Homeopathy

The concept of homeopathy is said to have originated with Hippocrates who thought of treating 'like with like'. It lay dormant until around 1790 when a German physician, Samuel Hahnemann, developed it further. He experimented on himself with quinine that was used to treat ague, the old term for malaria, and he found that he could reproduce the symptoms of the disease by increasing the dose. He concluded that it was the ability of quinine to mimic the symptoms of malaria that enabled it to cure the disease. He began to test other substances on patients. He called the practice homeopathy from the Greek homoios (the same) and pathos (suffering). He then experimented using poisons such as arsenic and belladonna in smaller and smaller amounts and concluded that they seemed to have a more specific effect on his patients.

His ideas spread throughout Europe and North America in the 19th century. As the scientific medicine of the 20th century advanced, homeopathy fell from favour. However, a number of homeopathic hospitals were incorporated into the NHS in 1948. NHS homeopathic treatment is still available and the Department of Health has confirmed that doctors can refer a patient for homeopathic treatment within the NHS.¹ However, not all Primary Care Trusts may have a service agreement with a provider of homeopathy. Also, a report in the Lancet in 2007 stated that "health service funding was being stopped for some of the UK's homeopathic hospitals, following an active campaign by doctors and scientists."²

There has been considerable interest in complementary and alternative medicine with a House of Lords Select Committee Report in November 2000³ and a subcommittee of the Royal College of Physicians set up to examine certain aspects. They reported in Clinical Medicine in 2003.⁴

In the UK, research published in 2001 showed that 47% of people have used complementary and alternative medicine (CAM) at some time in their lives and 10% use some form of CAM each year.⁵ Users tend to be older and female. Over 90% is purchased outside of the NHS. At least 10% of hospital physicians are also thought to use CAM as part of their clinical practice.⁶ A survey conducted in 2001 estimated that one in two practices in England now offer their patients some access to CAM.⁷

A report in the Lancet in 2007 stated that about 13,000 patients are treated at the five homeopathic hospitals in the UK each year. 14.5% of the population say that they trust homeopathy and £38 million is spent on homeopathy each year in the UK.²

There are a wide variety of homeopathic preparations, including ones made from belladonna (deadly nightshade), arnica, chamomile, mercury, sulphur, sepia (extracted from squid ink), snake venom and even compounds extracted from bodily fluids.

Homeopathic medicines are prepared by serial dilution in steps of 1:10 or 1:100, denoted by the latin numbers x and c respectively. At each step there is succussion, or vigorous shaking. The dilution most frequently sold in pharmacies is 6c, which is a 10^-12 dilution of the original mother tincture. Hence it is likely that a 6c dilution will contain just a few molecules of the initial substance, but much higher dilutions, such as the 30c (10^-60) will contain even less. A large number of homeopathic medicines have been described but about 200 are in regular use. Around 60% are of plant origin, the remainder are mostly of animal origin, mineral and chemical salts or disease products.

In prescribing such treatment, the homeopath will examine not just the symptoms and signs of the disease, but also constitutional factors peculiar to the patient, including their psychological state, environmental reactions and body habitus.

The mechanism of action of homeopathic drugs has never been fully understood or explained. The big challenge has always been around how such ultra-high dilutions can have clinical effect. The underlying philosophy is that the remedy will cause minimal symptoms of the disease and this will stimulate the body to begin the healing process.

The basic ingredient that is used is one that, if given in large enough quantities, would cause the symptoms of the disease. For example, the homeopathic remedy allium cepa is made from an extract of onions. If a person chops onions, they make the eyes sting and water and the nose run. Using the homeopathic philosophy of 'like for like', this means that a disorder with these symptoms should be cured by a small dose of onion. Hence allium cepa may be used to treat hayfever.

If 6c preparations contain just a few molecules of the original substance and higher dilutions are unlikely to contain even a single molecule, the mode of action is difficult to explain. In 1988, a French group published a paper in Nature claiming to have found that basophils continue to release histamine even when exposed to ultra-diluted anti-IgE, using the human basophil degranulation test.⁸ Others failed to reproduce these results.⁹

However, in 1999, a multi-centre experiment using a related method showed positive results.¹⁰ This led to the 'information medicine hypothesis' which is the leading current proposal for the mechanism of action of homeopathic medicine. It states that "water is capable of storing information relating to substances with which it has previously been in contact, and subsequently transmits this information to pre-sensitised biosystems. The process is thought to be mediated by structural modifications of water, analogous to the storage of information by magnetic media."¹ The shaking of the solutions (known as succussion) has been suggested as a possible mechanism for this.

