I think the only controversial principle of homeopathy is the degree of dilution of the medicines but one of the other principles that at first glance doesn’t make sense is that a smaller amount of something can have a greater effect. I think there are a number of reasons why that’s counterintuitive at first. One is that with poisons and drugs we’ve got used to the common phenomenon of bigger doses having more powerful, usually more toxic effects. You can be sure that if a small amount of a substance poisons you then a larger amount will poison you even more. In fact, it will probably kill you. That’s absolutely true. But if you reverse the direction, is it also true that a smaller amount of something will do the same as the larger amount did, but just more weakly? Strangely, the answer is……not always!
Here’s a couple of examples. Aspirin in large amounts increases body temperature. In fact, one of the signs of an aspirin overdose is hyperthermia. But a small dose of aspirin doesn’t put up the body’s temperature just a little bit. In fact it does the opposite. It lowers the body temperature, which is why we use it to treat a fever. Digoxin (from the Foxglove plant) in a high dose causes a highly irregular heart beat, but a small dose of digoxin doesn’t cause a small amount of irregularity, in fact it does the opposite. It produces a regulation of an irregular heart. An old term for this phenomenon is ‘hormesis’. It’s a term which fell into disuse but which has begun to reappear in two interesting areas.
First of all, in the area of toxicology. There’s an organisation called the International Dose-Response Society which seeks to promote research into hormesis. They distribute a newsletter from a scientific grouping which studies BELLE (Biological Effects of Low Level Exposures). You can find a radio item about this on CBC.
Secondly, Richard Bond, an Associate Professor of Pharmacology at the University of Houston, has proposed the term “paradoxical pharmacology” ( Bond, R.A.: Is Paradoxical Pharmacology a strategy worth pursuing? Trends Pharmacol. Sci 22: 273-276, 2001). This is a proposal for research to be done into the use of smaller amounts of drugs given intermittently in some situations to produce curative effects instead of the tolerances and toxicities which come from the use of large amounts constantly. His main area of interest is into the effects of beta blockers, which are drugs which are designed to block adrenaline and noradrenaline which increase the contractility of the heart. Logically, in a condition like heart failure where the body responds to the changed heart function by releasing more adrenaline and noradrenaline to increase the contractility of the heart, beta blockers should have made the situation worse. And in the short term they can do exactly that, but in the longer term they actually improve the situation. As he says –
Therefore, the paradox remains as to why impeding a contractile system results in an increase in contractility.
He cites the use of stimulants such as amphetamines to treat hyperactivity in children and skin irritants such as retinoic acid and benzoyl peroxide are used to treat acne, which is an inflammatory skin condition as other such paradoxical examples. (it’s also known than giving sedative antihistamines, like ‘phenergan’ to children who don’t sleep makes them more awake!) His potential explanation for these effects is interesting –
acute and chronic effects of drugs often produce opposite effects. This is particularly true for receptor-mediated events. For example, acute agonist exposure can produce activation of receptors and increased signaling, whereas chronic exposure can produce desensitization and decreased signaling
We tend to think of the chronic effects of something as just being a linear extension of the acute situation but that’s actually not true. Here’s his rather startling conclusion –
if acute versus chronic responses are often opposite in nature, and if the contraindications [of drugs] have been made based on the acute effects, there is a suggested list of where basic research can begin to look for clues to investigate paradoxical pharmacology. It is the list under ‘Contraindications’ because the opposite of contraindicated is indicated. This is the list where one would have found β-blockers in CHF just a short time ago. I suggest we test the first precept of medicine, ‘do no harm’, and determine its validity by performing basic research with paradoxical pharmacology. If medicine and pharmacology behave as other areas where short-term discomfort produces longer-term benefit, it might well be that we have paid a high price for accepting a presumption.
This is really another example of the non-linear nature of reality. You can’t take a simplistic notion like more of something will do more of the same so less of something will just do less of what more is, and declare it as a Truth. Life, it turns out, is more complex, and way more interesting! It’s Good Science.
Heroes Not Zombies 
All well and good, but do you accept that if a patient is given no aspirin at all, it has no effect and if a patient is given no digoxin at all, it has no effect (notwithstanding any placebo from the action of giving the patient a drop of water or a lactose tablet)?
