Narrator - Dr. Abel 00:00 Welcome to HelixTalk, an educational podcast for healthcare students and providers, covering real life clinical pearls, professional pharmacy topics and drug therapy discussions. Narrator - ? 00:11 This podcast is provided by pharmacists and faculty members at Rosalind Franklin University, College of Pharmacy. Narrator - Dr. Abel 00:17 This podcast contains general information for educational purposes only. This is not professional advice, and should not be used in lieu of obtaining advice from a qualified health care provider. Narrator - ? 00:27 And now on to the show. Dr. Sean Kane 00:31 Welcome to Episode 40 of HelixTalk. I'm your co host, Dr. Kane. I'm Dr. Schuman, and I'm Dr. Patel, and in this episode, we're going to be talking about homeopathic medicine, and we're going to tread lightly because this is a very controversial topic, but we're going to talk mainly about what is homeopathic medicine, what is the evidence behind it, and how does that kind of apply to the role of the pharmacist. Dr. Khyati Patel 00:52 Glad you mentioned that Dr. Kane, because I have a friend back at home in India who is a doctor of homeopathy, and I always wonder, you know, how she does her practice, or what she does as part of treating patients? Dr. Sean Kane 01:04 Yeah, well, I think to kind of kick it off, defining what is homeopathic medicine and distinguishing that from things that are pretty similar, so that everyone's on the same page in terms of what is homeopathic medicine. Speaker 1 01:16 So it is the theory that this disease can be as something can be cured by a highly diluted solution of a substance that causes similar symptoms of the disease in Healthy People, or like cures, like I know one example is going to be for allergy treatment or for anaphylaxis treatment, but for itching, do getting something that is in itself an irritant, like maybe histamine. And so they take a small particle of histamine and then do a minimum dose of it. So the more dilute it is, the more potent it would be. So therefore you dilute down this histamine as an irritant, and then that product, what's left then becomes a treatment for itching. Dr. Khyati Patel 01:50 It's kind of like the analogy where you need a diamond to cut the diamond. Dr. Sean Kane 01:54 The approach of homeopathy, as Dr. Sherman mentioned, is twofold. One is that light cures light, and two is the law of minimum dose, that the smaller the dose is, the more diluted is, the more powerful or more potent the medication is in helping cure or mitigate a disease process in the body. Dr. Khyati Patel 02:11 So these substances essentially are diluted into water, and the way they dilute it is by shaking it multiple times. And basically we say that it leaves like a memory in the water. I mean, the substance in itself is so little it might not even be there. There's some speculations about that. But basically it's a very, very diluted substance in the water. Dr. Sean Kane 02:35 Yeah, and sometimes they'll also use like an alcohol or other solvents. But the the key here is that it's always a very, very dilute product that is shaken or hit against a surface, and that kind of imprints the molecules into the water itself. And then you dilute it more and more to the point where, statistically, probably don't have any molecules left of what you Speaker 1 02:57 started with. But again, because the water by, you know, by the kind of one of the main tenants of it that water has memory. So therefore, even though you remove it, those molecules of the water still contain some some knowledge or some memory of it. And so thus taking it still contribute those pharmacologic Dr. Khyati Patel 03:13 properties, right? And then nowadays, we hear a lot about people moving away from Western medicine, or the traditional medicine, and, you know, getting the approaches of complementary and alternative medicine. There are various different types of it. But one thing we need to keep in mind is that homeopathy is different than your herbal practice or vitamin supplements, acupressure, acupuncture, certain probiotics, chiropractor practices, magnets, stone therapy, etc, etc. Speaker 1 03:43 Yeah. One of the things I actually do my first slide, and this is why, Dr. Kane, I'm so glad you brought this up. One of my first slides when I talk about herbals is, I say, I just want to let you know this is, we are not talking about homeopathy today. I don't want to address it one way or another. And then we go into talking we're going to talk about herbals. We're going to talk about vitamins, minerals, weight loss supplements. But again, to separate that out from what you know, within the true definition of homeopathy, there's Dr. Sean Kane 04:07 kind of two reasons why we see overlap of homeopathy with many of these other complementary and alternative medicines or cam. One reason is that very commonly, when a homeopathic product is prepared, it uses some of these herbs as an example that could also be used in herbal formulations that you would buy over the counter as an herbal product. The other thing is that homeopaths, so people who practice homeopathy, commonly use many of these different strategies, not just homeopathic medicine, but