, I was worried, because I wanted to do my pre-reg in hospital, and I knew that pre-reg places really were limited in my local area- only 7 for the whole city.

I was lucky, and I got in. My year was really lucky, as it turns out there were enough jobs going for each of us pre-regs- though I actually went elsewhere. Whilst community pharmacy jobs were plentiful, hospital pharmacy was a lot more difficult to get a job in.

Nowadays, it has changed so much. I don’t think I can ever really hear myself saying the sort of things I was told to an enthusiastic school child now. “You’ll never be out of a job” would just simply be a massive lie.

When I was choosing universities, there were only a handful that actually offered pharmacy as a degree. In recent years there has been a proliferation of universities offering it now though, and as a result, the number of graduates is increasing year on year. I’m sure this isn’t the whole reason, but we have now reached a point where pre-registration places are becoming really hard to come by. There is a group of potential pharmacists, year on year, who will simply never be able to get a place anywhere.

So what does that mean? Well, you can’t register as a pharmacist, so you can’t work in your chosen profession. You’ve still got a Masters degree- but you’re actually pretty limited as to what you can do with it. Sure, its equivalent or better than a pharmacology degree, but you’ll always have a question hanging over your career, whatever you choose to do: “If you’ve got a pharmacy degree, why aren’t you a pharmacist?”. There’ll always be a slight, unfair, cloud of suspicion there. It means, even for those lucky enough to get pre-reg places, that jobs are more and ore difficult to come by, wages are being lowered despite responsibilities and workloads being higher, and locum shifts are both hard to get and pay an awful lot less.

Several places that I do locum shifts for have an email alert system for new shifts. On several occasions, I have received an email, checked my diary for my availability, then rang back immediately only to be told that all the shifts have gone already. The good thing that comes out of this is that, once you get your foot in the door, there is an incentive to work hard and become known as one of the best, most hardworking locums, because then you will get offered shifts first. The bad thing is that its now really hard to get that first step on the ladder.

How do we fix it? I have no idea, as it’s a multifactorial problem. A cap on the number of students studying pharmacy does seem logical, but that’s already been stamped upon by the Minister for Universities, science and cities Greg Clark MP, who has said:

Having considered the evidence I have decided that it is not necessary to introduce a specific student number control for pharmacy. The government's objectives for pharmacy can best be achieved outside of a number control system. It is the government's policy to remove student number controls wherever possible to enable students to have greater choice and to encourage universities to offer better quality courses to attract students. I believe pharmacy students can and should benefit from this reform and not be restricted. Therefore there is no need to consider further options for a pharmacy number control.”

It seems to me that the one thing that Mr Clark isn’t considering is those students. Yes, they might have greater choice, but I wonder, if asked, where their priorities lie- would they rather have more choice, or would they rather have some security in their future. I wonder if it has occurred to him to ask them directly.

So it is that I, and a number of other pharmacists, are sadly starting to discourage students from looking at pharmacy as a profession. Its through no fault of their own, and its brilliant that so many young people want to be pharmacists- but its hard out there, and its only going to get harder. Our bright young potential pharmacists might be better off opting for a less focused, vocational degree.

Hxxx

 

When real science gets left out in the Coldzyme

There’s no getting away from it, folks. Its sniffle season. For the next 6 months or so, the sounds of sneezes, coughs, and millions of noses being blown will echo throughout the nation.

We all know by now that the common cold is a virus. We all know that there is no cure. We also all know that, although you feel like crawling into a small dark warm cave and dying at the time, its usually much better after a few days, and it goes away of its own accord. Cold and flu remedies do nothing to actually get rid of your cold- they are there to make you feel better during it, although many of them are actually irrational combinations of products in shiny boxes with a redonkulously high price.

It is often said that if someone did come up with a cure for the common cold, they would be millionaires. I was, therefore, surprised to read this week in Chemist + Druggist magazine that indeed, the first ever product to not only treat the symptoms but to act on the virus itself was winging its way to pharmacy shelves as we speak. Really? Because blimey charlie, if that's the case, then this product should be Big News. 

The product is ColdZyme, a mouth spray that costs £8.99 for 20mLs. Seems a pretty fair price to pay for a product which claims to cure the most prominent infectious disease in the western hemisphere. It seems odd, though, that instead of this marvellous scientific breakthrough being plastered all over the media and medical literature, the article announcing it is tucked away quietly in a barely read corner of a trade journal.

What is this breakthrough, miracle product that will powerfully break down viruses? Well, an enzyme called trypsin. An enzyme that already merrily and plentifully kicks about in your digestive system, breaking down proteins. An enzyme which, for the purposes of this product, is inexplicable being derived from cod (which has meant that I have had to resist the urge to refer to it as somewhat fishy.) An enzyme which should be stored at temperatures of between -20 and -80 degrees Celsius, to prevent autolysis. Now, I've seen some fancy medicine packaging in my time, but never a simple mouth spray bottle that can manage such cold chain storage feats. So, if trypsin really is present in this product, then it seems fairly likely that its going to be inactive, unless the manufacturers have found a way of warping room temperature. Or you happen to be in Winnipeg in the middle of winter.