There have been many publications and much debate and controversy about the evidence for homeopathy. On the whole, meta-analyses of homeopathy are inconclusive and don't provide sufficient information for conclusions to be drawn about homeopathy in general. Certain randomised controlled trails and clinical outcome studies have, however, shown some benefit. In summary: more research is needed.¹

In 1997, the results from a meta-analysis were published in the Lancet.¹¹ The conclusion was that homeopathy is more effective than placebo. However, criticisms were that they included studies looking at different clinical conditions and they were unable to state that homeopathy was more effective than placebo for any specific condition. These findings were not readily accepted as proof of the efficacy of homeopathy and a review in Bandolier was highly critical.¹² They praised the attempt to find and account for publication bias but they noted that:

• The median number of patients studied in each trial was 60.
• There were 24 clinical categories.
• There were four types of homeopathy.
• There were 50 classes of homeopathic remedy.

They noted that 42% of the trials found in favour of homeopathy but they observed that in trials of conventional medicine, such a disparate group of clinical conditions would not be assessed together.

There have been a number of Cochrane and other systematic reviews relating to homeopathy over the years. Some of these include:

• A review from Exeter of homeopathic arnica showed no benefit.¹³ Another study looked at homeopathic treatment after knee surgery (including arnica) and whether it reduced the need for morphine and found that it did not.¹⁴
• A 2003 Cochrane review concluded that it was impossible to assess the poor quality evidence about dementia.¹⁵
• The evidence about caulophyllum to induce labour is inadequate.¹⁶
• A Cochrane review in 2000 did not show enough evidence to support the use of homeopathy for asthma and it concluded that more research was needed.¹⁷ A review by the Centre for Reviews and Dissemination at the University of York also found no benefit from homeopathy for asthma.¹⁸
• A Cochrane review about the use of homeopathy to treat and prevent influenza showed some promising results but data was not strong enough to support/make a general recommendation.¹⁹
• There is no apparent benefit for reducing weight.²⁰
• Poor methodology of trials looked at in a systematic review was also a barrier to assessing homeopathy for depression. More research is needed.²¹
• A systematic review of homeopathy for anxiety and anxiety disorders could not draw any firm conclusions.²²
• A systematic review, published in the Lancet in 2005, concluded that the effects of homeopathy are no more effective than placebo.²³ However, the study has been criticised by the British Homeopathic Association.¹

Positive support for homeopathy

The British Homeopathic Association and Faculty of Homeopathy does, however, have a number of studies published on their website which they believe have been shown to support homeopathy by showing positive effects. They include studies looking at the treatment of asthma, influenza, glue ear, pain and upper respiratory tract infection.^24,25,26,27 However, they do also state that new, high quality, studies in homeopathy are needed. They point out that because of the individualised approach that homeopathy takes to treatment, where two patients with the same condition may be treated in different ways, this does make research more difficult.¹

A clinical outcome survey was conducted by Bristol Homeopathic Hospital between 1997-2003. It looked at clinical outcome in over 6500 patients treated with homeopathy, of whom more than 70% reported clinical improvement after homeopathic treatment.²⁸

It would seem reasonable to believe that even arsenic, diluted to the level of just a few molecules, is unlikely to be toxic and the evidence relating to homeopathy does seem to suggest that it is as safe as may be expected. However, adverse outcomes can result if an ineffective treatment is used for a serious and treatable condition.

Homeopathic immunisations are available and some parents opt for these for their children as they believe that they are safer than the conventional vaccines. However, they do not produce any antibody response and so, presumably, the children remain at risk of those serious diseases. Some non-medical practitioners claim that homeopathy is an effective substitute for immunisation but the Faculty of Homeopathy supports the Department of Health immunisation guidelines and provides an information sheet for parents.⁴ The faculty also advises against the use of its products for malaria.

The Society of Homeopaths is the largest professional organisation registering homeopaths in Britain. It has more than 2300 members who must satisfy the Society's educational and professional requirements and agree to practice within its code of ethics, standards and practice.²⁹

The Faculty of Homeopathy regulates the training and practice of homeopathy by medically qualified doctors, vets and other healthcare professionals. There is a published list of doctors who are members of the faculty.³⁰

The Medicines and Health Regulatory Agency introduced regulations in September 2007 that supported the use of homeopathic over-the-counter remedies for some conditions such as insomnia and constipation.²

There is some evidence that homeopathy may work for certain conditions but for many conditions for which it is currently used, the evidence is of poor quality and it is impossible to draw a firm conclusion about its effectiveness. However, we must remember that this is not the same as evidence of lack of efficacy. More research is needed in this area.

Complementary and alternative medicine does appeal to patients. We, as doctors, should help our patients to make informed decisions about their healthcare. We must provide them with the evidence about complementary and alternative medicine to aid their empowerment and decision making process.