they have kind of a holistic approach. It may include some of these other facets that are complementary and alternative medicine, but are not homeopathy. Speaker 1 04:44 So one thing I think that surprises a lot of people is looking at how common this is. We some you know, think, Okay, this, you know this. If this isn't something I haven't heard about, then maybe you know it's it's not that common. And thing is to look at the number of individuals when they did surveys, most. Reason that I'm aware of the 2012 National Health Interview Survey, they found out that 5 million adults in the US, so 2% of the population, 1% of one or 1% of the children, or 1 million used homeopathic products in the in the past year. And that's just the number that reported it, Dr. Sean Kane 05:16 and of those people that used it the total drug cost, so not including the cost of the homeopathic provider, but in terms of an office visit, but the actual drug cost itself last year, or a couple years ago, was $3 billion with a beat. So this is common enough that we see, you know, single number, percentages of people who are using homeopathic products, but also a pretty good amount of money in terms of healthcare dollars that go towards homeopathic products with the knowledge that the actual drug industry is, you know, multi billion dollar industry. So this is only a fraction of the actual health care dollars, but it still isn't nothing in terms of $3 billion Dr. Khyati Patel 05:53 so we heard about traditional medicine, and that the manufacturers put in lot of money into R and D, and then they jack up the cost of the medication to make the return out of it. When FDA approves it, how does the FDA approval happens for these homeopathic medications? Dr. Sean Kane 06:11 So it's actually really interesting, because homeopathic products, or medications, are regulated by the Food dragon Cosmetic Act of 1938 which is what we now consider the FDA. So around the night, the time of 1938 when they decided what is a prescription medication or a drug and what is not, they actually had a category just for homeopathic products, which is interesting, because at the time, the concept of homeopathy was almost dead. You know, they had somewhere between 10 and 20% of medical schools in the late 1800s were homeopathic schools, versus allopathic which is traditional medicine. At the time of 1938 there were no schools left of homeopathic medicine. So it's interesting to me that they had this provision in the 1938 act even though the art, if you will, of homeopathic medicine had really gone by the wayside in terms of training new clinicians. Speaker 1 07:04 And then just take a pair of contrast it to what the other things we have on the market. So OTC and prescription medications are required to prove safety and efficacy, but unlike those homeopathic medications, similarly to our dietary supplements, do not have to show that safety and efficacy. They have to, you know, once they're on the market, they can then remove them, but to get on the market, there's no sort of pre market approval needed. Dr. Khyati Patel 07:27 And so, you know, most of the listeners nowadays, you know, we all have electronic resources. You probably might not even heard of the term USP, which is the United States Pharmacopeia. But surprisingly, there is a Pharmacopeia for homeopathic medication that's approved in the United States. So any active ingredients that is part of this homeopathic medication, which is over the counter or prescribed, needs to be part of the HP us, which is the homeopathic Pharmacopeia of the United States. And this Pharmacopeia will describe the strength of the medication, the quality and the purity of the active ingredient in itself. Speaker 1 08:03 So for any listeners at home or in the office, if you look at a bottle, for example, of a homeopathic product, you will see the ingredient listed, and then you'll likely see the parentheses, HP, us. And that's compared to, say, an over the counter or, excuse me, or an herbal product supplement which may have USP in parentheses, again, from the United States Pharmacopeia, so that one difference, their different initials, different meaning. But you commonly see one of those two abbreviations on the product. Dr. Sean Kane 08:27 And this HP us is kind of how the homeopathic products get around having to prove safety and efficacy. Is that at the time that the HP us was was developed, they grandfathered the vast majority of the products that are in the HP us in terms of not needing to prove safety and efficacy. So at this point, many of the products are already in this catalog. And if you're a manufacturer of a homeopathic product, you don't have to do a study. You can just kind of cite this Pharmacopeia that has already been developed and is kind of approved by the US government. Dr. Khyati Patel 08:58 So for consumers of possible homeopathic medications. What should they be looking on the labeling when they are purchasing it over the counter? I know there are certain labeling requirements for non homeopathic OTC medications. Can you talk about that a little bit more? Dr. Kane, yeah. Dr. Sean Kane 09:16 So just like those OTC products, there are certain labeling