Medicine vs. Medical Device

The manufacturers make some really very extraordinary claims on their website, including one textbook example of special pleading. Their product, they state, isn’t a medicine. It’s a medical device, because it has no systemic effect. They then of course go on to helpfully tell us about the systemic effect it has:

“The medicines currently on the market only treat the various symptoms of a cold. ColdZyme treats the cause of the symptoms – the virus itself – and thus works both preventively against the common cold and shortens the duration of illness if you have already been infected.”

Right. So in the same breath, they are claiming that the product only forms a barrier, no more. But then they are also claiming that this barrier affects the ability of the virus to produce illness if you are already infected- viruses which are already through that barrier and inside your body. Come on, Enzymatica, you can’t have it both ways.

The Evidence

All these claims are backed up by evidence, right? Well, there is a tiny trial performed on only 46 people, which isn’t published anywhere. I can’t say whether or not it is a well designed trial, because I can’t see it in full, so to be honest, we pretty much have to just discount it. What we can do, however, if have a look to see if there is any other decent published information looking at the effect of trypsin on the cold virus. So I turned to the medical databases Medline and Embase, to trawl through the published medical literature. 

I did find one experiment which looked at the trypsin sensitivity of several human rhinovirus serotypes(1). And this appears to have found that viruses are only really susceptible to trypsin when there have been exposed to low pH, followed by neutralization- something which wont have happened to your common or garden cold viruses. I couldn’t find much else suggestive of a clinically significant antivirus action of trypsin.

The practicalities

This isn’t a simple, one-off- couple of sprays and away flies your cold sort of product. You have to use it every two hours, as well as after you brush your teeth and before you go to bed, and you have to continue this “until your symptoms are relieved”. That’s one hell of a regime. I have difficulty remembering to use medicines twice daily, never mind every two hours. I’ve never used this product, but I’d imagine that if it really does leave a “barrier” coating in your mouth, its a pretty unpleasant sensation. I can’t imagine many people sticking closely to these dosage instructions, and if the mechanism of action is as the manufacturer’s claim, skipping doses would cause the product to fail (if, indeed, it works in the first place)

We are also directed to “Start using ColdZyme® as soon as possible when you detect symptoms of a cold.”. Now, those of use who suffer with cold sores who have ever used aciclovir cream will know that this is often easier said than done- you probably haven’t got the stuff in the house, or at work, and by the time you’ve managed to get your hands on some, its already too late- your cold sore is out loud and proud, and using the drug will be pointless. Its likely that the very same thing will apply here. And remember that the incubation period for a cold is about 2 days- so the virus will already be cosily settled into your body before you even know about it. Its therefore completely ludicrous that this product claims to be able to reduce the length of a cold simply by forming a barrier.  

I know it can be used as a cold preventative, but how many people who feel completely fine are going to remember to use the product every two hours, every day, for the entirely of the cold season?

To Summarise

So, do I think there is scientific evidence to back up the extraordinary claims being made by ColdZyme? I might do when hell freezes over. Or at least when some decent trials are published, which might take just as long.  Do I think that this product should be sold through pharmacies? Absolutely not- this isn’t, if you ask me, real medicine. This is pure pseudoscience, trying its best to fool you into buying real medicine. Do I think lots of people will buy this, use it once or twice, then leave it to languish in their bathroom cabinet? Absolutely.

Here’s the problem though: this stuff will appear on the shelves of pharmacies all over. The pharmacists wont have a clue what this stuff is, and because they are really busy and probably quite tired at the end of each day, they wont be able to do the sort of evidence review I have managed to squeeze into a quiet moment. So they’ll get asked about it, and they’ll sell it. Some people will buy it and will feel better after a few days, and will think that the spray has made them better, forgetting that colds are self-limiting anyway. A customer might come back in the pharmacy one day, and say something like “hey, that new-fangled spray got rid of my cold!”, and the pharmacy staff will end up making recommendations on the basis of customer feedback and anecdotes, rather than on the basis of rational, scientific evidence. In my eyes, this really is a shame, and by selling this sort of nonsense, we really are cheapening our profession, and we're causing our customers to waste their money. 

If patients ask me about it, when I’m working behind the counter, I’ll tell them something along the lines of: “there’s no evidence or logical way that it works. It seems to be a bit of an expensive gimmick, with no decent basis to it. You’ll feel horrible with your cold, but it will start to go away of its own accord, I promise. In the meantime, you’d be much better off looking after yourself, having plenty of fluids and rest, and taking paracetamol according to the packet.”

