Response to Comments from the American Holistic Veterinary Medical Association on the AVMA Homeopathy Resolution

Detailed evidence supporting the AVMA resolution on homeopathy is available in The Case Against Homeopathy, and the Academy of Veterinary Homeopathy’s attempted counter arguments are examined in detail in The Evidence for Homeopathy-A Close Look. What is presented here is a response to a more abbreviated commentary on The Case Against Homeopathy produced by the American Holistic Veterinary Medical Association (AHVMA).

Comments on Resolution 3-2013 Homeopathy, from Connecticut
Nancy Scanlan, DVM, Executive Director
American Holistic Veterinary Medical Association

While the AVMA has models, such as their model practice act, the actual practice of veterinary medicine is a legal matter for state veterinary boards. The AVMA model practice act (AVMA2012) and a number of state practice acts include homeopathy specifically, as a reflection of this. The AAVSB comments on its model practice act definition of the practice of veterinary medicine: “The definition in Section 104 [Practice of Veterinary Medicine] is purposely broad in order to provide substantial latitude to the Board in the adoption and implementation of rules.” (AAVSB 2009)

This is irrelevant. The resolution has no binding legal force and specifically states that “veterinarians may legally employ any therapy that complies with the applicable laws and regulations governing the practice of veterinary medicine.” The fact that some state governments have recognized homeopathy as part of the practice of veterinary medicine has no bearing on whether or not it is an effective therapy. Just as there is political pressure from a passionate minority on the AVMA to reject Resolution 3, so similar pressure has been applied to other organizations to ignore the science showing homeopathy doesn’t work.

AHVMA maintains that one must include an expert in any discussion of a treatment modality, whether it be those taught in the core curriculum of veterinary schools or those taught as electives or special training outside of the core courses. Experts are those who use the modality in practice, and who are invited by practitioners of CAVM to lecture and write about its use. No one person can be an expert in all things, and so the person’s expertise should be specific to the subject being discussed. This resolution should be sent to a task force with representatives from both sides of the argument to in order to create a balanced document for delegates to base their decision upon. As a beginning, this document is accompanied by a White Paper supported by the Academy of Veterinary Homeopathy, which presents the rest of the evidence not present in the paper accompanying the Connecticut resolution.

This essentially says that only homeopaths are qualified to evaluate the validity of homeopathy.

However, homeopathy is not a recognized medical specialty in veterinary or human medicine, and the expertise homeopaths claim is self-determined. If a committee of believers in homeopathy is formed to evaluate the scientific evidence for homeopathy, the outcome is a forgone conclusion.

Homeopaths have a vested interest in declaring their own practice to be legitimate. The delegates and other veterinarians who may choose to evaluate the scientific literature concerning homeopathy have no “horse in the race,” as it were. If homeopathy were effective, conventional veterinarians would simply adopt it and offer it to their patients like any other therapy. This has not happened in the two centuries since the invention of homeopathy because a compelling scientific case for the theories and practices of homeopathy has not been made. It is not necessary that the delegates, or rest of the profession, rely on homeopaths to interpret the scientific evidence concerning homeopathy for us.

And finally, the White Paper in support of this resolution contains numerous misstatements and so cannot be used reliably to judge the resolution. It only addresses one part of homeopathic practices and by and large ignores others (such as less highly diluted remedies, different methods of diagnosis, etc.) that do not fit the items it is addressing. It ignores hundreds of legitimate research papers. And it relies in part on the 275 page House of Commons Science and Technology Committee (HOC Committee) report on Homeopathy (HOC Committee 2010), which may have been accepted physically by the Chief Scientific Advisor to the British government. However it was  NOT accepted by the British government. Part of the reasoning for not accepting the report was:

“our  continued position on the use of homeopathy within the NHS is that the local NHS and clinicians, rather than Whitehall, are best placed to make decisions on what treatment is appropriate for their patients -including complementary or alternative treatments such as homeopathy -and provide accordingly for those treatments.”  (Secretary of State for Health 2010) This is an essentially political question, and again the resolution does not in any way prohibit veterinarians from choosing to employ homeopathy. It expresses the opinion of the AVMA that the scientific evidence does not support homeopathy to be effective. This is the same conclusion reached by the House of Commons Science and Technology Committee and the science-based medical professions in general. It is up to politicians and courts to decide what implications the scientific consensus has for government health insurance and other matters of public policy, but that again has no bearing on the assessment of the scientific evidence concerning homeopathy.

The HOC Committee is a Parliamentary committee consisting of elected officials (laymen), similar to our House and Senate Committees. Like our congressional committees, the attitudes of the members of the committee influence the choice of witnesses called, the evidence accepted, weight given to evidence, and final conclusions. The HOC committee stated “It is not necessary for Scientific evidence to be absolutely uniform in order to establish that a practice is ineffective or unsafe.” One might say the same for establishing that a practice is effective or safe.

The citation of the HOC committee was simply to illustrate that bodies with far greater resources than the AVMA House of Delegates have investigated this matter and drawn a clear conclusion about the state of the science. The Case Against Hoemompathy does not rely on the HOC findings but evaluates the scientific evidence itself and merely uses the HOC hearings to help illustrate points that are rooted in this evidence.

Few of those called as witnesses by the HOC committee were practicing homeopaths: in the Memorandum submitted by David Tredinnick MP, Chairman, Parliamentary Group for Integrated and Complementary Healthcare , he stated:“ Only one doctor using homeopathy gave oral evidence, and none are scheduled for Monday. No doctors using homeopathy in a primary care setting have been asked. Dr David Reilly from the Glasgow Homeopathic Hospital is regarded as a leading expert on this subject and should have been called. In addition, the Society of Homeopaths, which was discussed both directly and indirectly as the principal organisation representing non-medical homeopaths, should have had the opportunity to put its views forward. I believe that the Committee should have ensured that all the experts in this field were given the opportunity to give oral evidence.”

The HOC did give homeopaths an opportunity to send a representative to present their position, but it did not defer to their expertise because only the homeopathic profession recognizes this as legitimate.

The White Paper accompanying this response from the AHVMA addresses the specific concerns about homeopathic theory and homeopathic research that are raised in the Connecticut White Paper. The following is a critique of the sections of the Connecticut White Paper which contain misleading statements:

Page 1 “There is no consistent body of in vitro or animal model research evidence  showing the presence of any biologically active factor in homeopathic remedies or a meaningful biological effect of homeopathic treatment beyond placebo. 

(Homeopathic remedies come in 4 groups of dilutions: X, C, L, and M. The X and C dilutions not only have demonstrable factors, some can be tasted. Dilutions made by compounding pharmacies of drugs used for cats and small dogs are in the X range. This includes items such as Humulin U-100 diluted to 10 U/ml, or interferon eyedrops diluted to 30 U/ml. Any veterinarian who uses Interferon as an oral medication and dilutes it as recommended has created a dilution that is the same concentration as a 6X dilution.)

It is disingenuous to suggest that homeopathy is not primarily concerned with the use of ultradilute remedies that do not contain measurable active ingredients. Insulin diluted to 10U/mL is not a homeopathic remedy; it is simply off-label use of a pharmaceutical. And herbal preparations which contain pharmacologically active ingredients are part of herbal medicine, not homeopathy.

According to the Academy of Veternary Homeopathy, “ A homeopathic remedy is a single substance derived from a plant, animal or mineral. This is then subjected to a special procedure called potentization….Dr. Hahnemann discovered that the effect of homeopathic medicines is strengthened dramatically upon successive dilutions and vigorous shaking between each dilution. The final dilution can be very high…These substances are specially prepared so that they have no toxic “side effects”…Homeopathy is a safe form of treatment in that there are no chemicals or drugs in the remedies so there are no side effects.” By their own definition, a homeopathic remedy no longer contains any chemicals from the original substance used.

Furthermore, the AVH specifically discourages the use of remedies containing conventional pharmaceuticals or herbal ingredients: “Drugs, herbs and other forms of treatment prevent cure and cause ultimate harm to the patient. Hahnemann states that only the medicine homeopathic to the patient’s condition is to be used in treatment…Drugs and methods of treatment which are not homeopathic to the case are to be avoided because of the possibility of interference with the progress of cure.”

Even the AVH white paper states, “medicines used in homeopathy are often administered in highly diluted form…their mode of action differs from substances given in pharmacologic doses and having direct agent-dependent actions on the body.” The document then goes to great lengths to defend the theory that ultradilute substances can have biologic effects, and all but a few of the papers cited relate to the investigation of ultradilute homeopathic remedies. Ultradilute remedies make up the vast majority of homeopathic treatment, and if these are ineffective (as the evidence clearly shows they are), then homeopathy is no more than a placebo therapy.

“While some apparently positive studies exist, published almost exclusively in journals dedicated to the promotion of homeopathy and other alternative therapies”

I have a 65 page list of references to published homeopathic articles, which includes the following journals in just the first 6 pages:

Immunology Today
Exp Biol Med
Comptes-Rendus de l’Académie des Sciences de Paris
Journal of Allergy and Clinical Immunology
Inflamm.Res.
Micron.
Nature
European Journal of Pharmacology
Biophys
Annals of the New York Academy of Sciences
Immunol Invest.

“some apparently positive trials exist, but these are of low -quality and highly subject to bias. Systematic reviews of the clinical trial literature consistently find no evidence of an effect beyond placebo” 

An implication that journals such as Immunology Today, Exp Biol Med, Journal of Allergy and Clinical Immunology, Annals of the New York Academy of Sciences, etc. publish inferior work

The level of evidence within the hierarchy of evidence-based medicine, and the quality of controls for chance, bias, confounding, and other errors, are determined by specific established criteria, including study design, sample size, randomization, blinding, control groups, and many others. The level and quality of a study, and the reliability of the results, is determined by these features, not by the journal in which the report is published. Even highly respected journals can publish results that are clearly false. A paper by Andrew Wakefield suggesting a relationship between vaccination and autism was published in the Lancet in 1998, and it was retracted in 2010 and Dr. Wakefield stripped of his license for the fraudulent and unethical study. The journal Nature published a paper reporting an effect of a homeopathic preparation on basophil degranulation in 1988, and then published a followup title “’High-dilution’ experiments a delusion” showing the results to be due to inadequate blinding. Even high-quality journals can, and often do, publish poor quality research. And the evidence in such journals cited by homeopaths in the AVH white paper did not even approach a compelling case for the efficacy of hoemopathy, as can be seen in The Evidence for Homeopathy-A Close Look, in which I review these citations in detail.

There is ample evidence for a publication bias in homeopathy journals and other journals devoted to alternative medicine. In 1995, only 1% of studies published in alternative medicine journals reported negative results, and in 2001 95% of such studies reported positive results (Schmidt, K., Pittler, M.H., Ernst, E., (2001a) A profile of journals of complementary and alternative medicine Swiss Med Weekly Vol. 131 pp. 588-591; Schmidt, K., Pittler, M.H., Ernst, E., (2001b) Bias in alternative medicine is still rife but is diminishing British Medical Journal Vol. 323 no. 7320 p. 1071)

A study published in 2005 (in an alternative medicine journal) found that 69% of homeopathy studies in mainstream journals reported negative results whereas only 30% of studies in alternative journals reported a negative result. (Caulfield, T., and DeBow, S., 2005 A systematic review of how homeopathy is represented in conventional and CAM peer reviewed journals BMC Complementary and Alternative Medicine Vol. 5 no. 12) 

Of the 16 veterinary studies listed in the CVMA white paper that reported positive results, 11 were published in journals dedicated to homeopathy or alternative medicine. Of the 15 veterinary studies listed in the CVMA white paper that reported negative results, only 2 were published in such alternative journals.