Homeopathy implies efficacy from a lactose tablet that was once in contact with some water which was once in contact with some other water which was once in contact with an arbitrary substance with only the most superficial connection with the patient’s condition (dilution is far from being the only controversial aspect of homeopathy!). Once you pass the limit of Avogadro’s constant in your dilution, you can continue diluting all you want because you are no longer dealing with small amounts but with none at all. ‘Paradoxical pharamcology’, intriguing though it may be, is irrelevant to homeopathy.
I’m also concerned (but not overly surprised) that you chose to respond to Andystat’s question in the comment on a previous blog post by ignoring his query and simply copying a list of criteria off the MHRA site. The question (which Andystat copied from me, with permission) was about your personal ethical stance. As a practising NHS homeopath you are happy to prescribe to your patients treatments, at taxpayers’ expense, for which there is absolutely no evidence beyond anecdote (in fact for which there is ample evidence from clinical trials showing that the treatment doesn’t work). That’s your personal moral choice.
The point is: if the same situation applied to a non-homoepathic treatment, if GlaxoSmithKline announced a new wonder drug for treating condition X and there were lots of patients who claimed it had helped them but all the clinical trials of the drugs showed that it had no effect whatsoever, would you be happy for the MHRA to grant Glaxo a license to sell that drug?
Hi Bob
… long time since we last spoke. I find your blog beautiful and impressive and fun. I’m planning to start a blog myself and I would really appreciate any advice you have for a new blogger. I plan to have a somewhat different but overlapping focus to Heroes not Zombies. Provisional title is Stress, Health & Well-Being. Do email me direct unless you feel this is a subject for more general discussion.
All good wishes for you
As aye
James
“I think the only controversial principle of homeopathy is the degree of dilution of the medicines”
But it’s not really a matter of degree is it? 10^-60 is far beyond what anyone could reasonably term “a degree of dilution”. It is a qualitative difference. The difference between something and nothing.
Are you the same M J Simpson who’s the Douglas Adams expert? I really enjoy Douglas Adams’ work. I haven’t read SFX magazine though (if I’ve made the right connections your website says you’re a staff writer there) and I must confess I have no expertise in Science Fiction or genre films. What I do have is almost 30 years experience working as a medical doctor.
Let me take your points one by one and give you my answers.
Do I accept that if a patient is given no aspirin, then they get no aspirin effects? Well, you have to take into consideration your placebo proviso there cos in any drug trial you’ll see some subjects who receive the placebo get some or all of the same effects as those who get the actual drug. This whole placebo phenomenon is quite fascinating. You’re probably also familiar with the nocebo effect where people on a trial might actually get harm from a placebo eg hair loss in a trial of chemotherapeutic drugs. You’ve probably also seen the studies where they gave medical students either an amphetamine or a barbiturate but actually told those who got the amphetamine that they’d been given a barbiturate and those who’d got the barbiturate were told they’d got the amphetamine. Interestingly they experienced the effects of the drug they’d been TOLD they’d been given even though the actual drug they’d received should have had the opposite effects.
Maybe paradoxical pharmacology is irrelevant to homeopathy, or maybe its not. I’m not sure we can say we know enough about it yet. But the reasons I mention it are that first of all, as you agree, its interesting, and secondly, it’s a good example of how real world phenomena are not as simple and linear as we used to believe they were.
Ah, you’re questioning my morality, is that it?
Well, my ethics are based on doing the best I can for each and every patient I meet. That involves prescribing the most relevant drugs, arranging for appropriate surgical interventions or counselling or whatever it is that seems to be in the best interests of the patients. What would be unethical would be for me to impose my beliefs on the patients who consult me. But I’m not the kind of doctor who says “I don’t believe in that kind of medicine so you can’t have it” I do practice Evidence Based Medicine. If the evidence base on homeopathy was as sure, and cut and dried as you imply there simply wouldn’t be any doctors or scientists who disagree with you. (I think its wrong to assume that anyone who disagrees with you is mentally your inferior by the way) My own interpretation of the randomised controlled trial evidence, the meta-analyses and both hospital and GP audits does not lead me to the same conclusion as you. It’s not true there’s no evidence. We have different opinions about the evidence.