Hxxx


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

 

The importance of a fluffy pen

Many years ago, in my pre-reg year, I was pulled into an office by my tutor and told that I needed to sober up. She didn't mean that in an alcohol sense, but instead that I needed to start being more serious, dour, and less quirky. She told me that my personality, as it was, wasn't right to be a professional.

At the time, I believed her. She told me that I would never make a good pharmacist if I carried on the way I was. I was terrified, as all I wanted to do with my life was to be a pharmacist. If I couldn't be a good one, then I would really need to change my personality.

All of this started because I had a Christmas pen. It played tinny music for an alarmingly long time when pressed, and it became a bit of a joke in the dispensary to sneak up behind me when I was working and set it off, making everyone dissolve into giggles. A dispensing assistant, who was wearing a Christmas tie, was also told off, and strongly advised to not wear it again.

But nowadays, I disagree heartily that you have to be serious to be professional. I think a little bit of well-placed silliness and a lot of humour can add to our professionalism.

We need to be approachable to patients. And what makes a person more approachable than a little bit of personality? Nothing, except perhaps a novelty pen. On a couple of occasions, women who have come to see me about the emergency hormonal contraception pill, and who have been very nervous, have ended up giggling at a ridiculously fluffy pink flamingo pen I used to have. It broke the ice, and they could see that I was a person just like them, and I wasn't going to sit there all business-suited and high and mighty at the other side of the table and judge them. They felt a lot more comfortable because of that pen, and I think I was able to help them a lot more as a result.

At the moment, I have a Special Pen in my desk drawer. It is comedically large, pink, and slightly phallic, with some floppy rubber spikes on the end. I like to take it out of my desk drawer and offer it up, straight-faced, when people ask to borrow a pen. 

my special comedy pen, with a banana for scale

my special comedy pen, with a banana for scale

We health care professionals deal with a lot of dark stuff on a daily basis: sickness, death, disability, anger, frustration etc. We need to balance that darkness out with something lighter. Whether its doing something daft in the dispensary to make your staff laugh for a few seconds when times are stressful, or donning a fox mask and writing silly things on the internet, it all counts. 

As long as we put the patient first, we treat others with respect, and we work within our limits, true professionalism doesn't have to mean that we all walk about with serious faces.


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?

 

Evidence-Based Ambridge

Ahh. Sunday mornings. They can mean only one thing: bacon.
Okay, two things: bacon and tea
Whoops, no let's make that three things: bacon, tea, and The Archers omnibus. 

So welcome to the first instalment of an occasional series (probably so occasional that this is the only one), in which I critically examine the treatment choices of the fictional residents of Ambridge. 

In today's omnibus, Hell-on's child falls over. There is much hysterical panic, and much bewailing the fact that she wasn't watching him properly. Apparently its hard to look after a child and gaze lovingly off into the distance in the direction of Rob Titchener's house. Who knew. 

But never fear, Hell-on's mother, Pat (who doesn't appear to have noticed that her husband has been kidnapped and replaced by an interloper), is on hand to reassure her that she has done her best with the arnica. 

Arguably, I'd say arnica is one of the most accepted forms of woo in the UK. Arnica cream is a standard item in many pharmacies, and I would say that many people know that it is supposed to be useful for bruises. I wonder just how many first aid boxes have a tube of arnica languishing in them, but I reckon it is quite a few.

Its also a poster boy for the sort of confusion that reigns between the public perception of homeopathy and herbal medicine. herbal arnica cream often sits side by side homeopathic versions with no explanation of the difference. 

Even Nelson's seem rather confused about which modality to use, with both herbal and homeopathic arnica sitting in their "Arnicare" range of products. I can't quite get my head around this to be honest. Imagine going into an off-license and seeing two bottles of Smirnoff, one of which contains vodka and one of which contains water, though the only difference on the label is that one says Smirnoff Vodka 30C. Hmm.

Does the distinction matter? Yes, I think it does. I think its pure, outright deception to sell a homeopathic product to someone expecting a herbal medicine. One has arnica in, one doesn't. 

Anyway, all of this is by the by. Obviously there is no evidence that homeopathic arnica works for bruising. It's homeopathy. It has nothing in it. 

And as for herbal arnica? there's also no evidence that it works, although there is a little bit of prior plausibility, in that some of the chemicals in the arnica plant have an anti-inflammatory and anti-platelet action. There is, however, no information on how clinically significant these actions are, and whether rubbing a bit of cream into an area would get these potentially useful chemicals to the right place in any meaningful amounts.

Let's not forget that bruises are self-limiting. They go away of their own accord (and probably at the same pace), regardless of whether or not you rub some gunk into them. herbal arnica isn't risk free: the cream can cause  contact itchiness, dry skin, and rash. Orally, arnica can be pretty nasty stuff, even causing coma and death in extreme cases. 

So, my evidence-based advice to Helen would be: kiss it better, and leave it be. Henry is a small child, and falling over is pretty common in that age group. Don't apply an ineffective treatment which could rarely lead to side effects, and save your money.