requirements that the FDA Act requires. So one is that, especially if it's an over the counter formulation, it has to describe an indication that is a self limiting indication. For example, it could be a headache, flu symptoms, kind of aches and pains and things like that. So they have to describe what it is indicated for. For serious Speaker 1 09:38 conditions, a prescription is required in about 5% of those cases. And rather than go into them at all, we can say that the criteria varies based upon States. Some individual states will have minimal requirements as to who could prescribe others to say it needs to be a physician or another traditional prescriber, Dr. Khyati Patel 09:55 and on the label, we know, unlike the other OTC medication, just. Sometimes just the active ingredients. This needs to list all the ingredients. So the active ingredients needs to also have strength listed, basically how many times it's diluted. And usually this is denoted by a Roman numeral. So 1x means it's 10th of a dilution. 2x means it's 100th of a dilution. You will also see 1c which is which is also 100 of the dilution. But then you will also see 2c which is 110 thousandths of a dilution. Dr. Sean Kane 10:29 And just to break it down a little bit in terms of what's going on, if I wanted to make, let's say 2x product. What that means is that I'm going to take, let's say, one mL of whatever herbal product, I think is a homeopathic product. I'm going to add that to nine mls of a solvent like water. So I have one part per 10 of total parts in this solution. I'm going to mix it up, shake it up, pit it against an old book or whatever. And then within that, I'm going to take, let's say, one mL of that mixed solution. I'm going to do it again. That would be a 2x solution, given that I've diluted it one to 10 two times. And the same is true with the C, but with the C, instead of diluting it into 10 parts, we'll dilute it into 100 parts. So the number is how many times you do the dilution, and then the Roman numeral is how dilute it is when you do that dilution in the first place. Dr. Khyati Patel 11:21 In addition to the dilutions, this label should also include the direction for you. So that's common practice for other OTC ingredients, OTC medications as well. Speaker 1 11:31 So some examples of products that you may see on the shelf, or, you know, we call maybe the top sellers of our homeopathic remedies would be, would be, and they have some some interesting names of pain relief, homeopathic analgesic, topical cream, relax calf and foot cramps. Those are available tablets, comms, forte, sleep aid, gout control, Camellia, teething relief, very descriptive one, nervous tension, anxiety and worry relief, 4.5 out of five stars, though, on Amazon, another one, ocelo coxine, it's for flu. Five Star Review. 849 reviews, though. So again, people are using these products. Dr. Sean Kane 12:07 And just to kind of emphasize the Oscillococcinum, this is one of those homeopathic products that I would I would say is one of those hotter homeopathic products, not just because on Amazon, it has 800 something reviews, but this is frequently mentioned in the literature specifically because of the product involved in the dilution involved. So the dilution of this Anas barbariae, which is the active ingredient, is 200 C, which is equivalent to one part of the Anas barbariae to 100 to the power of 200 which means basically that there are no molecules left. And the other interesting thing is that this Anas barbariae is extracted from the liver and the heart of a goose. So even if a goose was expensive, the production of this would be incredibly cheap, just like all other homeopathic products, because you don't need much to start with, as you're diluting out all the way to 200 C, it's almost a statistical guarantee that there are no molecules left when you have this final product, which makes Speaker 1 13:05 it interesting then, because, again, for a quality control standpoint, it's hard that you can't then go back and see, for example, in herbal medications, there's been some controversy about, well, we run it and analyze it to see if it's really what it's supposed to be. If it's essentially diluted to where there's nothing there. It's hard to then prove whether this water I'm holding is the same as the water you're talking about. Dr. Kane. Dr. Sean Kane 13:25 And again, with the theory, or the proposed mechanism, of homeopathic medicine, the theory is that the water has some memory of this ingredient, and that the more dilute you make it, the more potent or powerful it is. So we can't measure water memory, at least we don't know how to and that is kind of the rub of many of the homeopathic medications. Dr. Khyati Patel 13:48 So I remember, you know, a lot of moms who had their kids sick with flu like symptoms and stuff, picked up Oscillococcinum from the aisle of homeopathic medication and brought it to the pharmacy when they were picked up, you know, their medication, prescription medications, too. So again, this is not a cure for flu. It's basically reduces the duration or the symptoms when you have Dr. Sean Kane 14:10 the flu, yeah. So that's a great segue into, you know, how effective? What