Back to my evidence based practice….irrespective of the interpretation of the evidence base, evidence based practice demands that both professional expertise and patients’ values and perspectives are taken into consideration in making a clinical recommendation. Most patients who come to Glasgow Homeopathic Hospital come because the “proven” drugs haven’t worked for them. That’s their experience. But here’s my challenge to you -What do you think we should offer these people? More of the same, or something different? Have you got a view on that? Because these are real people with real illnesses who are very very keen for some relief. My own annual appraisals and those of my colleagues who practice homeopathy show that most of the patients we treat do indeed get the relief they seek. Strikes me that’s why I should turn up to work every day. If you think homeopathy is nonsense though, what proposals do you have for the care of these patients? I wonder what’s been planned for the care of patients who lost the help they’d previously received at Tunbridge Wells Homeopathic Hospital for example? I haven’t read anything about the PCT’s plans for them.
If you are M J Simpson the writer, then I can assume you haven’t had the experience of dealing with patients. I’ve been a doctor for 30 years next year, working in hospitals and general practice over that time and you know it’s pretty challenging to deal with people in their greatest distress. You learn to live with uncertainty, to be flexible, tolerant and to develop a practice of not judging others. My motivation has always been to do my best to help them find relief from that distress, but to go even further than that and try to help them to have a better experience of health. I don’t think life is a simple matter of black or white, right or wrong, proven or unproven, or any other two-valued way of thinking.
It’s easy for people to be destructive and critical and pull things down. What’s harder is offer solutions, to create and to build things up.
And finally!
The wonder drug question! It’s back to the oversimplification thing again – is the world so black and white? Is knowledge ever complete? Funny how you chose Glaxo for your example when it was Allen Roses, VP Genetics, Glaxo, who said “the vast majority of drugs – more than 90% – only work in 30 – 50% of people. Drugs out there on the market work, but they don’t work in everybody”
Here’s my answer – first I’d like to know that the MHRA were convinced of its safety. If it killed people in the trials I wouldn’t be happy for it to be licensed. I’m pretty amazed that viagra got a license when there had already been fatalities in the trials actually! But if it was safe and there were “lots” of clinical reports of its benefit, then, yes, I’d be happy for it to be granted a license in the knowledge that researchers would continue to study the drug. This is a pretty normal process and it’s brought about changes in our understandings of many drugs over the years – resulting in changes in practice and the removal or withdrawal of several drugs from the market (usually for safety reasons mind – RCTs are actually NOT the best way to show a drug’s safety profile – that often doesn’t come to light until a lot more people with a range of co-morbidities and so on have actually taken it)
Hi James
thank you for your positive feedback. I really appreciate it. I’ll get in touch by email about starting blogging but I thought it’d be helpful to put your comment up here too.
I’ll do a post about it too because I think it’s always good for us to share our experiences so we can learn from, and support each other.
Yes plh it is a qualitative difference. And when there is a qualitative difference we tend to find that different rules emerge. I’m not a laboratory scientist but I do know that those who study ultra high dilutions find it fascinating. And I think they also understand that they are studying the difference not between something and nothing but the difference between something and something else! I think its a great area of exploration. There’s so much to be discovered in the world don’t you think?
(For the record, I don’t write for SFX magazine and don’t own a single Douglas Adams book. I am an NHS employee with a background in biochemistry.)
The concept of ‘paradoxical pharmacology’ clearly *is* irrelevant to homeopathy because homeopathy does not deal in reducing the amount of active substance but in eliminating it altogether. There are few differences in this world bigger than the difference between ‘some’ and ‘none’.
You say “What would be unethical would be for me to impose my beliefs on the patients who consult me” but you *are* imposing your beliefs by reinforcing their misunderstanding about the world. The ethical thing to do would be to tell these people objective truth, supported by evidence, rather than your own view of the world which is based on a 19th century understanding of disease rather than a 21st century one. I expect my doctor to know how the human body works and to tell me the truth based on current understanding of human biology, not a version of the truth developed by one maverick scientist 200 years ago before germ theory. If I went to him asking for an outdated treatment based on easily disproven, outdated ideas I would expect him to correct me. That’s part of his job.
You also ask “What do you think we should offer these people? More of the same, or something different? Have you got a view on that? Because these are real people with real illnesses who are very very keen for some relief.” I think there is some value in placebo treatment but I expect doctors to know that they’re giving a placebo rather than maintaining that the pill they prescribe has some magical ability at odds with the laws of physics, chemistry and biology.
Lactose pills and bottles of water are very cheap. When homeopathy companies dress them up as ‘treatments’ the price increases enormously though the contents and their potential placebo effects remain the same. As an NHS employee I am expected to practice best value so I don’t see how your hospital’s purchase of expensive snake oil can be justified when tap water, if prescribed with the same level of ritual, would have the same effect.