And while some positive studies have been reported in mainstream journals, it is still true that the vast majority are found in dedicated journals with a clear bias. And the systematic reviews cited in the CVMA white paper also demonstrate clearly that the higher level and quality and the better control for bias in a study, the less likely the results are to be positive, consistent with homeopathy being a placebo therapy. Only when low-level and low-quality studies are given equal weight (as in the Swiss homeopathy report) can one manufacture the appearance of strong research support for an effect above placebo.

Also on page 2: the first of several citations from the 2010 report from the House of Commons Science and Technology Committee, which was notaccepted by the British government

The conclusions were accepted by the Scientific Advisor to the government, but for political reasons (including pressure from the Royal Family, who are believers in homeopathy, the official policy of the government has not yet moved into alignment with the position of the scientific and medical communities that the NHS should not offer an ineffective therapy. However, two of the five homeopathic hospitals funded under the NHS (Liverpool and Tunbridge Wells) have closed in the last year, as well as numerous other facilitieg offering homeopathy in the UK. The politics are catching up to the science.

Page 7, item II G cites the AAVSB’s stance that “CE programs that advocate unscientific modalities of diagnosis or therapy are not eligible for RACE approval,” implying that they never approve CE on homeopathy. On page 14 item IIA states that “Since 2009, the Registry for Approved Continuing Education (RACE) has denied approval for continuing education offerings involving the teaching of homeopathy.” RACE approved the following 3 lectures on homeopathy at the 2009 AHVMA annual conference:

Pointers to Case Taking andCase Organization

Some Methods for Handling and Understanding Complex Cases

Dealing with the End Stage and Hospice Patient

All 3 were presented by Larry Bernstein, VMD, who uses homeopathy extensively in his practice, as well as teaching and lecturing regularly on the subject.

In 2011, the AVH sued the American Association of Veterinary State Boards because its RACE committee had begun denying approval for homeopathy CE course which had previously been approved despite not meeting the requirements for RACE approval, which sate:

[approved courses must] build upon or refresh the participant in the standards for practice and the foundational, evidence-based material presented in accredited colleges or schools of veterinary medicine or accredited veterinary technician programs…CE programs that advocate unscientific modalities of diagnosis or therapy are not eligible for RACE approval…All scientific information referred to, reported or used in RACE Program Applications in support or justification of an animal-care recommendation must conform to the medically accepted and scientifically supported standards of experimental design, data collection and analysis.

The AHVMA went so far as to set up an alternative CE approval organization, Registry of Alternative and Integrative Veterinary Medical Education (RAIVE), in order to skirt the mainstream process. This organization is not recognized by any mainstream veterinary group, just as the alternative board certification in homeopathy created by the AVH is not recognized by the AVMA as a legitimate specialty board. These are all examples of the AVH attempted to force homeopathy to be judged by different standards from scientific medicine, standards set by homeopaths. The lawsuit was dismissed by the court in 2012, and RACE does not currently accept homeopathy course as approved CE.

Page 7, item III A: The statement from NCCAM that “Rigorous, well-designed clinical trials for many CAM therapies are often lacking; therefore, the safety and effectiveness of many CAM therapies are uncertain” also applies to the 50% (about 1500) of conventional therapies that are also of unknown effectiveness because of lack of well-designed research. (Clinical Evidence editors, HOC committee 2010) In addition, NCCAM still includes homeopathy in its list of Complementary and Alternative Medicine research that it will fund. (NCCAM)

Simply untrue. While there is rarely perfect evidence for any practice, the evidence base is far stronger for conventional medicine than for homeopathy. (Imrie, R. Ramey, D. The evidence for evidence-based medicine. Complementary Therapies in Medicine (2000), 8, 123-126.) A survey of the literature shows that in the following areas of conventional medicine, the majority of practices are based on compelling scientific evidence:

96.7% of anesthetic interventions (32% by RCT, UK)

approximately 77% of dermatologic out-patient therapy (38% by RCT, Denmark)

64.8% of ‘major therapeutic interventions’ in an internal medicine clinic (57% by RCT, Canada)

95% of surgical interventions in one practice (24% by RCT, UK)

77% of pediatric surgical interventions (11% by RCT, UK)

65% of psychiatric interventions (65% by RCT, UK)

81% of interventions in general practice (25.5% by RCT, UK)

82% of general medical interventions (53% by RCT, UK)

55% of general practice interventions (38% by RCT, Spain)

78% of laparoscopic procedures (50% by RCT, France)

45% of primary hematology-oncology interventions (24% by RCT, USA)

84% of internal medicine interventions (50% by RCT, Sweden)

97% of pediatric surgical interventions (26% by RCT, UK)

70% of primary therapeutic decisions in a clinical hematology practice (22% by RCT, UK)

72.5% of interventions in a community pediatric practice (39.9% by RCT, UK)

Thus, published results show an average of 37.02% of interventions are supported by RCT (median = 38%). They show an average of 76% of interventions are supported by some form of compelling evidence (median = 78%).

We also wish to note:

the Banerji protocol (using homeopathic remedies) Best Case Series on cancer was accepted by NCCAM and NCI at NIH. It was presented to the Cancer Advisory Panel for Complementary and Alternative Medicines. NCI is devising “Practice Outcomes Monitoring and Evaluation Systems Study for Bronchogenic Carcinoma” at their  clinic, with a goal of designing a protocol for treatment of these cases at institutions in the US. (Banerji 2007) The NIH has asked for animal studies before final approval, and currently a board-certified veterinary oncologist is working with the proponents of the Protocol to develop a design for the study.

After 200 years, the best homeopathy can show is a “best case series?” It is well-established that case reports and case series are useful for generating hypotheses, not proving or disproving them. And NCCAM has a long history of funding ridiculous homeopathy research which identifies no benefits but doesn’t discourage homeopaths either.

The Case Against Homeopathy cites numerous systematic reviews of clinical trials, a much higher level of evidence, which shows homeopathy does not work.

In conventional science, radical ideas are proven or disproven, and accepted or rejected accordingly, much more quickly. The notion that Helicobacter caused GI ulcers was radical when proposed in 1982 and had won a Nobel prize by 2005. This was because compelling evidence at all levels, including high-quality clinical trials, was developed. Homeopathy has failed to do this but proponents refuse to accept this and continue to argue for more research. How long is it reasonable to continue investigating despite persistent failure when the notion is theoretically impossible and incompatible with established science to begin with? As the House of Commons Committee concluded, “There has been enough testing of homeopathy and plenty of evidence showing that it is not efficacious. Competition for research funding is fierce and we cannot see how further research on the efficacy of homeopathy is justified in the face of competing priorities.”

Page 8:

Thefourth paragraph describing “sympathetic magic” has nothing whatsoever to do with the way that homeopathic remedies are selected.

Sympathetic magic is a term from cultural anthropology. The theory of sympathetic magic was first developed by Sir James George Frazer in The Golden Bough. He further subcategorised sympathetic magic into two varieties: that relying on similarity, and that relying on contact or ‘contagion’ (emphasis added):

“If we analyze the principles of thought on which magic is based, they will probably be found to resolve themselves into two: first, that like produces like, or that an effect resembles its cause; and, second, that things which have once been in contact with each other continue to act on each other at a distance after the physical contact has been severed. The former principle may be called the Law of Similarity, the latter the Law of Contact or Contagion. From the first of these principles, namely the Law of Similarity, the magician infers that he can produce any effect he desires merely by imitating it: from the second he infers that whatever he does to a material object will affect equally the person with whom the object was once in contact, whether it formed part of his body or not.”

Homeopathy is a classic example of this variety of pre-scientific superstition.

The paragraph describing what one is able to buy in a homeopathic preparation also has nothing to do with the homeopathic idea of “like cures like.”

These examples illustrate the fact that homeopathic remedies are produced from starting materials that have no plausible connection to any disease etiology. The basis for such choices is pre-scientific superstition, including the notion that anything which causes symptoms of illness in a healthy person can be used to combat those same symptoms, regardless of their cause, in a patient.

Vaccines and some conventional medications, such as nitroglycerin for angina, stimulants for attention-deficit hyperactivity disorder, and digoxin for congestive heart failure match the “like cures like” principle.

Again, untrue. Vaccination doesn’t work because of the “like cures like” principle. Vaccine antigens stimulate a specific immune response to a particular antigen from a pathogen by a mechanism that has been intensively investigated and characterized in detail. There are many different kinds of vaccines (whole cell, protein-based, DNA-based, killed and modified live, etc) which are developed and which function to treat or prevent specific diseases according to the pathogenesis of those diseases.

This is drastically different from a magical principle of “like cures like” that is applied to every medical condition regardless of the etiology or pathogenesis. The superficial similarity of vaccines using small (but measurable and highly specific) doses of an antigen and homeopathy using small (and usually non-existent) doses of a starting material is not a true correspondence between the theories behind the two interventions, nor does it demonstrate that homeopathy works. Even so-called “nosodes” homeopathic “vaccines” made from material gathered from a sick individual and diluted and shaken until nothing remains then used to treat or prevent that illness in a real patient, have been proven not to work (e.g. Larson L., Wynn S., and Schultz R.D. A Canine Parvovirus Nosode Study. Proceedings of the Second Annual Midwest Holistic Veterinary Conference 1996.)

Page 14, Item II B states “The AVMA requires specialty boards to demonstrate “a substantial body of scientific  knowledge, ” and does not recognize the Academy of Veterinary homeopathy certification process due to the failure to meet this requirement.” The Academy never applied forspecialtyboard certificationand so has never been judged by AVMA or the ABVS for any body of scientific knowledge. (This was verified by both the Academy of Veterinary Homeopathy and by the American Board of Veterinary Specialties in November 2012.)

The AVH has not applied because they know they cannot meet the standard. Human homeopathy is also not recognized as a medical specialty. Unless homeopaths can meet these standards and obtain this status, they have no legitimate claim to any specialized expertise that must be acknowledged or deferred to.

Page 15, item IIA quotes items about the British Medical Association dating from an anti-homeopathy campaign in that countryduring the year of 2010. The statements attributed to the British Medical Association are not found on their website. Instead their websitesuppliesinformation about the Society of Homeopaths, the Faculty of Homeopathy, and the regulation of homeopathic medicines, as well as the Complementary and Natural Healthcare Council which informally regulates homeopathy as well as other modalities.In addition, a recent article in the Sept 14 isue of the British Medical Journal was favorable, stating “Modern medicine has real capacity to do harm but often minimal good; homeopathy has minimal capacity to do harm but real capacity to do good. Homeopathy is an easy target; we would be better to focus on the failings of conventional medicine. Homeopathy is bad science but good medicine.” (Spence, 2012)

A small number of individual physicians, like individual veterinarians, may support homeopathy, but it is not accepted as legitimate medicine by the BMA or mainstream medicine. At a BMA conference in 2010 voted overwhelmingly in favour of banning homeopathic remedies being funded by the NHS and withdrawing backing for the UK’s four homeopathic hospitals. They added that NHS doctors should not be given homeopathy training and remedies should be taken off shelves “labelled medicines” and put on shelves “labelled placebos”.( http://www.nursingtimes.net/whats-new-in-nursing/primary-care/bma-votes-against-homeopathy-funding/5016611.article, http://www.telegraph.co.uk/health/healthnews/7861240/Chemists-should-be-forced-to-label-homeopathic-remedies-as-placebos-say-doctors.html )

One general comment about foreign organizations(cited starting on page 15):

The EU recognizes homeopathy. Germany, France, and India incorporate homeopathy as part of their health systems. The British government has pointed out to the HOC Committee that if they were to enact their recommendations, it would breach their treaty with the EU.(Secretary of State for Health, 2010)

Numerous veterinary and human medical groups have acknowledged that homeopathy is not a legitimate therapy. Political pressure to refrain from such a declaration is stronger in some places than others, but this has nothing to do with the state of the scientific evidence or the truth of the matter.