is the efficacy of these homeopathic products as a whole? But also, you know, focusing on a couple particular ones, generally speaking, if you were to talk to a traditional Western healthcare provider, so we call those allopathic providers, they're going to argue that homeopathic products are definitely no better than placebo and no worse than placebo, so no side effects, no efficacy, that the effects that we see are placebo effects, and that's How that they would argue that. Speaker 1 14:42 But then a proponent of homeopathic medicine will come and potentially will cite one of a few of a small selection of clinical trials for some of these products, and they'll show a positive effect. And then there's also many, many positive reviews, again, that we see in various publications or various sites. And then there can be some clinical. Experience as well. Somebody saying, This is what I used, and it was for my patients, and Dr. Sean Kane 15:03 it was beneficial. So essentially, we have lots of kind of word of mouth evidence, and we have lower quality, you know, traditional evidence based medicine articles that are available, some of which do show some benefit, but many of them have methodologic flaws that introduce a lot of bias that make us wonder whether the effect that we see is a true effect or not. Speaker 1 15:24 Yeah, it's difficult to run a randomized, controlled trial if you if different patients are receiving all sorts of different treatments, and again, the consistency internally of them. It's hard to quality control or check those when you're providing a product to many people about whether or not it's standardized, right? Dr. Khyati Patel 15:39 And then also, from what I know, back in the days in India, when my mom used to be on this medication, I know that if I'm treating somebody's thyroid that medication, it's going to be different for Mrs. X versus Mrs. Y. So again, we can't do a standardized dose studies using homeopathic products, but based on the available evidence, basically, we find out that homeopathic medication is no more effective than a placebo. What you said, Dr. Kane, that, you know, there are huge methodological flaws in these trials. We haven't found whole lot of randomized, you know, blinded, control trials for these ingredients Dr. Sean Kane 16:20 either, and also, which is a very common theme in many of the complementary and alternative medicine trials, we see a lot of bias introduced because the manufacturer of the product is the one that runs the trial, collects the data, analyzes the data, and makes the publication. Then, also, in the same vein, with this cam realm, we see publication bias just like we do in normal medicine, in that if you're the manufacturer of Oscillococcinum And you have a negative result, you're not going to publish that data, because no one's forcing you to publish it, and the FDA is not going to go to your asking for data, whether it was positive or negative data. Speaker 1 16:54 And the one thing we can do, as always, is go to a meta analysis to then look at these different pieces of data, try to fit them into a bigger puzzle and see kind of what that picture gives us. And what we find is that the smaller, low quality trials are most likely you say there's a significant benefit, but then it doesn't always hold up when you get to more robust trials. And admittedly, though that's the same thing what we see in in traditional medicine as well, a lot of treatments will talk about a benefit, and you know, 1020 people, but then when you hold it up to a more robust randomized trial, you don't see the same benefit. Dr. Sean Kane 17:27 And this is a common danger in meta analyzes, is where you take really low quality data by grouping them together, it doesn't magically turn that data into golden data. So bad data in is going to equal bad data out. So the meta analyzes that we have do their best, and that's all we can ask of them, with the notion that whatever conclusion you come to because you have poor data, initially, you're not going to just magically come up with the best possible reasoning or answer in your meta analysis. Absolutely. Dr. Khyati Patel 17:56 And we have some other evidence available from around the world. So in 2015 the Australian Government published, or kind of conducted, a comprehensive assessment. They have their equivalent of FDA, which is the National Health and Medical Research Council, and they found that there is basically no health conditions for which any homeopathic medication is effective. Dr. Sean Kane 18:20 And in 2005 there was a review published in The Lancet that said that if you only look at the high quality trials that are out there, so if you exclude the really low quality in terms of flawed trial designs and things like that, homeopathy was no better than placebo in that circumstance as well. Speaker 1 18:36 And then in 2007 Al tunk and colleagues suggested that homeopathy in children and adolescents. At first, it didn't have any convincing, convincing evidence of efficacy. And then secondly, the available data there, once again, was in both low quality and then very limited. Dr. Sean Kane 18:51 So to kind of summarize it, we just don't have good trial data to