Harmless Homeopathy?

Home , Alternative medicine, Edzard Ernst, Homeopathy

EDITORIAL

“Homeopathic remedies are used by many rheumatological pa ents … There is no compelling evidence that they are eﬀ ec ve beyond a placebo eﬀ ect.”

Homeopathy is a school of medicine that relies The assumption that homeopathy can do no on the ‘like cures like’ principle. Most homeo- harm is widespread; the absence of an active pathic remedies (i.e., all beyond a 12C ‘potency’) ingredient in homeopathic remedies seems to Edzard Ernst are so dilute that they do not contain a single signal absence of any risk. Yet there are sev- Complementary Medicine, active molecule. Despite its biological implau- eral different ways in which homeopathy could Peninsula Medical School, sibility, homeo pathy is again highly popular. harm patients. Universi es of Exeter & During the past 5 years (2002–2007), UK sales Plymouth, 25 Victoria Park of homeopathic remedies have increased by Homeopathy as an Road, Exeter, [101] 24% . Homeopaths treat mostly chronically alternative medicine EX2 4NT, UK ill patients, including many who are suffering When Hahnemann developed homeo pathy, he Tel: +44 139 242 4989 [1] from rheumatol ogic conditions . The reasons was adamant that it should be used as a replace- Fax: +44 139 242 7562 for the popularity of homeopathy are diverse and ment of conventional medicine. He even called [email protected] range from frequently misleading information homeopaths that used it alongside mainstream for the public, to the fact that patients tend to treatments ‘traitors’ [9]. In Hahnemann’s time highly value the empathetic and lengthy encoun- this, perhaps, made some sense – many conven- ter with clinicians. Crucially, the notion that it tional therapies were more dangerous than the cannot cause harm is widespread. For key facts diseases they sought to cure. Today this is no about homeopathy see BOX 1. longer the case, and most homeopaths therefore use their remedies as a complement rather than The evidence an alternative to mainstream medicine – most, The trial data pertaining to homeopathy as a but by no means all. Whenever patients with treatment of rheumatic conditions have recently a serious condition opt to employ homeopathy been reviewed in some detail [2]. TABLE 1 summa- instead of effective interventions, harm is almost rizes the evidence available to date [3–7]. Only unavoidable. However, at present, there is no two studies exist that have tested the effective- systematic research of this issue with respect to ness of homeopathy as a treatment of ﬁ bromy- rheumatological diseases. algia [3,4]. They found encouraging results, but A relatively well-investigated example of two studies are clearly not enough for drawing homeopathy replacing effective interventions ﬁ rm conclusions. For osteoarthritis, the data are is the negative attitude of many ‘professional’ contradictory [5] and, for rheumatoid arthritis, (i.e., not medically trained) homeopaths the majority of the available trials are negative towards immunizations. Consulting profes- [6,7]. Thus, there is a paucity of reliable trials sional homeopaths and following their advice and a lack of independent replication. Different have now become major reasons for parents to rheumatic conditions have different underlying not immunize their children (doctor homeo- patho genesis. Therefore, a treatment might work paths and their professional organizations for one but not for another disease. However, the are often not against immunizations). If this totality of the available evidence fails to conclu- trend continues, we will lose herd immunity sively demonstrate that homeopathy is effective from infectious diseases, and epidemics from beyond a placebo effect for any rheumatic con- the past will be the likely consequence [10] . ditions. This is, of course, in stark contrast to Some homeopaths recommend using homeo- an upcoming WHO report, which apparently pathic remedies as an alternative to immuni- concludes that “the evidence was positive for zations. Helios (Tunbridge Wells, Kent, UK), rheum atic diseases” [8]. a major UK manufacturer, sells over a dozen