As examples:

In the UK, in December 2011, the Veterinary Medicines Directorate (VMD) in the Department for the Environment Food and Rural Affairs (Defra) – which governs the use of medicines in animals – made clear that homeopathic treatments could only be classed as medicines, and thus prescribed by vets, if they were able to demonstrate efficacy. In the past year the British Medical Association has adopted an extremely robust approach on the issue, rejecting the use of homeopathy by the British National Health Service and calling for homeopathic products to be stored away from medicines in pharmacies and chemist shops on shelves marked “placebos”. In Sweden, veterinarians are prohibited from prescribing homeopathic remedies. In November 2005 the Federation of Veterinarians in Europe (FVE) issued a strategy document including the statement that the veterinary profession is rooted in science and evidence-based veterinary medicine. In the explanatory discussion of this strategy document it was explicitly stated that the FVE rejects non-evidence based medicines such as homeopathy. Earlier in 2005 the European Board of Veterinary Specialisation (EBVS) made a clear statement with regard to alternative modes of treatment: The EBVS only recognises scientific, evidence-based veterinary medicine complying with animal welfare legislation. Specialists or colleges practising or supporting implausible treatments with no proof of effectiveness run the risk of withdrawal of their specialist status. No credit points can be granted for education or training in these so-called supplementary, complementary and alternative modes of treatment. In October 2006, the general assembly of the Royal Netherlands Veterinary Association agreed to discontinue the official status of the group of veterinarians working with homeopathy.

page 16: Item IIIC “the FDA …  has made no attempts to regulate their use or require any evidence of safety and efficacy”

ignores the fact that the proper preparation of homeopathic remedies is recognized by the FDA and is part of their Pharmacopoeia.

You can read FDA regulations regarding homeopathic remedies here: http://www.fda.gov/ICECI/ComplianceManuals/CompliancePolicyGuidanceManual/ucm074360.htm(accessed 10/29/2012)

Homeopathy was grandfathered into the 1938 law establishing the FDA because it was proposed by a Senator who was also a homeopath. What this means is that homeopathic remedies do not have to prove safety and efficacy through scientific testing as conventional medicines do. This exception to the usual standards of scientific evidence is a historical and political one, but it is not an endorsement of homeopathy by the FDA. As the National Center for Complementary and Alternative Medicine states, “FDA does not evaluate the remedies for safety or effectiveness.” The FDA’s own web site state, “FDA is not aware of scientific evidence to support homeopathy as effective.”( http://labels.fda.gov/)

As for veterinary homeopathy, the FDA has stated that the grandfathering of homeopathic remedies for human use into drug laws do not apply to veterinary medicine. In a 2006 statement regarding regulation of milk pasteurization, for example, the agency stated, “Homeopathy is an alternative therapeutic modality developed in the late 1700’s by a German physician for use in humans. Homeopathic medicine is considered an unconventional form of veterinary practice. FDA can find no justification for regulating veterinary homeopathic drugs any differently from other drugs subject to the FFD&CA. There are currently no FDA approved homeopathic drugs for veterinary use.” The FDAs CVM has chosen not to enforce this law, as yet another  political concession to homeopaths, but this by no means constitutes FDA approval of homeopathic remedies as effective the way a drug approval does. (www.homeopathicpharmacy.org/pdf/articles/vet_drugs.pdf)

“The FDA CVM identifies all drugs intended for animal use which have not passed the new drug approval process as unapproved animals drugs, and this is true for homeopathic remedies as well (http://www.fda.gov/AnimalVeterinary/ResourcesforYou/ucm268128.htm). Use of such drugs are tolerated, but veterinary use of homeopathy is not approved or endorsed by the FDA.”

Page 16, Item III D:

European regulations (the regulations in question are from DIRECTIVE 2001/83/EC OF THE EUROPEAN PARLIAMENT AND OF THE COUNCIL of 6 November 2001 on the Community code relating to medicinal products for human use.)

Despite what is implied, those regulations were established for “clinical trials, to provide a special, simplified registration procedure for those homeopathic medicinal products which are placed on the market without therapeutic indications.” (Emphasis is the author’s.) In other words, instead of labeling them “for hepatitis” the labelwould have no indications. They also have to be in a form “which do(es) not present a risk for the patient.”

“The smallest dose that results in the obligation to submit a doctor’s prescription”does not mean inactive. Advil is active, as is prescription-level amounts of ibuprofen, but Advil does not need a doctor’s prescription.

In addition “acknowledged to have no recognized therapeutic use” is for those remedies eligible for the simplified procedure. The rest of the regulations say “The usual rules governing the authorization to market medicinal products should be applied to homeopathic medicinal products placed on the market with therapeutic indications.”Despite the implications, the rest of the regulations make it clear that these regulations recognize that there are homeopathic remedies with therapeutic use.

Nonsense. The language of these regulations is intended to allow homeopathic remedies to be marketed despite having no proof of efficacy for specific clinical indications. The caveat is that they cannot claim such an indication on the label. This is one more political accommodation for homeopaths that exempts homeopathy from the standards of evidence to which conventional medicine is held, and the AVMA should not continue to tacitly approve of such a double standard by refraining from stating the obvious: that homeopathy has failed the standards of proof expected of legitimate scientific medical therapies.

“3. The label indicates the absence of any recognized therapeutic use” is describing the label, not the remedy.

Labels are regulated in both Europe and the U.S. as a way of ensuring that false claims are not made regarding safety and efficacy. If a product cannot be labeled as having a specific effect, that is because it has not been scientifically shown to have that effect. That’s the whole purpose of a drug label.

Page 17, III E

“NHMRC’s position is that it is unethical for health practitioners to treat patients using homeopathy,”

The current Homeopathic Working Committee, working until June 30 2013, is creating an information paper and position statement on homeopathy. The draft is not published on their website and the 2010 paper cannot be considered an official representation of their opinion.(NHMRC 2012)

While not yet official policy, it indicates that before the application of outside political pressure, groups like the Homeopathic Working Committee of the NHMRC and the House of Commons Science and Technology Committee consistently come to the conclusion, when evaluating the evidence, that homeopathy is ineffective. Whether these conclusions are then adopted as official policy depends, as in the case of Resolution 3, on political factors as well as scientific evidence.

Page 17, item IV A discussing “The dangers of homeopathy” states “There have been some reports of detectable heavy metal contamination of homeopathic remedies.”

There is a single citation which reports contamination of products from Croatia. Products used in the US are of American and British origin.This was cited by the flawed HOC Committee report.

That was simply one example. There is ample evidence of the harm from the use of homeopathy, both direct and indirect.

For example, Posadzki P, Alotaibi A, Ernst E. Adverse effects of homeopathy: a systematic review of published case reports and case series. Int J Clin Pract. 2012 Dec;66(12):1178-88 states:

“In total, 38 primary reports met our inclusion criteria. Of those, 30 pertained to direct AEs of homeopathic remedies; and eight were related to AEs caused by the substitution of conventional medicine with homeopathy. The total number of patients who experienced AEs of homeopathy amounted to 1159. Overall, AEs ranged from mild-to-severe and included four fatalities. The most common AEs were allergic reactions and intoxications. Rhus toxidendron was the most frequently implicated homeopathic remedy. Conclusion:? Homeopathy has the potential to harm patients and consumers in both direct and indirect ways. Clinicians should be aware of its risks and advise their patients accordingly.”

Similarly, Freckelton I. Death by homeopathy: issues for civil, criminal and coronial law and for health service policy. J Law Med. 2012 Mar;19(3):454-78 states:

“In India, England, New South Wales and Western Australia civil, criminal and coronial decisions have reached deeply troubling conclusions about homoeopaths and the risk that they pose for counter-therapeutic outcomes, including the causing of deaths. The legal decisions, in conjunction with the recent analyses of homoeopathy’s claims, are such as to raise confronting health care and legal issues relating to matters as diverse as consumer protection and criminal liability. They suggest that the profession is not suitable for formal registration and regulation lest such a status lend to it a legitimacy that it does not warrant.”

Page 18 states “not all homeopathic medicines are administered at a high dilution.” This istrue for a wide variety of homeopathic medicines. This negates the general representation of the Connecticut white paper that homeopathic remedies have no effect because of their ultra-high dilutions.

Yet the vast majority are, and the remainder have been exempted from demonstrating safety and efficacy by scientific investigation by the label “homeopathic.” If they are truly effective, there should be clinical trial evidence to show this, and there is not.

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Evidence Update-Most Homemade Cancer Diets for Dogs are Inadequate

I have often discussed the problems with homemade pet diets, which are frequently recommended in books and websites that complain about commercial food or proclaim some magic method for preventing or curing disease. Raw diets, grain free diets, and other fads often involve making pet food at home from recipes from self-proclaimed experts in nutrition, though there are also commercial versions of each fad available not long after it takes hold. Of course, the only real experts in pet nutrition are those board certified by the American College of Veterinary Nutrition. And while there is ample evidence that homemade diets are often nutritionally inadequate, (e.g. 1, 2) most of the scary claims about commercial diets are just myths and misconceptions.

A recent study has reinforced these already well-established points.

Heinze CR, Gomez FC, Freeman LM. Assessment of commercial diets and recipes for home-prepared diets recommended for dogs with cancer. J Am Vet Med Assoc. 2012 Dec 1;241(11):1453-60. doi: 10.2460/javma.241.11.1453.

This study looked at recipes from books and web sites that recommended diets for dogs with cancer, as well as commercial diets marketed for use in canine cancer patients, and evaluated the nutritional adequacy of the diets based on established AAFCO or NRC guidelines. The findings were quite clear, and the recommendations consistent with those veterinary nutritionists have been making for some time.

Published recipes of home-prepared diets for pets with various health conditions are rarely nutritionally adequate. None of the 27 recipes identified and evaluated met NRC RA or AAFCO nutrient profiles for all essential nutrients. In some cases, the recipes contained excessive, potentially toxic amounts of nutrients.

Recipes formulated or provided by veterinarians were not more nutritionally sound than were recipes formulated or provided by nonveterinarians.

Only 2 of 39 (5.1%) commercial diets had passed AAFCO feeding trials (one for adult maintenance and the other for all life stages). The majority (35/39 [89.7%]) of the diets were formulated to meet AAFCO nutrient profiles for all life stages (27 diets) or adult maintenance (8 diets

There is a paucity of experimental data that support specific nutrient profiles or ingredients for dogs with cancer. Dogs with cancer do not have higher or lower requirements for protein, fat, calories, or any other specific nutrients, compared with requirements for healthy dogs. Therefore, it is of concern that none of the recipes for home-prepared diets met NRC RA or AAFCO nutrient profiles for adult maintenance in dogs… All of these inadequate diets have the potential to cause nutritional disease at a time when nutrition should be optimized to provide maximum metabolic support and immune system function and to help decrease adverse effects attributable to cancer treatments.

Commercial diets and recipes of home-prepared diets reflected the current popularity of grain-free diets. No data support health benefits of non-grain sources of carbohydrate over carbohydrates provided by grains; however, many manufacturers still tout the nutritional superiority of grain-free products.

Grain-free diets are often marketed as lower in carbohydrate content, but this is not a consistent finding. Approximately one-third of the recipes of grain-free home-prepared diets and commercial diets did not meet the defined criteria for low-carbohydrate diets.

Low-carbohydrate diets are commonly recommended for dogs with cancer on the basis that many cancer cells use aerobic glycolysis and fermentation of pyruvate to lactate as a main source of energy… it is theorized that feeding a low-carbohydrate diet could effectively starve cancer cells through a decrease in the supply of glucose. However, despite the fact that this theory has been in existence for nearly a century, minimal data have been published to support the tangible benefits of low-carbohydrate diets for any species of animal with cancer. To our knowledge, there are no published data to support the contention that low-carbohydrate diets are of clinical benefit with regard to tumor growth, disease-free interval, or survival time in dogs, and further studies are required before appropriate recommendations can be made.