either support or refute you know whether homeopathic medicine is something that is efficacious. I think based on the data that we do have, it would suggest that it probably is no better than placebo, although there are some trials that do have quote, unquote promising effects, but it's hard to take those trials in the face of many of the methodologic flaws in the studies and publication bias and manufacture bias and things like that. Dr. Khyati Patel 19:17 So we pretty much ruled out that there is no effect of the homeopathic medication. What about side effects of these meds? Dr. Sean Kane 19:26 And that's a great question, because probably the lack of side effects is one of the biggest reasons why consumers tend to like homeopathic products is that they don't see the side effects that they see with more of the Western allopathic prescription medications. So again, water with memory is still just water. So we don't see adverse effects from these products because they don't have any active ingredients that are retained in the products because of the multitude of dilutions that occur. Speaker 1 19:53 Now, there has been one, I guess, fairly important product, that was implicated with a serious adverse reaction, really, within the last. Few years, and that one is the Zicam nasal swab. And so what these were is one dilution and two dilution. So 1/10 and 100th zinc based salts were actually removed from the market because permanent loss of smell from their use. So, you know, we think of certain products, certain herbals over the counter, homeopathic as being safe. But every now and then, we have to remember that these still are medical products, and they still can't have issues. Dr. Sean Kane 20:24 And proponents of homeopathy would say that that Zicam zinc-based nasal swab was not very dilute, and that's the reason why you see some of these adverse effects, is that it wasn't really following the philosophy, if you will, of homeopathic medicine. With that said, I think that really exemplifies this gray zone of is it an herbal product? Is it a vitamin or mineral, or is it an actual homeopathic product? This is really close to being both, which, again, I think adds to some of the confusion about homeopathy Dr. Khyati Patel 20:53 and so much then not giving them any side effect, I'm afraid that I'm not going to be able to treat the condition for which I'm giving this medication to the patient. So for example, if patient has real infection, they probably will need an antibiotic, which is proven in clinical trials that would eradicate the infection or treat the infection. I'm not sure, sure if you know, I would be giving an homeopathic medication, hoping that patient would get better. Dr. Sean Kane 21:19 Absolutely, and that's really the problem. So as clinicians, we're not really worried about the side effects. There are no drug interactions with any homeopathic product. We're worried about basically not giving the patient appropriate therapy and instead giving them something that is not proven and is not effective in the face of something that is proven and effective, that is either available as a prescription or an over the counter product. Speaker 1 21:39 And then again, the harm is also going to come, if you think about the opportunity. Cost here. So most homeopathic products are not cheap. So what are you substituting? You know, what are you doing instead of that money if you're spending it for the homeopathic product is that, you know, coming at a cost of other supplements or even prescription co pays that I have, you know, limited resources here, am I going to divert it from that medicine to this homeopathy. And so again, is what are we not giving then potentially that would work versus something that we are giving them instead. Dr. Sean Kane 22:09 And for me, at least the two most concerning examples of basically giving this homeopathic product in the face of an actual product are quote, unquote, homeopathic immunizations. These are not safe and effective, and we do have safe and effective immunizations for flu and many of the you know, viral childhood illnesses, it can be very severe and bacterial illnesses. But then two, I was reading about homeopathic malaria prevention, which, again, is not safe and effective when we do have safe and effective malaria prophylaxis regimens. So that's those two are great examples of it doesn't make sense that those products would be available to a consumer when we have these other products that we know are safe and effective and proven because I think it's misleading to the consumer, especially in those scenarios, absolutely. Dr. Khyati Patel 22:54 And you know that goes back to your 4.5 out of five stars on Amazon. I mean, the product is basically being sold because of the consumer reviews and how they, quote, unquote, feel when they take this medication. Dr. Sean Kane 23:06 And, you know, to be honest, for this HelixTalk episode, I think at least I was a little bit hesitant, because this is such a polarizing topic. I don't want hate mail, although I do want email from listeners about their impressions. But this is so polarizing, if you take any side on this issue, there are plenty of people on both sides that are