Box 1. Ten key facts regarding homeopathy. evidence in this area. If such information were provided, most patients may opt not to use home- Developed by the German physician Samuel Hahnemann opathy and, in those who nevertheless do, the (1755–1843) placebo response would disappear. Hugely popular in the 19th century Originally advocated as a true alternative to (i.e., replacement of) Unreliable research conventional treatments Homeopaths have published several ‘studies’ Presently again popular in the context of a boom in ‘alternative medicine’ with impressive sample sizes apparently show- Now mostly (but not exclusively) used as an adjunct to ing that homeopathy does, after all, work. For conventional treatments instance, Spence et al. published an observa- Based on two main principles: tional study including a large number of patients – Like cures like (n = 6544) with diverse diseases. A total of 10% – Ultra-high dilutions of these patients suffered from rheumatological Clinical practice involves elaborate, lengthy and empathetic conditions. They were treated with homeopathic history taking, which maximizes placebo effects remedies and various conventional treatments. Prescriptions are highly individualized The majority (71%) of these patients later Approximately 150 controlled clinical trials exist stated that they had improved and the authors The totality of this evidence fails to demonstrate effectiveness strongly implied that this improvement was due beyond placebo to homeo pathy [1] .

‘homeopathic vaccinations’. However, there is “…many pa ents are led to believe that no good evidence to suggest that these treat- homeopathy is supported by good science. ments are effective. The opposite is true, but few lay people will appreciate the o en complex issues of Unethical placebo research methodology. In defense of homeopathy, some might argue ” that it is useful for many patients through max- imizing the placebo effect. Placebo and other nonspecifi c effects have been shown repeatedly To claim that “homeopathic intervention to benefi t patients, for example, see [11,12] . A offered positive health changes” [1] or to con- typical homeopathic consultation lasts approxi- clude that “the study results show that homeo- mately an hour. Homeopaths ask a myriad of pathic treatment is a valuable intervention” [1] is questions regarding matters that conventional misleading. To mislead patients can cause harm. doctors would find trivial or meaningless. The fi ndings of such studies are invariably widely However, many patients feel warmly understood reported (e.g., in the lay press). Consequently, and like the idea of a remedy tailor-made for the many patients are led to believe that homeopathy complexity of their illness. Therefore, patients’ is supported by good science. The opposite is true, health may improve simply due to expectation, but few lay people will appreciate the often com- empathy and time. Many rheumatologists might plex issues of research methodology. The outcome view such effects as welcome. of such studies can, of course, be ‘positive’, in the However, they are not always positive. As total absence of any specifi c therapeutic effects, pointed out previously, the placebo response can due to a range of factors: regression to the mean, be at the expense of forfeiting an effective therapy, natural history of the disease, placebo effects, con- particularly if the homeopath is not medically comitant treatments, social desirability and so on trained. Moreover, the placebo response is unreli- [13]. If, in clinical trials, these factors are accounted able and usually of short duration. In addition, for, homeopathic remedies are regularly shown to we should not forget that effective treatments also be pure placebos [14,15] . generate a placebo response and that conventional doctors can (and should) also be sympathetic and Adherence to ethical standards empathetic. Crucially, the homeopathic placebo Most British professional homeopaths are reg- response is only possible if the most fundamen- istered in The Society of Homeopaths (SoH). tal rules of medical ethics are violated. Informed To be a member of that body, a practitioner has consent of patients would mean that patients are “agreed to be bound by and observe [the] Code being informed regarding the lack of plausibil- of Ethics, and supply the Society with a signed ity of homeopathy and the unconvincing clinical statement to witness this agreement” [102] . The

8 Int. J. Clin. Rheumatol. (2009) 4(1) future science group Harmless homeopathy? EDITORIAL

Table 1. Evidence relating to homeopathy as a treatment of rheumatic conditions. Condition Type of Findings Conclusion Ref. evidence Fibromyalgia RCT n = 30, rhus toxicodendron was superior to Not enough trial data available [3] placebo for some end points RCT n = 62, individualized homeopathy was superior to [4] placebo for symptomatic improvement Osteoarthritis SR Four RCTs with a total of 406 patients, two RCTs No ﬁ rm conclusions possible [5] suggested effectiveness while two failed to do so Rheumatoid SR Three RCTs with a total of 266 patients, one RCT The majority of the available trial data [6] arthritis suggested effectiveness, while two failed to do so fail to suggest effectiveness RCT* Failed to generate a positive result [7] *Published after the systematic review. RCT: Randomized, controlled trial; SR: Systematic review. code sets out the ethical rules by which mem- On the same website [103], we also ﬁ nd a bers must abide. They include the following plethora of therapeutic claims (BOX 2). statements [103]: None of these statements are supported by good [14] “All speculative theories will be stated as such evidence . They do ‘expressly or implicitly’ and clearly distinguished” claim “to cure named diseases”, and therefore vio- late the SoH’s Code of Ethics [102] . They are also “No advertizing may be used which expressly misleading and therefore potentially harmful. or implicitly claims to cure named diseases” Conclusion “Advertizing shall not be false, fraudulent, misleading, deceptive, extravagant or sensa- Homeopathic remedies are used by many tional” rheumatol ogical patients [1] . There is no compelling evidence that they are effective beyond The SoH’s own website includes the following a placebo effect. Rheumatic patients might be assertions [103]: harmed in a variety of ways through homeo-