The number of recommendations for feeding raw meat diets to cancer patients is a concern because contamination with pathological bacteria has been reported for raw meat for human consumption and for commercial raw diets. Cancer patients, even those not receiving chemotherapy, likely have some degree of altered immunoregulation, and many dogs receiving chemotherapy are clinically immunosuppressed, which dramatically increases the risk of illness or even death from contaminated food sources. In humans, the risk of illness attributable to foodborne bacteria in cancer patients is such a concern that patients receiving chemotherapy are commonly advised to eat raw fruits and vegetables only when at home.

It is possible that feeding a diet that does not meet AAFCO recommendations or NRC RAs for various nutrients may not cause overt clinical disease. Although some nutrient deficiencies (eg, thiamine or taurine) can be evident in adult animals after a food deficient in those nutrients is fed for weeks to months, it can be months to years before clinical signs are evident for other nutrient deficiencies (eg, calcium in an adult animal). The status of many nutrients is not easily determined, and the first clinical signs of deficiency may be catastrophic (calcium deficiency resulting in osteopenia and pathological fractures or taurine deficiency resulting in dilated cardiomyopathy).

Currently, the authors are aware of no evidence to suggest that cancer patients have nutrient needs that differ dramatically from maintenance requirements. Many dog owners change to home-prepared diets because of an overall perception that they are healthier than commercial diets, rather than because they provide specific nutrient profiles. Thus, it appears appropriate that home-prepared diets be formulated to meet nutrient guidelines similar to those of commercial products.

Bottom Line

Homemade diet recipes are almost always nutritionally inadequate, even if formulated by a veterinarian (unless they are a board-certified nutritionist)

There is no evidence for benefits from current nutritional fads such as raw or grain-free diets, but there is the potential for harm from these diets.

Commercial diets are consistently more appropriate nutritionally than homemade diets.

There is little evidence to support the idea that cancer patients should be fed a different diet from healthy dogs (with the possible exception of extra fatty acid supplementation).

Posted in Nutrition | 61 Comments

What “Experts” in Homeopathy are Supposed to Believe

One of the most compelling letters of support for the AVMA resolution on homeopathy came from a source that might seem unexpeted, Dr. Narda Robinson, Assistant Professor of Complementary and Alternative Medicine at the Colorado State University Veterinary School of Veterinary Medicine. Dr. Robinson is that rare bird, a practitioner of some alternative therapies who is also a proponent of taking an evidence-based approach to CAM. I think of her as sort of the Edzard Ernst of veterinary medicine. Dr. Robinson and I disagree (sometimes right in the comments section of this blog) about a number of therapies, but her genuine interest in a rigorous application of real science to the evaluation of CAM is refreshing and desperately needed in the field, and I respect her opinion even when I dont’ agree with it.

And like Dr. Ernst, Dr. Robinson has paid a price for her integrity and willingness to reject pseudoscience like homeopathy despite its affiliation with therapies she uses that are also lumped under the expansive and vague umbrella term of CAM.  She is often upraided as or more harshly even than I am by proponents of practices she challenges.

Dr. Robinson has graciously allowed me to post the letter she submitted in support of AVMA Resolution 3. It refers specifically to the Academy of Veterinary Homeopathy Standards of Practice, which I have written about before. These standards are inherently ridiculous in that they attempt to create the aura of legitimate scientific expertise in a field that is fundamentally incompatible with modern science. However, the are most worrisome in that they reveal the often hidden belief among too many homeopaths that hoemopathic treatment should be seen as an alternative to conventional, sceintific medical care. This attitude places our patients at risk and represents the greatest danger of homeopathy, which of course is rarely directly harmful since it only a placebo.

December 15, 2012
To: AVMA House of Delegates
Re: Comment on Proposed Resolution 3 

Dear Delegates,

I am writing to convey strong support for proposed Resolution 3, which recommends that the AVMA adopt a policy stating that homeopathy is ineffective and should be discouraged as a veterinary therapy.

I find especially telling and disturbing the “Standards of Practice” put forth by the Academy of Veterinary Homeopathy (AVH), the sole certifying body for veterinary homeopathy.1 The AVH stresses that consumers interested in pursuing homeopathic treatment for their animal consult a certified veterinary homeopath (CVH) so that they “will know that the AVH Standards of Practice is (sic) being upheld and that their veterinary homeopath is practicing according to the laws of homeopathy.” In fact, all AVH members must agree to the AVH Standards of Practice.2 3 Considering that the American Holistic Veterinary Medical Association has insisted that so-called “experts” in homeopathy participate in discussions that evaluate the legitimacy or effectiveness of this approach,4 it would be wise to closely examine the standards that homeopathic experts (CVH) are exhorted to uphold.

Of the 15 standards posted by the AVH, the first 8 suffice to highlight the risk of delivering ineffective healthcare to animals. They also illustrate how homeopathy might harm animals and threaten public health by omitting proven, scientifically based, medical and preventive measures designed to treat illness early and effectively as well as limit the spread of infectious disease.

Specifically, the AVH Standards of Practice state:

1) Only the remedy that is homeopathic to the patient is to be used.

2) Drugs and methods of treatment which are not homeopathic to the case are to be avoided because of the possibility of interference with the progress of cure.

With these recommendations, the AVH is essentially advising veterinarians to avoid vaccines, antibiotics, analgesics, cardiac medications, anti-epileptics, anti-inflammatories, chemotherapeutic drugs, immunosuppressant medications, inhalational anesthetics, and more. This denies animals safe, proven, clinically meaningful treatment and risks spreading communicable and preventable diseases to other animals and humans. The AVH cites the basis of this standard from an early 19th century tome: “Drugs, herbs and other forms of treatment prevent cure and cause ultimate harm to the patient.” 6

3) Use of acupuncture and moxa is not compatible with homeopathic treatment because of its effect on the vital force of the patient.

4) Treatment of symptoms by electrical or electromagnetic application is to be avoided because of its tendency to suppress symptoms in the patient. Use of electricity and effects of magnets are suitable in treatment when administered according to homeopathic indications only.

The recommendation to exclude therapies based on an abstract concept of “vital force” interference illustrates how unscientific thought from a bygone era continues to influence those who use homeopathy today.

5) Only one homeopathic medicine is to be given at one time.

In practice, this standard of practice translates into a homeopath guessing at a remedy, treating an animal with a treatment indistinguishable from a placebo for several weeks or months while withholding appropriate medications. If the animal fails to improve, the homeopathic veterinarian attempts to cure with another placebo for several weeks. How long must an animal suffer before known and effective care is offered? Sometimes such “trials” continue for months, thereby diminishing conventional care options

by allowing illnesses to worsen and pain to reach unbearable levels.

6) Medicines are most suitably given by mouth.

This directive, adapted like the others from an early 19th century homeopathic text7, was formulated prior to the development of the modern hypodermic needle in 1853 and the disposable syringe in 1956.

7) The patient should receive nutritious food that does not, in itself, have medicinal effects.

This standard contradicts the advances made by nutritional medicine and the research performed on therapeutic diets for organ failure or nutrient intolerance, posing further harm for animals by denying them preventive and restorative dietary modifications.

8) Symptoms on the skin or surface of the body that have expressed as a localized lesion are not to be treated in a vigorous way with the intent to cause their disappearance or by surgery to remove them. These are to be treated primarily by internal homeopathic treatment.

Recommending that veterinarians allow skin lesions to grow robs the animal of effective treatment for known dermatologic conditions. Cancerous lesions that could have been cured with early intervention may enlarge or metastasize, requiring painful, costly, and invasive care or palliation. This error of omission stems from an early 19th century idea, now perpetuated by the AVH: “Hahnemann explains that local lesions are expressions of internal disease and that eradication of this expression before the internal disease is treated curatively harms the patient and makes curative treatment impossible.”8 As the Iowa Board of Medicine contends, “The public needs to be informed that this practice [homeopathy] may not be useful and that it may divert individuals from other, more efficacious modalities of care while taking precious time for homeopathy to take effect. In addition, patients may spend considerable money for treatments that may not be effective. The Board’s position is ‘buyer beware’.”9

Conclusion

In summary, the Standards of Practice put forth by the AVH to be upheld by all members, including its “most expert” certified veterinary homeopaths, recommend that veterinarians commit serious, potentially life-threatening errors of omission that pose substantial risk to both animal and public health. By upholding this resolution, the AVMA will send a clear message to consumers about the risks to which they expose their animal and, possibly, themselves if they opt for what is essentially placebo medicine in place of effective, modern, scientific healthcare.

Sincerely,

Narda G. Robinson, DO, DVM, MS, FAAMA
Director, CSU Center for Comparative and Integrative Pain Medicine
Assistant Professor of Complementary and Alternative Medicine

 

References

1 The Academy of Veterinary Homeopathy (AVH) web page. Why Should I Become a Certified Veterinary Homeopathy? http://www.theavh.org/certification/index.php .

2 The AVH web page. http://www.theavh.org/referral/index.php.

3 The AVH membership application. http://www.theavh.org/documents/AVH%20Membership%20app.pdf . The application form states, “Our organization is founded on these principles and the preservation of proper application of homeopathic principles is our cornerstone…We have found that the correct application of these principles creates a higher level of success in homeopathic practice…We do not require our members to practice homeopathy to the exclusion of other modalities but we do require that, in cases where homeopathy is used, it be used according to these principles.”

4 American Holistic Veterinary Medical Association website homepage. http://www.ahvma.org .

5 The AVH web page. Standards of Practice and Purpose of the Academy of Veterinary Homeopathy.http://www.theavh.org/referral/sop.php.

6 The AVH membership application. http://www.theavh.org/documents/AVH%20Membership%20app.pdf . Original reference cited by AVH as Hahnemann S. Organon of Medicine, 6th edition, paragraphs 23, 25-45, 69, and 291.

7 Hahnemann S. Organon of Medicine, 6th edition. Denoted in the AVH Standards of Practice as their main source. 1st edition, 1810; 6th edition, completed in 1842. Translated into English by Naude A, 1982.

8 The AVH. Member Application form, available at http://www.theavh.org/documents/AVH%20Membership%20app.pdf .

9 Iowa Board of Medicine. A policy statement on homeopathy. Approved by the Board on June 28, 2001. http://medicalboard.iowa.gov/policies/homeopathy.html

 

 

Posted in Homeopathy | 3 Comments

The Evidence for Homeopathy-A Close Look

A number of defenses of homeopathy have been offered in response to AVMA Resolution 3, declaring homeopathy to be ineffective. The most comprehensive, though not at all compelling or convincing, has been a white paper offered by the Academy of Veterinary Homeopathy (AVH), The Evidence for Homeopathy, in response to the CVMA white paper The Case Against Homeopathy. I have taken on the tedious, but I believe important, task of reading through this paper, and all of the references cited, to evaluate the quality of the arguments and the evidence. My response, The Evidence for Homeopathy- A Close Look, illustrates why this attempt to defend homeopathy, with the best evidence the AVH can muster, only confirms and illustrates the problems with homeopathy explicated in the CVMA white paper.

 

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Growing Support for the AVMA Resolution Declaring Homeopathy is Ineffective

As I discussed last month, the AVMA House of Delegates will soon vote on Resolution 3, declaring that all veterinary therapies should be judged by the same standard, the standard of scientific evidence, and that homeopathy has consistently failed to meet this standard over 200 years and should be discarded. Lots of people have weighed in on this important topic. Of course, the Academy of Veterinary Homeopathy (AVH) and American Holistic Veterinary Medical Association (AHVMA) are strongly opposed to the resolution. This is no surprise since it challenges practices that form the core of their professional identity (and a significant source of income). However, support for the resolution has come from a small but diverse group of organizations willing to take an unpopular stand, based on principle and scientific evidence, and openly criticize the merits of homeopathy.