Finally thank you for your answer about the hypothetical big pharma question. Your view that drugs should be licensed even if they are proven to not work is frankly scary but I’m sure that the guys at Glaxo and AstraZeneca would love to get more people like you onto the MHRA board.
Hi M J, thank you for clarifying who you are (a little bit). I’m never quite sure why people feel the need to remain anonymous while engaging in a conversation on the net.
Can I ask you to have a go at my question to you please? For the patients who have until now being claiming they receive benefit from homeopathic clinics, once the clinic is lost (like in Tunbridge Wells), what would you offer those patients instead?
Erm, I would refer the honourable gentleman to paragraphs four and five of my previous comment, beginning “You also ask…”
But just in case that isn’t clear, my suggestion is that if these people respond so well to a placebo, they should just be given a plain sugar pill (with a little bit of medical rigmarole) which will have exactly the same effect as what you currently give them but will cost the taxpayer considerably less and will not insult people’s intelligence by claiming that the laws of the universe do not apply to sugar pills if they are prepared in the correct manner.
I appreciate that if this idea was instigated you could be out of a job so I can see why you wouldn’t like it but hopefully you can understand why, as a taxpayer, I would quite like you and all your colleagues to be re-employed doing something more appropriate to a 21st century health service.
MJ was obviously a lot less busy than I have been today, and I really don’t think I can add much more to what he has had to say.
All the quite basic science that I know, and the basic maths that I did many years ago, have given me the knowledge that the dilution of a homeopathic preparation means that there is nothing in a homeopathic medicine except water. It is then given to patients as if it actually has an effect beyond placebo.
I find that distasteful, deceptive, and quite wrong.
While I appreciate that you, Bob, have a faith in homeopathy that is unshakeable, it seems to be based on just that, a belief, rather than on any evidence that stands scrutiny.
The problem is that Homeopaths are currently going beyond the “take this for your headache dear” type treatments, and venturing into trying to deal with real medical issues.
The Society of Homeopaths recently suggested that they were ideally placed to deal with the worlds upcoming avian flu problems, with homeopathic treatments being easy to manufacture and cheap. They were quite serious and I was quite shocked.
Homeopathic clinics exist in Africa to treat Malaria and AIDS, and homeopathic treatments are being sold for my own incurable CLL. (I have a few years left yet thank goodness)
Do you understand where I’m coming from?
Bob,
Your blog just featured on the dashboard page of wordpress.com.
Gosh.
Andy, thank you for such a considered reply. I’m pleased to hear what you passionately feel. There’s no way in this world that everyone is going to think the same way, perceive life the same way or make the same choices. The fact that you and I are different is just reality. I know you judge me for my own stance in these issues and there really isn’t anything I can do about that. Suffice it to say I work with a clear conscience. I would never insist someone take a homeopathic medicine and I wouldn’t judge them either for taking one or not taking one. I do have certain beliefs that’s true. Who doesn’t? And one of my beliefs is that doctors should practice in the best interests of their patients. You’d have to ask my patients and my peers who assess my performance annually if I manage to do that, but those processes of feedback say I do. That’s my bottom line.
I do NOT support the practice of any kind medicine by unregulated practitioners. You’ll see that in my statement about homeopathy on my tabbed page at the top of my blog. I’m amazed that animals have more legal protection than human beings in the UK. Doesn’t seem right to me. If you check with the Faculty of Homeopathy, one of my professional bodies, you’ll see that’s a shared conviction.
Misdiagnoses and delayed diagnoses are never a good thing. And denying a patient the chance to have the appropriate treatment for their condition is never a good thing. This is where you’re coming from, isn’t it? On this issue, we don’t differ.
None of my colleagues would suggest they can cure incurable diseases. Our service exists to try and help patients have an improved quality of life whatever their disease. They don’t choose between us and the surgeons or oncologists or GP, or whoever. They attend all of us and we all communicate and we all use our own skills to play a part in their care.
Very interesting post. It shed good light on dosage and relation to homoeopathy.
I’m not at all medically inclined, but I guess the ingredients in homoeopathic medicines are so diluted as to be immeasurable by humans. Immeasurable but existing.
Or the ingredients have gone but the water changed imperceptibly. Imperceptibly, but not physiologically.