“…Homeopathic remedies … work by gently pathy. The UK government’s chief scientifi c boosting the natural energy of the body” adviser, Sir David King, recently even warned that homeopathic remedies put lives at risk “Children respond exceptionally well to [104] . The risk–benefi t profi le of homeopathy homeopathic treatment…” as a treatment of rheumatic diseases is not

“Homeopathic remedies … work at an ener- demonstrably positive. getic level, stimulating the body’s own healing abilities…” Box 2. A selection of therapeutic claims of The Society of Homeopaths’ website. “Homeopathy can help boost your child’s natural immunity” (this assertion was made “Homeopathy can help with unwanted side-effects of in the context of childhood vaccination) medication … [and] lessen or even remove the need for some or all of your existing medication” Most homeopathic remedies are highly dilute “Homeopathy treats … acute fevers, sore throats and and have no pharmacological effects. Their toothache, and chronic illness such as arthritis, eczema, asthma, mode of action (if any) is unknown and even anxiety and insomnia” proponents of homeopaths admit ‘we don’t “Nux vomica 6c … [is] a marvellous hangover remedy” know’ [16] . There is no good evidence to show “Chicken pox … can be treated at home with homeopathic that homeopathy remedies affect the immune remedies” system of children. A recent systematic review “Homeopathy is an alternative to hormone replacement has failed to produce good evidence that it therapy” works particularly well for pediatric patients [17] . “Acute conditions [of children] such as ear infection, tonsillitis The above-listed statements [103] are therefore and ﬂ u, can be resolved rapidly using the right remedies” “…Homeopathy … can lessen the chance of side effects from highly speculative. However, contrary to what vaccination” the SoH’s Code of Ethics demands [102], they are [103] not ‘clearly distinguished’ as such. Taken from .

future science group www.futuremedicine.com 9 ERDITORIALEVIEW Ernst

Summary Future perspective Most homeopathic remedies do not contain Currently the evidence fails to show that any active molecules. Therefore, homeopathy homeopathy generates more good than harm. is often considered to be devoid of risk. This Future research needs to scrutinize the value article questions this assumption. It is argued of homeopathy according to generally accepted that homeopathic remedies have not been shown scientifi c standards. If homeopathy does not to be effective; using them as a replacement of meet these criteria, it will become obsolete. effective treatments can therefore cause harm. Using them as a placebo may be unethical. Financial & competing interests disclosure Furthermore, misleading information about The author has no relevant affi liations or fi nancial homeopathy may put patients at risk. The over- involvement with any organization or entity with a fi nan- all conclusion is that the risk–benefi t profi le of cial interest in or fi nancial confl ict with the subject matter homeopathy is not demonstrably positive. or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or “Future research needs to scru nize the value options, expert testimony, grants or patents received or of homeopathy according to generally accepted pending, or royalties. scien fi c standards. If homeopathy does not No writing assistance was utilized in the production of meet these criteria, it will become obsolete.” this manuscript.