The Evidence-Based Veterinary Medicine Association (EBVMA), which was involved in drafting the white paper supporting the resolution (The Case Against Homeopathy), submitted this letter to the Delegates:

November 30, 2012

I am writing on behalf of the Board of Directors of the Evidence-Based Veterinary Medicine Association (EBVMA) to encourage you to support AVMA Resolution 3 in the AVMA House of Delegates during the 2013 Winter Session.

The AVMA has issued many policy statements acknowledging that veterinary medicine should be based on sound, legitimate science. The AVMA Policy on Complementary and Alternative Medicine, for example, states, “Claims for safety and effectiveness ultimately should be proven by the scientific method…Practices and philosophies that are ineffective or unsafe should be discarded.” However, despite overwhelming evidence and consensus among scientists that homeopathy is ineffective, a few veterinarians continue to promote it as an adjunct or alternative to conventional scientific medicine. This diminishes the credibility of the veterinary profession and does a disservice to our patients and our clients.

Other national veterinary groups, including the Australian Veterinary Association and the British Veterinary Association, have publically acknowledged that homeopathy is not an effective therapeutic approach. As the leading veterinary association in the world, it is important that the AVMA also demonstrate its commitment to modern, evidence-based medicine and the interests of our patients and the public. Resolution 3 protects the integrity of the AVMA and the veterinary profession as well as the trust of the public on which we depend.

The EBVMA Board of Directors unanimously endorses Resolution 3 and the supporting documents introduced to the AVMA House of Delegates by the Connecticut Veterinary Medical Association, and we encourage you to support passage of this important policy statement.

Sincerely,

Brennen McKenzie, MA, VMD
President, Evidence-Based Veterinary Medicine Association                                                          

EBVMA Board of Directors
Brennen McKenzie, VMD, MA
Stuart Turner, DVM, MS
Annette O’Connor, BVSc, MVSc, DVSc, FACVSc (Epidemiology)
Thomas Doker, DVM, MPH
Ken Drobatz, DVM, MSCE, DACVIM, DACVECC
Virginia Fajt, DVM, PhD
Joe Hauptman, DVM, MS, DACVS
John Gay, DVM, PhD, DACVPM
Brad Hanna, BSc, DVM, MSc, PhD
Marnie Brennan, BSc (VB), BVMS, PhD                                                                                           

The American College of Veterinary Clinical Pharmacology also submitted the following letter of support:

December 11, 2012
AVMA House of Delegates
Re: Comment on Proposed Resolution 3 for the House of Delegates 2013 WinterSession

Dear Sirs/Madams:

The American College of Veterinary Clinical Pharmacology (ACVCP) supports the proposed Resolution 3 for the Regular Winter Session of the AVMA House of Delegates in January 2013, submitted by the Connecticut Veterinary Medical Association. The Resolution proposes that AVMA have a policy that states homeopathy is an ineffective practice and that its use as a veterinary therapy be discouraged.

The ACVCP concurs with the authors of the Resolution and its accompanying white paper that there is strong evidence that the theoretical foundations of homeopathy are inconsistent with established principles of chemistry, physics, biology and physiology, and that clinical evidence has not proven the practice of homeopathy to be effective at treating or preventing disease. The ACVCP cannot support any treatment modality not supported by clinical evidence of efficacy, particularly if such treatment may result in financial loss to the owner and may harm the animal due to delayed/withheld treatment with remedies that have been proven to be effective.

The ACVCP urges the House of Delegates to approve this resolution, which sends a message about the importance of science and the principles of evidence-based veterinary medicine when treating veterinary patients.

Respectfully,

On behalf of the American College of Veterinary Clinical Pharmacology

Dawn Merton Boothe, DVM, PhD
Diplomate, ACVIM (Internal Medicine), Diplomate ACVCP
President, American College of Veterinary Clinical Pharmacology
Professor, Anatomy, Physiology & Pharmacology
Director, Clinical Pharmacology
College of Veterinary Medicine

The American Academy of Veterinary Pharmacology and Therapeutics also submitted a supporting letter, and the American Society of Laboratory Animal Practitioners has indicated it supports the resolution as well.

A number of individual veterinarians from around the world have also indicated their agreement with the resolution and the contents of the CVMA white paper.

Individual Veterinarians
Gary Block, DVM, MS, DACVIM (Internal Medicine)

Steven Budsberg, DVM, BS, MS, DACVS

Tad Coles, DVM
Carmen Czachor, DVM

Valeri Devaney, DVM

Arnold Goldman, DVM, MS, MPH

David Haas, DVM

David Jaggar, MRCVS, DC
Linda Jorgensen, DVM, DACVIM
Susan Jelinski, DVM, PhD
Rebecca Greene, DVM

Philip J Johnson, BVSc(Hons), MS, Diplomate ACVIM-LAIM, Diplomate ECEIM,
MRCVS William Kurmes, DVM
Elaine Burkhart DVM

Robert Larson, DVM, PhD

Roy Montgomery, DVM, PhD
 
Gerald S. Post, DVM, MEM, DACVIM (Oncology)
 
Narda G. Robinson, DO, DVM, MS, DABMA, FAAMA

Mark A Holmes MA, VetMB, PhD, MRCVS
Tatjana K. Mirkovic, BSc, DVM, DACVIM (Internal Medicine)
Joerg Steiner Joerg Steiner, DVM, PhD, DACVIM, DECVIM-CA
Timothy A. Allen, DVM, DACVIM (Internal Medicine)
Wendy Foster BSc DVM DVSc DACVIM
Douglas C. Bronstad, DVM, DACVIM (Internal Medicine)
Tabitha A. Hutton, DVM, MTR, DACVIM (Internal Medicine)
David W. Ramey, DVM
Susan Jelinski, PhD DVM Mark Rishniw, BVSc, MS, PhD, DACVIM (Cardiology & Internal Medicine)
Leonard D. Jonas DVM, MS, DACVIM
Martin L. Whitehead BSc, PhD, BVSc, CertSAM, MRCVS
Fiona M.K. James, DVM, MSc., DVSc., ACVIM (Neurology)
Brad Burrington, DVM
Richard Meadows, DVM, DABVP
Romain Beraud, DVM, MSc, DES, dipl. ACVS
Deborah Cottrell DVM

The AVH and AHVMA have tried to cast this debate in terms of malign personal agendas and bias, but this is both an inappropriate and unprofessional attempt to dodge the substance of the issue and patently untrue. Of the 92,000 veterinarians in the U.S., about 133 are members of the AVH, and while not only AVH members employ homeopathy, it is likely to be only a tiny percentage of the profession. This passionate and vocal minority is entitled to make their case publically, as are skeptics of homeopathy. However, the case should be argued on the basis of the evidence, not innuendo and personal attacks. It is clear that recognition of the implausibility and lack of efficacy of homeopathy is widespread in veterinary medicine, and attempts to characterize the situation otherwise are merely a distraction from the facts.

Posted in Homeopathy, Law, Regulation, and Politics | 3 Comments

Supraglan Replaced By Adrenal Harmony Gold: Different Ingredients, Same Empty Promises

Note. Updated with correction Jan. 30, 2013 (see below)

One of the most widely read, and controversial, reviews I have written was for an herbal combination product called Supraglan which was marketed to treat hyperadrenocorticism, also known as Cushing’s Disease (and also its opposite, Addison’s Disease). Essentially, the company made numerous dramatic claims about both the safety and effectiveness of this product without any appropriate scientific evidence to support them. But despite the near miraculous results claimed for this product in testimonials on the company web site (which, of course, prove nothing for reasons I have discussed before), shockingly no scientific evidence has come to light in the two years since I first discussed Supraglan showing that it had any benefit at all. Instead, the company has ceased marketing Supraglan and replaced it with another product, the more soothingly named Adrenal Harmony Gold. The new product comes with equally miraculous testimonials.

But I have to wonder why, if Supraglan was so amazingly safe and effective, the company chose to stop making it rather than pursing the scientific research that would have given it legitimacy, and a much wider market. And why, if Supraglan was so successful, did the company use only one of the ingredients from Supraglan in the new concoction? And if Supraglan didn’t really do all the things claimed for it in those testimonials, why exactly should we believe the same kind of anecdotes for the new product?

What are the Claims?
So how are the claims and the evidence for the new product? Sadly, just as empty and misleading as for Supraglan.

  • Promotes healthy skin and coat
  • Helps normal hair growth
  • Supports normal thirst and urination
  • Supports healthy weight, normal appetite
  • Supports proper muscle tone

The herbal actions in Adrenal Harmony Gold are: adaptogenic, antioxidant and will support the nervous system. These herbs are particularly suited to supporting the adrenal glands and its functions. “Adaptogens” are a group of herbs considered to nourish and balance the adrenals, helping the body adapt naturally and have normal levels of energy. Antioxidants counter oxidative (free radical) damage that can lead to degeneration.

Together, the ingredients in Adrenal Harmony Gold target the body systems that help to keep the adrenal and anterior pituitary hormones in a healthy and normal balance. They also contribute to the body’s healthy stress response for normally calm moods and sleep.

Adrenal Harmony Gold targets the HPA axis (hypothalamus-pituitary-adrenal) to strengthen the body’s internal feedback mechanisms.

These claims and explanations for the supposed mechanism of action of this product are not supported by scientific evidence. The product is claimed to normalize the symptoms associated with Cushing’s disease, but no plausible scientific explanation for why it should is given. Vague claims like “nourishing” and “supporting” the adrenals are meaningless.

As far as the inclusion of supposed antioxidants, I’ve pointed out before that the hype about antioxidants far exceeds the evidence (c.f. this article also) of any real value, and some evidence has developed showing that they have significant potential risks, including increasing the likelihood of some diseases and interfering with some kinds of medical therapy. So while the potential uses of antioxidants deserve further study, the automatic assumption that they are a good idea is increasingly contradicted by the evidence. In any case, there is no evidence that Cushing’s is caused or exacerbated by oxidative processes or that antioxidants would be beneficial.

The notion of “adaptogens” is also not a concept that is supported by much legitimate scientific theory or research. The idea is that certain herbs can, by some vague mechanisms not yet identified, “restore balance” to any system in the body. This concept has more to do with vitalist spiritual beliefs about health and disease being due to “imbalances” in some vague vital energy than with a scientific understanding of homeostasis.

While herbs undoubtedly contain active chemical ingredients which could possibly have medicinal value, there is no reason to think these medicines are fundamentally different from much better studied conventional medicines. The notion that herbs can act primarily to bring a disease organ system “into balance” regardless of the specific disease the patient is suffering from is pure pseudoscience.

The company web site talks a lot about Cushing’s disease caused by excessive use of steroids. This is a form of the disease which is completely avoidable unless a patient has another medical condition which requires prolonged, relatively high doses of steroids. In these cases, there is no “imbalance,” there is simply an adverse effect to a medication needed for another reason, and as always the risks and benefits of the medication have to be weighed. Cushing’s disease may be better than death from autoimmune disease, for example. And if the steroids are not truly needed, then the Cushing’s disease can be cured simply by gradually taking the patient off of them. The only potential use for herbal therapy here would be to minimize symptoms without addressing the cause, and there is no evidence showing this product can do that.