I’ve never tried homoeopathy by the way, but I don’t knock it. If it didn’t work no one would entertain it. People know this type of treatment just after nutraceuticals, so it’s survived the criticism for a long time.
Just to reply to Mo above.
There is no evidence to support “Immeasurable but existing”. A molecule cannot be broken down into component atoms and still retain its properties.
As to the memory of water, does the water retain a memory of everything else it has had in solution since the dawn of time? Or just the things that the homeopath wants it to remember?
Bob,
I think I have successfully linked my blog this time.
Andy
Hi Andy,
first off, thanks for the link to your blog and congratulations on your recent good news. I think more people should be encouraged to blog about their health and illnesses experiences the way you do. I don’t know why, but yours is actually the first such blog I’ve read and I’m inspired to encourage patients to do something similar for themselves. In fact, I’m talking to an MS Newly Diagnosed group tonight and I think I’ll raise it with them. OK, I know this is straying a bit off topic but you know I think being allowed/encouraged or whatever to create and share your own narrative is a positive contribution to getting well. One of my patients yesterday said at the end of the consultation “thank you for allowing me to tell my whole story in my own words and my own time. I’ve never had that opportunity before”.
You see my blog is “heroesnotzombies” because I think autonomy, a sense of self and the use of narrative to make sense of our experience is all so important (see my post on Jean Kazez’s ‘The Weight of Things’ for more on that.)
Mo, that’s such a great phrase – “immeasurable but existing” – thought-provoking! I know what you mean Andy about saying if something isn’t measurable then it doesn’t exist but I can’t say I think the world’s like that.
Is all of existence measurable? If something isn’t measurable can we say it doesn’t exist? In fact, some would argue that what can’t be measured is often not only real but most important – take pain for example – can’t be measured but sure exists!
And I really like your question about the memory of water – does it only have the memories the homepath wants it to have? Or the memories the homeopath and the patient together want it to have? Or…..?
Can I use that as an inspiration for another post? It’s got me thinking…..
Hi Bob,
MJ and Andy have pretty much covered the issues I have with some of your comments and your post, but I just wanted to expand on something, which MJ points out. He says: “I expect my doctor to know how the human body works and to tell me the truth based on current understanding of human biology…If I went to him asking for an outdated treatment based on easily disproven, outdated ideas I would expect him to correct me. That’s part of his job.” Reasonable, yes?
You say “You’d have to ask my patients and my peers who assess my performance annually if I manage to do that [treat in the best interests patients], but those processes of feedback say I do.”
I think that if you are pandering to your patient’s ignorance and personal belief systems, it’s not surprising that they are giving you good appraisals. People rather like authority figures to take them and their ideas seriously. But this whole ‘everyone’s opinion is valid’ is a fallacy. Not every situation requires ‘balanced’ viewpoints. Some arguments are just plain wrong. In part, this is the fault of the media for giving any crackpot idea a voice and credibility. But I shouldn’t have to pay for the same with my taxes.
Hi Ambrielle,
100% yes – in fact I’m not sure how a doctor would get through medical school without learning how the human body works!
You know I don’t find my patients are ignorant nor do they need “pandering”.
Sackett, who originated the modern conception of Evidence Based Medicine said this “Evidence-based medicine is not “cook-book” medicine. Because it requires a bottom-up approach that integrates the best external evidence with individual clinical expertise and patient-choice, it cannot result in slavish, cook-book approaches to individual patient care. External clinical evidence can inform, but can never replace, individual clinical expertise, and it is this expertise that decides whether the external evidence applies to the individual patient at all and, if so, how it should be integrated into a clinical decision” I agree with that whole-heartedly.
You say “People rather like authority figures to take them and their ideas seriously”. Well, you know, if I ever have to consult a doctor I’m sure I’ll want to find one who takes me and my ideas seriously. Wouldn’t you?
“Well, you know, if I ever have to consult a doctor I’m sure I’ll want to find one who takes me and my ideas seriously. Wouldn’t you?”
No, not if I’ve picked up some silly or misguided ideas from the media or some self-serving advertisement by a company selling snakeoil. I would expect to be put right pretty smartly, especially if it’s going to put my health at risk.
I guess people like different styles of consulting and that we all try to find a doctor we can relate to and trust. I find most patients want to be listened to carefully, taken seriously, treated with care, and helped to find the solutions which are best for them.
Don’t you find that with your patients, Ambrielle?