equally fervent in arguing on their own behalf. Speaker 1 23:28 And certainly, and it's area too, where not everyone. It's not simply a black and white, because again, is many individuals, and many probably in the in the audience listening, who use herbal medicines, who use complement and alternative medicines. Who then may say, well, they those individuals themselves, may say, Well, I agree with homeopathy, or I may not. So it's not even an alternative versus traditional, but even sex within that, that group Dr. Sean Kane 23:52 as well. You know, in terms of why it's so polarized, it's definitely the what is homeopathy versus other? Cam, complementary and alternative medicines. The other thing that makes it so controversial is basically the scientists and clinicians arguing that it just doesn't make sense. And I think that if you think about the dilution and the concept of water retaining memory of the substance, and things like that, that really flies in the face of what we know about chemistry and physics and biochemistry and how drugs interact with the body and things like that. As an example, 30 C, which is a very, very common dilution that would be one part per 10 to the power of 60. So very, very dilute. If you think about Avogadro's number, which is 6.022 times 10 to the 23rd that means in one mole. So if we take table salt as an example, 58 grams is one mole of table salt, sodium chloride, that has basically six times 10 to the 23rd molecules in it. And if you dilute a substance all the way out to 10 to the 60th statistically, you have no molecules in your final dilution. And because of that, that's one of the biggest arguments from more of the allopathic medicine. Side is that it just doesn't make sense that you would give someone something that has no molecules left over in it. You've diluted it out all the way Speaker 1 25:06 you compare it to again, we do a lot of things that we measure in parts per million, and we're not even close to million there. We're many, many, many zeros past parts per million. And I Dr. Sean Kane 25:15 don't have any of the examples, but many of the opponents of homeopathic medicine liken it to pouring table salt in the ocean, and that's essentially kind of the dilution that you're getting. And I think that on the side of homeopathic medicine, they would argue absolutely, that makes it so much more potent. That's the entire intent. And that's why there's this discussion or debate with it, is that, although on the allopathic side, people say that doesn't make sense. On the homeopathic side, people are saying that's exactly what we want. Dr. Khyati Patel 25:44 So basically, what needs to be done is probably the proponent of homeopathic medication need to probably have an organized research done with the very high quality evidence available. Maybe that would prove the allopathic proponents wrong. Speaker 1 26:00 Alright, sorry. But again, even there, it's hard, because even the opponents of homeopathy is sometimes not always tactful. I mean, you hear talk about quackery pseudoscience, you know that we're taking back to the Dark Ages some of our scams or nonsense things like that. So again, it's really hard to get that meet in the middle, kind of approach to rationally discuss these things. Dr. Sean Kane 26:18 Yeah. So to kind of wrap up, I think it would be helpful to for the listeners to kind of talk about, you know, from the pharmacy side, if you walk through any retail pharmacy in the US, you're very likely to see a number of homeopathic products. We've mentioned, a couple of them for aches and pains, flu symptoms, for helping you sleep at night, things like that. So kind of, what is the role of the pharmacist in homeopathic medicine. Dr. Khyati Patel 26:42 I think the biggest thing I can compare this to is, again, I'm talking about an herbal product and not really a homeopathic medication. Is when I see patients for diabetes in my clinic and they say they're taking cinnamon. Now we know with cinnamon, there is half of the evidence available that said it works. Half of the evidence says it doesn't work. So basically, it neutralizes the effect. And to me is, you know, as long as it's not harming them, as long as they're not choking on the powder or having heartburn, because it can cause, you know, it's a spice and it can cause heartburn, and it's inexpensive to their pockets, then they can go ahead and take it, because they would feel that I am doing something to help my diabetes, you know, I'm not only listening to my doctors and doing all this, but I'm taking cinnamon on top of it. So it's kind of like going back to then homeopathy. Well, it's kind of like placebo. It's not going to be effective, but it's also not going to hurt them, as long as, you know, it's not an immediate condition, like an infection, or they're in ICU or something, Speaker 1 27:44 and that's where the proponents would say, yes. And we're also going further than that. It's not just the providing, the provision of something that's, you know, there's questionable efficacy, or at least it's, it's negligible, but it's also this holistic approach too. Is we're not just giving them the substance and just saying, hey, it may work or it doesn't see