However, most cases of Cushing’s disease in dogs are caused by a benign tumor in the pituitary gland. The “imbalance” is due to excessive production of a pituitary hormone which, in turn, causes too much steroid production in the adrenal glands. The scientific therapies for this are to take away the pituitary tumor surgically (which is commonly done in humans but which is not usually possible in dogs for anatomical reasons), or to reduce the production of steroids by the adrenal glands. Any herbal therapy that is going to effectively treat this disease will need to be able to reduce the amount of active steroid hormone by some means. It is certainly possible such an herbal therapy may be developed, but if it is effective it will act as a medicine, and like all medicines it will have its side effects and limitations which must be considered along with its benefits. It will not, however, magically make the symptoms go away without actually treating the cause of the disease and without any possible risks.

Finally, a few cases of Cushing’s come from an aggressive cancer in the adrenal gland. This tumor is usually not very responsive to medications and needs to be removed surgically in those cases in which that is possible. Sadly, many of these patients eventually die of this cancer. No “nourishing” or “balancing” of the adrenals or “strengthening of the body’s natural feedback mechanism” is going to help these dogs. And delaying real therapy while messing around with an untested herbal remedy only decreases the chances of a good outcome.

Now could herbal therapies reduce symptoms even if not treating the cause of the disease? It’s possible, but like all other medical claims it should be proven by appropriate research, not wishful thinking and testimonials. The company claims is has “integrated the latest scientific research” with the “time-honored, traditional uses” of herbs to create this product. Let’s see what the science actually says about the ingredients in this product.

The Ingredients and The Science
Here are the ingredients listed for the product (with no specific quantities listed) and some of the statements made about them:

  • Fresh Ashwagandha root (Withania somniferum)*: A primary adaptogen in this formula, Ashwagandha assists the adrenal glands directly to respond normally and produce healthy amounts of cortisol. This is a well-known herb for helping      the body’s stress levels and supporting normal, restful sleep.

Coming from the Ayurvedic herbal tradition, this ingredient has the usual thousand-and-one traditional uses, including as a non-specific tonic improving any and every symptom or disease. The plant contains varying amounts of a wide range of chemicals, and there have been some laboratory animal studies (mostly in rodents) indicating these chemicals have a variety of physiological effects. Some studies do suggest the plant can lower steroid hormone levels in rats exposed to chronic stress. This, however, says nothing about the effect on dogs with pituitary tumors or other causes of Cushing’s disease.

There is little research on the use of the herb in humans, and I could find none specifically relating to Cushing’s disease. There is one case report which suggests the herb might raise steroid hormone levels, which would be the opposite of the desired effect in Cushing’s disease. There appear to be no clinical studies on the use of this product in treating dogs with Cushing’s disease.

This summary of the research identifies a lot of interesting preclinical studies suggesting the chemicals in this plant might do interesting things, but it identifies no reliable evidence to support using it to treat Cushing’s disease in dogs.

 

  • Holy Basil leaf (Ocimum sanctum): Also called Tulsi, Holy Basil is a gentle adaptogen for supporting the adrenal glands. Of key importance, adaptogens will neither cause the body to relax nor become stimulated, necessarily. Rather, their action is to assist the body to adapt as needed and bring it back into balance. For that reason, adaptogens are used for a variety of reasons when normal adrenal function is desired.

Also common in Ayurvedic medicine, this herb has a very similar profile in terms of the evidence available for it. Lots of pharmacology studies characterizing the chemicals it contains. A moderate number of rodent studies showing physiological effects, including a few that suggest it might ameliorate the effects of chronic noise stress. No clinical trials in humans or dogs suggesting any usefulness in Cushing’s disease.

 

  • Fresh Turmeric rhizome (Curcuma longa): One of the best antioxidant herbs      available, Turmeric also supports liver health. Turmeric can be difficult  for the body to absorb. Our extraction method using fresh, organic Turmeric is an extremely potent liquid extract, much stronger than a simple glycerin extraction and captures all of the useful constituents of this herb, including curcumin and other curcuminoids.

Turmeric is one of the most intensively examined herbal agents, with a wide range of proposed uses. With regard to the treatment of Cushing’s disease, I have found no clinical studies in humans or dogs to suggest a benefit. There is one study that found changes in the secretion of steroids by cow adrenal cells in the lab under specific conditions. And there are some of those “chronic stress” studies in rats which suggest some interaction between curcumins and the hypothalamus/pituitary/adrenal (HPA) system. Does this mean these chemicals could be useful as medicines in diseases involving the HPA system? Sure. Does it mean they are safe and effective for treating Cushing’s disease in dogs? Absolutely not.

The National Center for Complementary and Alternative Medicine says:

There is little reliable evidence to support the use of turmeric for any health condition because few clinical trials have been conducted.

Preliminary findings from animal and other laboratory studies suggest that a chemical found in turmeric—called curcumin—may have anti-inflammatory, anticancer, and antioxidant properties, but these findings have not been confirmed in people.

There is even less evidence in dogs. And there have been reports of allergic reactions, liver problems, and other side effects. Any chemical that exerts a substantial effect on the body is going to have unintended effects some of which can be harmful. This is as true for herbal products as for conventional pharmaceuticals.

 

  • Bacopa herb (Bacopa monnieri): Bacopa exhibits uses both as an adaptogen and as an antioxidant. It has also been used for stress and is said to generally contribute to healthy moods and cognitive function.

This herb has been studied primarily for effects on anxiety, depression, memory, and other behavioral conditions. There is a fair bit of laboratory rodent research showing effects on stress response, including steroid levels, but again this is quite different from the physiology of Cushing’s disease. This kind of pre-clinical research is not a reliable indicator of whether a medicine will be safe or effective in actual clinical use. I have found no clinical research in humans or in dogs to suggest this herb is appropriate for Cushing’s disease.

 

  • Sarsaparilla root (Smilax officinalis): A traditional herb of the south western      United States, Sarsaparilla has a long-standing use for helping the body to normally excrete excess toxic materials through the lymphatic system. It has also been used to support liver function and healthy blood pressure levels.

Claims about “toxins” are a mainstay of alternative theories and treatments of disease, and they are mostly nonsense, the “evil humours” of today’s pseudoscience. Given that the idea of mysterious unnamed “toxins” being involved in Cushig’s disease is nonsense, there is little reason to think this herb would be useful for excreting these toxins. As usual, there are no clinical studies in any species that suggest this is safe and effective as a therapy for patients with Cushing’s disease.

 

  • Astragalus root (Astragalus membranaceous): Another popular      “adaptogen”, Astragalus helps the body’s normal ability to adapt to stress. It also contains polysaccharides, constituents that assist the body’s normal immune response to fight off bacteria and viruses.

Again, the claims for the concept of “adaptogens” are not strongly supported by scientific evidence, so this is not a compelling reason to use this herb. And while it is true that patients with Cushing’s disease have impaired immune function, the notion of “boosting the immune system” is about as legitimate as “cleansing toxins” or “protecting against stress.” Vague claims about broad and non-specific health effects, which are uniformly beneficial and never harmful, are a clear warning sign of unscientific and unreliable nonsense. In the absence of any actual clinical studies to suggest this herb is beneficial for Cushing’s patients, these arguments are certainly no reason to use it.

 

  • Milk Thistle seed (Silybum marianum): A gentle and effective herb for normal liver function, Milk Thistle assists the liver to metabolize drugs and toxins to be excreted by the body. The liver also plays a role in denaturing some circulating      hormones.

This is one of the few ingredients in this concoction with at least a plausible argument for why it might be useful in patients with Cushing’s disease. There is reasonable evidence that silymarin has protective effects in the liver, and the liver does experience the accumulation of glycogen and other adverse effects of chronically high steroid levels in animals with Cushing’s. However, the evidence for the benefits of milk thistle is generally still weak and mostly concerns toxic and infectious liver disease. There does not appear to be any specific research suggesting a benefit for patients with Cushing’s, so wile the idea is at least plausible, it remains undemonstrated.

 

  • Blessed Thistle flower (Cnicus benedictus): Blessed or Holy Thistle has similar uses as Milk Thislte for liver support. Additionally, it has been shown to exhibit      support for the immune system and digestion.

There is generally very little research on the potential medicinal value of this herb, and none I could find on its use for patients with Cushing’s disease. The Natural Medicines Comprehensive Database indicates there is insufficient evidence to draw conclusions about claims for any medicinal use.

 

  • Chaste Tree berry (Vitex      agnus-castus): Used for its gentle, tonic action on the anterior pituitary, Vitex is an amphoteric herb, meaning it will help maintain      normal hormonal levels, rather than cause them to go higher or lower. Commonly used for female health matters, Vitex is included in this formula for its affect on the pituitary’s action in adrenal hormone regulation

This is the only one of the ingredients in this product that does appear to have been tested for use in patients with Cushing’s disease. Unfortunately, it didn’t work. Lots of anecdotal reports suggested this herb might have benefits in horses with Cushing’s disease, and uncontrolled evaluation by the manufacturer of a chaste tree berry product seemed supportive of these claims. However, a clinical trial comparing this product to conventional treatment concluded:

Vitex agnus castus Extract,the commercially available form of Vitex agnus castus, did not have a beneficial effect in horses with pituitary pars intermedia hyperplasia (Equine Cushing’s Syndrome).

Whether positive or negative, these results may not be relevant to treatment of Cushing’s in dogs, which involves a very different mechanism than in horses. No studies are available in dogs with Cushing’s.

 

  • Prickly Ash bark (Zanthoxylum americanum): Used by many First Nations communities at one time, the bark of the Prickly Ash tree has been termed an      “alternative”, meaning that it will help support normal flow of lymphatic circulation. It also helps maintain normal arterial and capillary circulation.

This herb contains chemicals which have shown some potential antibiotic and antiparasitic properties, though there are no clinical trials of this use. And, almost needless to say at this point, there is absolutely no evidence it is beneficial for dogs with Cushing’s disease. “Supporting normal lymph flow” is not only ridiculously unlikely but not in any obvious way relevant to the needs of patients with Cushing’s disease. And how or why it would maintain normal arterial and capillary circulation (but not venous circulation?), or why this would be relevant for these patients, is also unclear.

Bottom Line
Like Supraglan, this product contains a hodgepodge of herbal ingredients with rationales that are mostly based on traditional use, anecdote, or the findings or in vitro laboratory studies, none of which on their own justify clinical use of any medicine.  Many of the theoretical rationales for the selected ingredients, such as “boosting the immune system” or “excreting toxins” are complete nonsense. There are potentially plausible rationales for the use of a couple ingredients, such as the milk thistle. There is not, however, any clinical trial evidence to support the use of this product for Cushing’s disease in any species. The only ingredient which appears to have been tested for use in patients with Cushing’s disease is the chaste tree berry extract, which failed to show any benefits in a clinical study in horses.

This product will undoubtedly be promoted not only with dubious rationales and a lack of real scientific data showing any benefit, but also with miraculous anecdotes and testimonials supporting its effectiveness. I expect to see passionate, even angry comments from users of the product who are certain, based on their personal experiences, that it works. Apart from all the usual reasons why such uncontrolled observations are not useful in establishing safety and efficacy for any medical therapy, I will point out right from the beginning that the same miraculous testimonials supported the benefits of Supraglan, which many people claimed to have cured their dogs of Cushing’s disease. So why, exactly, did this miraculous product suddenly disappear, replaced by another with almost none of the same ingredients? And why, if the testimonials for Supraglan turned out to be as unreliable as testimonials usually are, should we take those for Adrenal Harmony Gold any more seriously?

** Update Jan. 20, 2013:

Having looked into these products in more detail, it appears that the initial report I found stating Supraglan had been discontinued was inaccurate. Petwellbeing distributed it from 2007 until 2012 and then ceased distributing it and replaced it with Adrenal Harmony Gold. But NHV Natural Pet Products still manufactures Supraglan.