7 Fisher P, Scott DL: A randomized controlled 15 Shang A, Huwiler-Muntener K et al.: Bibliography Are the clinical effects of homoeopathy Papers of special note have been highlighted as: trial of homeopathy in rheumatoid arthritis. placebo effects? Comparative study of • of interest Rheumatology 40, 1052–1055 (2001). placebo-controlled trials of homoeopathy and •• of considerable interest 8 No authors listed. The evidence for allopathy. Lancet 366, 726–732 (2005). 1 Spence DS, Thompson EA, Barron SJ: homeopathy. Complementary medicine. The most recent meta-analysis suggesting that Homeopathic treatment for chronic disease: a November/December 10, (2008). the effects of homeopathy are due to placebo. 6-year, university-hospital outpatient 9 Ernst E: The heresy of homoeopathy. observational study. J. Altern. Complement. Br. Homeopath. J. 87, 28–32 (1998). 16 Kayne SB: Homeopathic practice. Pharmaceutical Press, London, UK (2008). Med. 11, 793–798 (2005). 10 Ernst E: Rise in popularity of complementary Widely publicized observational study and alternative medicine: reasons and An insight into the thinking of homeopaths. that typifi es the limitations of consequences for vaccination. Vaccine 20, 17 Altnuc U, Pittler MH, Ernst E: Homeopathy such investigations. S90–S93 (2002). for childhood and adolescence ailments: 2 Ernst E, Pittler MH, Wider B, Boddy K: The Addresses the antivaccination attitudes systematic review of randomized clinical Desktop Guide to Complementary and shared by some practitioners. trials. Mayo Clin. Proc. 82, 69–75 (2007). Alternative Medicine (2nd edition). Elsevier 11 Kaptchuk TJ, Kelley JM et al.: Components Systematic review casting doubt on the Mosby, Edinburgh, UK (2006). of placebo effect: randomised controlled trial homeopathic notion that homeopathic Comprehensive review of all major in patients with irritable bowel syndrome. remedies work particularly well for children. complementary therapies. BMJ 336(7651), 999–1003 (2008). 3 Fisher P, Greenwood A, Huskisson EC et al.: An attempt to differentiate the Websites Effect of homoeopathic treatment on various factors that contribute to the 101 Alternative medicine now mainstream. fi brosistis (primary fi bromyalgia). BMJ 299, placebo effect. Channel 4 News. 27 Jul 2007 (Accessed 24th 365–366 (1989). 12 Zhang W, Robertson J, Jones AC et al.: The April 2008) 4 Bell IR, Lewis DA, Brooks AC et al.: Improved placebo effect and its determinants in www.channel4.com/news/articles/society/ clinical status in fi bromyalgia patients treated osteoarthritis: meta-analysis of randomised health/alternative+medicine+now+mainstrea with individualized homeopathic remedies controlled trials. Ann. Rheum. Dis. 67(12), m/630472 versus placebo. Rheumatology (Oxford) 43, 1716–1723 (2008). 102 Society of Homeopaths: Code of Ethics and 577–582 (2004). Meta-analysis demonstrating the potential Practice (2004) (Accessed 20th August 2008) 5 Long L, Ernst E: Homeopathic remedies for importance of the placebo effect for www.homeopathy-soh.org/about-the-society/ the treatment of osteoarthritis a systematic osteoarthritis patients. documents/CodeofEthicsApr04.pdf review. Br. Homeopath. J. 90, 37–43 (2001). 103 Society of Homeopaths (Accessed 20th 13 Ernst E: Dissecting the therapeutic Systematic evaluation of the totality of the response. Swiss Med. Wkly 138(1–2), 23–24 August 2008) data from randomized clinical trials. (2008). www.homeopathy-soh.org 104 Cockcroft L. Homeopathic remedies ‘put lives 6 Jonas WB, Linde K, Ramirez G: Homeopathy 14 Ernst E: A systematic review of systematic and rheumatic disease. Rheum. Dis. Clin. reviews of homeopathy. Br. J. Clin. at risk’. Telegraph, 19 April, 2008 (Accessed North Am. 26, 117–123 (2000). Pharmacol. 54, 577–582 (2002). 3rd October 2008) www.telegraph.co.uk/news/uknews/1571800/ Systematic evaluation of the totality of the Summary of all systematic reviews published Homeopathic-remedies-’put-lives-at-risk’.html data from randomized clinical trials. on the subject of homeopathy.

10 Int. J. Clin. Rheumatol. (2009) 4(1) future science group