it later, but then there's, there's discussion, there's consultation. And we think about, admittedly, this is what's going to look attractive versus some of the ways traditional medicine may have gone, where we're talking about, you know, shorter appointments, sitting down for a few minutes, writing something down, handy restriction, versus an opportunity to have that meaningful discussion, and that that holistic approach. And again, that's what's going to look very attractive. And sometimes we know from placebo studies that it's those interactions, those meaningful interactions, of everyone that's into the study that that provides benefit on its own. Dr. Sean Kane 28:31 Yeah, and I think that maybe not so much with diabetes, where there's measurable things, but especially with the touchy feely symptoms of well, you know, do your legs ache at night. If we give a placebo to that patient, whether they know it's placebo or not, if it helps. Does it really matter that it's only placebo? You know, there's all sorts of tricks to make a placebo better, and it could be playing it up, as the healthcare provider saying how many patients you've given this to and how many of them seem to benefit from it, reading Amazon reviews is kind of the surrogate for that. Being more expensive. More expensive usually means it works better in terms of a placebo effect, better packaging, better marketing, bigger claims in terms of how effective it is, and things like that. All of those really contribute to the placebo effect. And even if you don't believe in homeopathic medicine, some argue that the placebo effect is real enough that if it is a self limiting condition where we don't have treatment for it, like an antibiotic as an example, does it really matter if we're giving the patient placebo, and we know they're getting placebo, and maybe even the patient knows, but in the at the end of the day, if they feel better, does that matter? Absolutely. Dr. Khyati Patel 29:36 And you know, just segueing back to the holistic approach drum, you mentioned, more and more pain management providers are using that approach, where they're not only trying the opioid like medications to treat the pain, but then they're doing all this cam therapy. And one of the segues to Cam therapy could be this homeopathic medication, even if it's giving placebo effect. Speaker 1 29:57 And we know people are starting to look at. Square for it. As, as you mentioned, again, going back to pain manager, that as individuals move away from some of the opioid types treatments that we are having a huge demand at our facility about, you know, looking at things like acupuncture and acupressure as techniques, really, again, as just thinking in these global tools. So people are continuing to be interested in these and and we so we know a lot of the reviews you're going to get on these, on these sites, again, going to Amazon are going to be pretty positive. So most of them will say, either it really does work, or it doesn't have any interactions, or doesn't have side effects or or listing it is all natural. And those are emotional words. You know, all natural. Again, that is something we you know as consumers. You know many other areas of Food and Agriculture go in that same way. So those are very important, powerful things to say. Dr. Sean Kane 30:42 And I'm looking through some of the Amazon reviews for some of these more popular products. A couple of them stood out to me just to share. One was for neuropathic pain cream, and the the user who provided the review said, this is apparently a very smelly cream. He said that the smell was not offensive to him. In fact, if it was odorless, I would probably think it didn't work. But seriously, it works. So again, thinking about what are factors that provide a better placebo rate, something like a very strong scent or something visually, how the product looks or the packaging really plays a huge role. And again, thinking about some of the other comments that we've seen for a foot cramp tablet, the user said that they're worth their weight in gold to me, and well worth the expense. So it's not that consumers don't realize it. It's an expensive proposition, but from their point of view, if it quote, unquote, works, they don't care as much about the cost of it. Speaker 1 31:35 Yeah, just another example for that tells us a lot of information about individuals as well as the reasoning is looking at an Amazon review excerpt for a kit that contained 36 different homeopathic remedies, and each one was at that 30 C concentration, so fairly diluted. There they said, I also use these on my pets, with great success. And I'm a beginner when it comes to homeopathy, and I'm very overwhelmed by the number of remedies available and the number of ways to determine which remedy is right for which person which symptom, when you get it right, the results are near miraculous. So again, that an individual using strong language like that, in and of itself, is going to is going to propagate more and more use of these. So it's important to discuss and be aware of it. Dr. Sean Kane 32:13 And anytime I see reviews like this for anything, my brain immediately goes to like a telemarketing thing that you'd