This doesn’t change the substance of this post, since Petwellbeing marketed Supraglan with all the claims and testimonials discussed in the post on that product and then replaced it with a different product containing different ingredients and marketed in the same way. Both products lack sound scientific evidence to support the claims made for them.

The Petwellbeing.com page on Supraglan at the time of the original review can be found HERE.

 

Posted in Herbs and Supplements | 59 Comments

Health & Human Services Inspector General Finds Dietary Supplement Companies Make Misleading, Unsupported Claims and Ignore FDA Regulations

I have discussed the bizarre and ineffectual regulatory scheme for dietary supplements in detail previously. The stunningly misnamed Dietary Supplement Health and Education Act (DSHEA) basically exempts any product called a “supplement” from any meaningful regulation to ensure safety or truthfulness in advertising. Companies selling supplements aren’t supposed to make claims about their products without good scientific evidence, and they aren’t allowed to claim to treat any specific disease, only to support the body’s normal “structure and function.” And all such products are supposed to carry the Quack Miranda Warning, which basically says the FDA hasn’t evaluated the companies’ claims and can’t guarantee the product is safe or effective.

Unfortunately, compliance is totally voluntary with no oversight or enforcement mechanism. The FDA isn’t allowed to verify the truthfulness of any marketing claims before a product goes on the market, and the burden for showing a product is harmful after it available is so high it is almost impossible to stop the sale of anything marketed as a dietary supplement. The fox is the only one with a key to the henhouse.

The government has repeatedly found casual and widespread violation of even the very limited regulations that exist. The FDA has found serious safety and quality control lapses in dietary supplement manufacturing. The GAO has reported on deceptive marketing of herbal remedies. And now the Department of Health and Human Services Inspector General has issued a report confirming that the “structure and function” claims analyzed for 127 supplements failed to meet even the limited requirements of DSHEA. The report concluded:

Overall, substantiation documents for the sampled supplements were inconsistent with FDA guidance on competent and reliable scientific evidence. FDA could not readily determine whether manufacturers had submitted the required notification for their claims. Seven percent of the supplements lacked the required disclaimer, and 20 percent included prohibited disease claims on their labels. These results raise questions about the extent to which structure/function claims are truthful and not misleading.

The report illustrates both the toothlessness of the voluntary guidelines as well as the lack of real scientific evidence to support the kinds of claims supplement manufacturers routinely make. Only 66 out of 104 companies contacted even agreed to submit information to investigators supposedly substantiating the claims they made for their products. And the documents that were submitted did not justify any confidence in the claims these manufacturers make. A few telling details from the report:

In contrast to FDA guidance, most substantiation was not derived from human studies.

Of the 34 percent of substantiation documents that were human studies, none met all of FDA’s recommendations for competent and reliable evidence.

10 percent of the documents appeared to have no significance in supporting structure/function claims.

FDA guidance recommends that when determining whether a claim is substantiated, manufacturers should consider all available scientific evidence—both favorable and unfavorable—and present the evidence in context. Interviews with staff at the National Center for Complementary and Alternative Medicine at the National Institutes of Health indicated that a large body of science exists that contradicts existing structure/function claims. Yet, 96 percent of the human studies we received were favorable to the supplements’ claims, suggesting that manufacturers either have not considered the body of available scientific evidence, that there is a positive bias in the documents selected to substantiate their claims, or that no such contradictory evidence exists.

85 percent of the 557 human studies we reviewed were not randomized, double-blind, parallel group, placebo-controlled trials.

49 percent of the human studies were not based on populations similar to those that will be consuming the supplements.

Seven percent of supplements in our sample were missing the required disclaimer for structure/function claims

Overall, the evidence submitted to support claims made about the effect of these supplements were cherry-picked to appear more positive than the total body of evidence available, consisted largely of unreliable pre-clinical studies and a few poor-quality clinical trials, and often had nothing at all to do with the claims being made. And presuming that those companies willing to voluntarily submit their supporting evidence had, in fact, better evidence to offer than those companies who ignored the request, it is very likely that most structure and function claims are completely without any basis in science at all.

It never ceases to amaze me that people rail vociferously (and often with good reason) at the misdeeds of pharmaceutical companies and yet seem perfectly comfortable with allowing a multi-billion dollar herb and supplement industry monitor itself and make barely even token efforts to find out if their products are safe or do what they are being taken for. This report recommends that the FDA seek the statutory authority to verify structure/function claims, and that would be a good start, though it seems unlikely in the current political climate. What would make even more sense, and would be more likely to protect the public from unsafe and ineffective supplements and deceptive advertising, would be to scrap DSHEA and regulate all medical products by the same, science-based standards of evidence. Sadly, something that reasonable seems even less likely to be possible.

                                                       

Posted in Herbs and Supplements, Law, Regulation, and Politics | 3 Comments

AVMA Considers Resolution Acknowledging Homeopathy is Ineffective

A recent article in the Veterinary Practice News (VPN) revealed that the American Veterinary Medical Association (AVMA) is considering a resolution, proposed by the Connecticut Veterinary Medical Association (CVMA), relating to homeopathy, specifically, and to the role of science and scientific evidence in evaluating veterinary therapies more generally. The full text of Resolution 3 is available here, but the core of the measure consists is the following:

RESOLVED, that the American Veterinary Medical Association (AVMA) affirms that—

1. Safety and efficacy of veterinary therapies should be determined by scientific investigation.

2. When sound and widely accepted scientific evidence demonstrates a given practice as ineffective or that it poses risks greater than its possible benefits, such ineffective or unsafe philosophies and therapies should be discarded.

3. In keeping with AVMA policy on Complementary and Alternative Veterinary Medicine, AVMA discourages the use of therapies identified as unsafe or ineffective, and encourages the use of the therapies based upon sound, accepted principles of science and veterinary medicine.

4. Homeopathy has been conclusively demonstrated to be ineffective.

The resolution is supported by a detailed white paper, The Case Against Homeopathy.

The first three statements in the resolution are not likely to be controversial, and they are already included, usually implicitly, in a number of existing policy statements. The most directly relevant is the AVMA Policy on Complementary and Alternative Medicine, which states, “Claims for safety and effectiveness ultimately should be proven by the scientific method… Practices and philosophies that are ineffective or unsafe should be discarded.”

This has been the official policy of the AVMA for over a decade. However, no alternative therapy has ever been acknowledged to be ineffective or discarded, including homeopathy. There is, as the white paper makes clear, overwhelming evidence that homeopathy has no benefit beyond placebo, but because it is a belief system rather than a medical discipline, practitioners of homeopathy are unlikely to ever accept this. The final statement in the resolution is controversial only because this small group, passionate and ideologically committed to homeopathy, will undoubtedly challenge it vigorously.

And despite the fact that the vast majority of veterinarians do not practice homeopathy, any criticism of practices other veterinarians employ, regardless of the evidence against them, seems to have become virtually taboo within the profession. Collegiality and unity sometimes seem to take precedence over science and the interests of our patients and clients. However, there are a number of reasons why this resolution is important for the profession, as well as patients and their owners.

As has been discussed frequently before (1-8), offering homeopathic treatment without clearly identifying it as a placebo is unethical. It places patients at risk by substituting an ineffective therapy for real treatment, and it denies pet owners the right to make fully informed decisions about the care of their pets. Mainstream veterinary medicine has left behind bloodletting, purgatives, and many other 18th and 19th century therapies which failed the test of scientific validation, and it is not in the interests of our patients, our clients, or our profession to endorse a belief system like homeopathy which has similarly failed to generate meaningful evidence of real benefits beyond placebo effects in the last two hundred years.

Several organizations have endorsed the proposal. The Evidence-Based Veterinary Medicine Association has issued this statement urging passage of the resolution:

The AVMA has issued many policy statements acknowledging that veterinary medicine should be based on sound, legitimate science. The AVMA Policy on Complementary and Alternative Medicine, for example, states, “Claims for safety and effectiveness ultimately should be proven by the scientific method… Practices and philosophies that are ineffective or unsafe should be discarded.” However, despite overwhelming evidence and consensus among scientists that homeopathy is ineffective, a few veterinarians continue to promote it as an adjunct or alternative to conventional scientific medicine. This diminishes the credibility of the veterinary profession and does a disservice to our patients and our clients.

Other national veterinary groups, including the Australian Veterinary Association and the British Veterinary Association, have publically acknowledged that homeopathy is not an effective therapeutic approach. As the leading veterinary association in the world, it is important that the AVMA also demonstrate its commitment to modern, evidence-based medicine and the interests of our patients and the public. Resolution 3 protects the integrity of the AVMA and the veterinary profession as well as the trust of the public on which we depend.

The EBVMA Board of Directors unanimously endorses Resolution 3 and the supporting documents introduced to the AVMA House of Delegates by the Connecticut Veterinary Medical Association, and we encourage you to support passage of this important policy statement.

There have also been endorsements from the American College of Veterinary Clinical Pharmacology (ACVCP) and the American Academy of Veterinary Pharmacology and Therapeutics  (AAVPT). Not surprisingly, the Academy of Veterinary Homeopathy (AVH) and the American Holistic Veterinary Medical Association (AHVMA) are fighting the measure.  According to the VPN article,

Proponents of homeopathy welcome introduction of the resolution.

“This is a wonderful chance for us to educate other vets about the benefits of homeopathic veterinary medicine,” said Jeff Feinman, VMD, CVH. “The main argument [against] homeopathy is that it’s implausible, and we will show that that’s not true at all. The research is just now catching up with the basic science.”

It will be interesting to see how homeopaths attempt to make the argument that homeopathy is actually consistent with basic scientific knowledge, given the strong case to the contrary (for example, The Science of Homeopathy).

I suspect the attempt will involve some reference to quantum physics. By virtue of being strange, counterintuitive, and impossible to truly understand without fluency in advanced mathematics, quantum physics is a popular rope among proponents of pseudoscientific therapies like homeopathy. The argument seems to be something along the lines of, “Quantum physics is weird and true. Homeopathy is weird. Homeopathy must be true.”

There are a number of problems with this fallacious argument, including the fact that there is no demonstrated connection between the oddities seen at the subatomic level and the notion that water which once had some kind of substance in it magically remembers that substance and can thus cure patients afflicted with symptoms that might or might not be caused, in healthy patients, by that substance.

Another argument the AHVMA brings up in their comment about the resolution is that no homeopaths were consulted by the CVMA in developing the proposed resolution. The AHVMA says, “when anyone considers a modality, they should talk to people who are considered experts in the field.” This sounds quite reasonable, but it skips over the fact that homeopathy is not a recognized medical specialty in which one can legitimately be said to be an expert. Though homeopaths have gotten together and created certification standards for themselves, these are not recognized by the American Board of Veterinary Specialties, The European Board of Veterinary Specialties, the American Board of Medical Specialties, or any other organization responsible for identifying and accrediting medical experts. Astrologers and Psychics have organizations that accredit practitioners of these methods, but that’s not a mark of legitimacy to those practices.

Ordinary veterinarians are capable of evaluating the scientific evidence and drawing a reasonable conclusion on the merits of homeopathy. Homeopaths, on the other hand, will never acknowledge the lack of evidence supporting their claims since to do so would be to invalidate their own profession. So the suggestion that the AVMA should set up a “task force” to evaluate homeopathy and advise the House of Delegates is like arguing that creationists should advise school boards on how to teach evolution. We don’t need task forces with specialists in bloodletting, faith healing, or other belief systems claiming, against significant evidence, to be medical therapies, and there is no reason to have one for homeopathy.

The AVMA House of Delegates will debate Resolution 3 on January 5. The delegates consist of representatives of the state veterinary medical associations and a number of allied organizations. The list of delegates can be found here. I encourage all veterinarians to contact their delegates and urge them to support this resolution.