see on TV where you know you have a vacuum cleaner or OxiClean or whatever, that they use adjectives that even if it doesn't work, your brain is conditioned to think it's miraculous, or it's so effective, and things like that. And I think that, again, that contributes to this placebo rate that we see. We're all flawed in the sense that flu symptoms that improve over time, we can't tell whether it was time that helped your flu symptoms or the ocelotoxin that you took. So because of that, we see this cause and effect versus Association and causation, and we jumped to the fact that this medication must have made that effect. Dr. Khyati Patel 32:55 So bottom line, what do we do as pharmacists? Is it really ethical for us to go ahead and recommend or even sell a medication that is not effective. I mean, we see, you know, an aisle in pharmacies that says homeopathic medication aisle. So what do we do Dr. Sean Kane 33:10 about that? At least for me, I am very on the fence. For me, I don't believe that any of the homeopathic medications have strong evidence to suggest efficacy, and I know that they are extremely safe. If I was a pharmacist at a retail store, I'd have, I would definitely never recommend a homeopathic product, and I feel very hesitant to sell a homeopathic product, and a patient was very passionate about obtaining that product, given what I know about the lack of efficacy benefit that we can see with it. And again, Speaker 1 33:39 in a similar way, my concern, too is going to be, is if they are to be used, I would say, could it, you know, potentially in combination with existing evidence based treatments, but never, never, never. Should have used as an alternative again, unless there were serious, serious contraindications to what we already have. That I don't think this is just a substitutionary, or at least not at its goal, right? Dr. Khyati Patel 34:00 And my concern would be that they're, you know, it's okay if they're using it for what you be said, touchy feely, you know, subjects or diseases. But I've seen episodes or incidences back home again in India, where patient had a dengue fever and did not want to go along with the allopathic medication. This is a real infection which could be detrimental if not treated properly. That person was ordered to homeopathic medication to treat this infection, and turned out that the person passed away due to the complications. Had that person sought out real medical care, emergent medical care at a hospital or a clinic, a regular doctor clinic, there might have been a different outcome altogether. Dr. Sean Kane 34:42 Yeah, and I think one of the problems here is that, financially, on the business side, every retail pharmacy has a vested interest in providing these homeopathic products. And the same reason that they're providing herbal products, the same reason that they're providing cigarettes and beer, they make money off of these products. And in the case. Threats. There's kind of an ethical issue in providing that in a healthcare scenario. That's kind of the rub is that the pharmacy in the store makes money off of selling these products, and I'm sure that the markups are quite good, given that there's no active ingredient in these products. I don't even know that if you objected as a pharmacist, that you'd be allowed to remove any of these products from the shelves, because I'm sure that they build enough revenue to pay for your salary in the first place. Yeah, again, Speaker 1 35:22 just to look at, and that's where it's been polarizing. Even we can go back a little bit of cigarettes, where CVS has pulled cigarettes from their stores, Walgreens has not. So even within, they can be then polarizing. And you may see a similar polarity there, within a lot of places, in terms of homeopathy, as well as if you know something, again, you know may be concerning, or you're concerned about what people are not using. You know, is it? You know, within your practice and your morals and your ethics, you know, do you consider those kinds of things in terms of what you're selling? Dr. Sean Kane 35:49 So I think that wraps up our discussion on homeopathic medicine. Clearly a controversial topic, plenty of ethical dilemmas involved in it, plenty of issues with evidence based medicine, and what is appropriate versus inappropriate in terms of how we're treating patients, and certainly something that we'll keep a pulse on as we move forward. So with that, if you haven't given us a five star review on iTunes, we'd really appreciate it. We're trying to climb up the medical podcast category in iTunes. You can find us at HelixTalk.com with that, I'm Dr. Kane, I'm Dr. Schuman, Dr. Khyati Patel 36:17 and I'm Dr. Patel, and this time, I'm going to say, educate your patients. Narrator - Dr. Abel 36:20 Well, if you enjoyed the show, please help us climb the iTunes rankings for medical podcasts by giving us a five star review in the iTunes Store. Search for HelixTalk and place your review there Narrator - ? 36:32 to suggest an episode or contact us. We're online at HelixTalk.com thank you for listening to this episode of HelixTalk. This is an educational production copyright Rosalind Franklin University of Medicine and Science.