References

  1. Smith, K. Against homeopathy-A utilitarian perspective. Bioethics. 2012;26(8):398-409. which is reviewed at this link, for those who do not have access to the journal: http://www.sciencebasedmedicine.org/index.php/placebos-as-medicine-the-ethics-of-homeopathy/
  2. Freckelton I.Death by homeopathy: issues for civil, criminal and coronial law and for health service policy. J Law Med. 2012 Mar;19(3):454-78.
  3. Smith, K. Why homeopathy is unethical. Focus on Alternative and Complementary Therapies 2011;16(3):208–211.
  4. Shaw D. Homeopathy is where the harm is: Five unethical effects of funding unscientific “remedies.” J Med Ethics. 2010;36:130-131
     
  5. Shaw D. Unethical aspects of homeopathic dentistry. Br Dent J. 2010 Nov 27;209(10):493-6.
  6. Ernst, E. The ethics of complementary medicine. J Med Ethics 1996; 22: 197-198.
  7. Rollin, B. and Ramey, D. “Ethics, Evidence, and Medicine” in Ramey, D., Rollin, B. Complementary and Alternative Veterinary Medicine Considered. Iowa State Press, 2004.
  8. Rollin, B.  An ethicist’s commentary of the case of a veterinarian utilizing homeopathic therapy. Can Vet J. 1995 May; 36(5): 268–270.
Posted in Homeopathy, Law, Regulation, and Politics | 23 Comments

Eric Weisman Gets Fine and Probation for Violating Court Order

I recently received a comment from Mr. Eric Weisman, promoter of Evolution Diet, regarding a post I wrote about his products in 2009. The comment was full of conspiracy theories, baseless accusations, and a general disregard for truth. At that time of my original article, I knew only that Mr. Weisman was making claims about his diet, as well as other commercial diets and veterinary medicine as a profession, that were untrue and without any basis in fact. It later became clear that Mr. Weisman isn’t interested in facts at all when a reader pointed out that Mr. Weisman had been sanctioned numerous times for violating the terms of his license as a chiropractor and for practicing veterinary medicine without a license. In an update to my original post, I made available the public documents showing this pattern of dishonest behavior, for which Mr. Weisman ultimately lost his license to practice chiropractic.

Unfortunately, this did not disabuse him of the mistaken belief that he was qualified to practice medicine on both humans and animals, since he was subsequently charged with violating the terms of this court injunction along with new counts of practicing medicine without a license and mistreatment of animals, as I reported in an update last year. The allegations included some horrific descriptions of unethical behavior, including this from a veterinarian at the University of Minnesota,

Weisman brought in a cat he suspected had kidney failure and cancerous lesions, the complaint said. According to the U’s veterinarian, the cat had neither – it died of pneumonia, was unable to absorb nutrients from the food it ate and had broken bones in each of its front legs. The suspected cancerous lesions, the veterinarian said, were actually scabs caused by the cat walking on its joints instead of its broken feet, the complaint said.

Earlier this year, Mr. Weisman and the authorities reached a plea deal in which he pled guilty to violating the terms of his earlier court agreement. In return for this plea, he received a fine a 90-day suspended sentence, and probation, and the other charges were dropped. Interestingly, Mr. Weisman did not deny that he diagnosed a dog with cancer and prescribed treatment for it or that he recommended treatment to a man with lymphoma, he merely claimed that in doing so he explicitly told them he wasn’t a doctor and so was not legally allowed to practice medicine. Apparently, this disclaimer, followed by behavior indistinguishable from the practice of medicine, is sufficient to absolve Mr. Weisman of legal responsibility for his actions.

Naturally, Mr. Weisman sees his conviction as a vindication, and it’s hard not to see why when such egregious disregard for the law of the truth meet with such mild sanction. And it seems clear that no lesson has been learned here. While sprinkling his web site with disclaimers about not being allowed to practice veterinary or human medicine, statements like this are still to be found there:

Q. I have concerns about how healthy a Vegetarian Diet is for my Pet. My pet is having some problems and I have been feeding my pet another pet food or Evolution for a while and I’m not sure if it’s the food causing the problem.

Please phone me immediately with any Health Concerns at 651-221-9056 and leave a message for me, Eric Weisman, Scientist, Dr. of Health Sciences. I have helped many Dogs, Cats, Ferrets and Humans with Health and Behavior Issues in 1000’s of cases. I am an internal disease expert with many years of both Nutrient Compound Procedure and Drug-Surgery Health Experience and feeding a Meat Based or Vegetarian Diet to many types of animals, including wild outdoor animals and exotic pets. Although it is far better to phone for the fastest response, you may also e-mail us about health, behavior, and product issues at weisman@qwestoffice.net. For Urgent issues,call 651-492-2190.

We can tell you exactly how we treat a Dog, Cat or Ferret with the same or similar condition you or a veterinarian describes. I will give you the most accurate information possible about our Nutrient Compound Procedures. I can also use your Veterinary Diagnosis and we can review your Veterinary Lab Work & Diagnosis. I would also be glad to work with your veterinarian, although that will involve extra veterinary expense. Again, I will tell you about all the supplements and what we do in the same or similar case. Because of current law, we can not refer to our Nutrient Compound Procedures as a diagnosis, prevention, treatment or cure. I am a former physician with 23 years of experience with humans. I have worked and helped people in thousands of cases with their dogs, cats and ferrets for 20 years explaining exactly how I use nutrient, botanical and pharmaceutical procedures in cancers, immune system disfunction and failure, infectious disorders, kidney and liver failure, etc..

Despite have no recognized medical credentials, Mr. Weisman is willing to make recommendations and sell products to people with ill pets by representing himself as “an internal disease expert” and a “former physician” (not a former chiropractor stripped of his license, which would be accurate). This seems quite clearly to violate the terms of Mr. Weisman’s plea, but ultimately that is up to the Minnesota Attorney General, or perhaps the Little Canada City Attorney.

Posted in Law, Regulation, and Politics, Nutrition | 4 Comments

Can you own an idea? Hemopet sues Nestle-Purina and Hill’s over Nutrigenomics.

Intellectual property law is a complex, often bewildering tangle that I make no claim to be deeply conversant with. However, it has always struck me as odd to consider the notion that ideas can be owned. While I understand the purpose of allowing innovators to profit from their work, I also see knowledge, particularly knowledge about the physical world to which we all have access, as something impossible, or at least inappropriate, to try and restrict in the pursuit of market advantage. In any case, whatever one thinks about the underlying philosophical and moral issues, the processes of claiming and enforcing ownership of an idea often make interesting narratives.

A recent example is a lawsuit filed by veterinary Hemopet, a blood blank and diagnostic testing company founded by Dr. Jean Dodds, and the pet diet manufacturer Nestle-Purina. Dr. Dodds is herself a complex character. She has done great and important work in promoting transfusion medicine and is well-regarded as an advocate and researcher, though without a traditional academic background or affiliation. She is undoubtedly a pioneer in veterinary medicine.

However, like many pioneers she holds a number of views which are not compatible with a conventional medical or scientific understanding, and her accomplishments do not automatically make these views legitimate. She goes beyond the available evidence in claiming that vaccines are an established and important cause of disease (so-called vaccinosis). Her theories about thyroid disease are not generally accepted by endocrinologists, though they are widely promoted by practitioners of alternative veterinary medicine. In fact, Dr. Dodds’ ideas are quite popular with this community, and in addition to being on the board of the American Holistic Veterinary Medical Foundation, she has been awarded the honor of Holistic Veterinarian of the Year.

This current lawsuit stems from a couple of other projects of Dr. Dodds which are not part of mainstream science-based medicine. She has developed a method which she claims can identify dietary sensitivities in animals through testing saliva (a claim most immunologists and dermatologists do not accept), and she has patented an idea for implementing a nutrigenomics program for identifying and modifying disease risk in animals.

Nutrigenomics is an interesting idea. The theory is that the expression and function of genes interacts with specific nutrients in a way that can be identified and manipulated through gene sequencing, dietary modification, and other diagnostic, preventative, and therapeutic practices. If that sounds vague, it is. The idea is far from being established even in general principle, much less in actual clinical practice, and there is little evidence to suggest any specific diagnostic or therapeutic approach that can be owned and marketed exists. The term nutrigenomics, and the small amount of laboratory research suggesting that it might one day be a real approach to health, have been used to market specific products well before this is justified by appropriate scientific evidence. And not only has Dr. Dodds joined in this practice, she is apparently willing to sue to assert her ownership of the general idea in animals.

The initial details of the lawsuit, and the patents Hemopet alleges have been infringed, are contained in this complaint:

Hemopet v.Nestle-Purina Petcare Company Patent Infringement Complaint

There is a great deal of repetitive verbiage describing the patents held, but the general sense is that Hemopet has patented the idea of using a comprehensive computer database containing information about individual animals and groups of animals, as well as the results of both legitimate and questionable or misapplied laboratory tests, to identify health risks and appropriate nutrition for companion animals. The description seems to envision a database and consulting system made available, for a fee, via the Internet. Here are a few selections from the patents:

…it is necessary in animal health diagnosis and care that appropriate predictive testing for diseases and disorders of animals be achieved in order to reduce morbidity and mortality, and improve the quality of life and lifespan. Currently this is not done in relation to the health assessment data of an animal together with the genetic data related to that same animal. Current tests do not provide as much data as possible to attain correct diagnosis and disorder predictions with the net result of an improvement in the quality of life and increased longevity.

The disclosure is directed to a method, apparatus and system of obtaining, analyzing and reporting laboratory test data in relation to the health assessment data of an animal together with the genetic data related to that same animal.

The disclosure also provides a bioinformatics system for inputting, controlling, analyzing and outputting of a broad range of criteria related to the health, genetic background and longevity of animals. This includes a system concerning phenotype data and genetic data relating to animals. Further, there is provided a system for screening of genetic data and genomic mapping, and integrating the phenotype health assessment data and genetic identifier and assessment data in a computerized data processing resource (“CDPR”).

The present disclosure offers a unique solution to above-described problems by providing an apparatus, method and system, in relation to animals, for performing data analyses of biological specimens from specific subject animals or animal groups in relation to specific subject animal or animal groups of genetic data. The apparatus, method and system comprises a controller for obtaining, inputting, and analyzing biological, physiological, and pathological test data together with genomic mapping and genetic screening data into the CDPR.

The biological, physiological, and pathological data of the subject animal or animal group and the genetic data of the subject animal or animal group are communicated to a remote user as raw data or as related, analyzed biological, physiological, and pathological data and genetic data. The remote user can also appropriately access the CDPR to input data to, or obtain data from, the CDPR.

The disclosure also includes the step of reporting the determination of the health care, well-being, nutrition or other therapeutic requirements and suggestions or health on a communications network including the Internet. Preferably, there is a payment procedure for the report which is achieved through the Internet.

A further aspect of the disclosure is the accessibility of the health assessment database and/or genetic database or other databases of the CDPR by the remote user selected on the basis of password, security control, and financial payment such that the data can be transmitted into and from the CDPR by a computer network. Use of selected passwords, encryption systems, and payment systems are employed to facilitate and restrict the flow of data in and/or out of the databases.

A diagnosis of the health of an animal is obtained through a combination of computerized data analysis, and human interpretation. Data relates to the physical characteristics of the animal, and includes data obtained from a physical inspection of the animal. A blood or other fluid sample is used to obtain a computer generated laboratory analysis. This is reported through an internet network to specialist for analysis by a specialist clinical pathologist. The clinical pathologist has the data relating to the physical characteristics, and thereby makes a diagnosis of the animal’s overall health status.

So what appears to have been patented here is the idea of collecting a wide range of pieces of information about an animal in a computer, passing it around to people, and using it to “reduce morbidity and mortality, and improve the quality of life and lifespan” in companion animals. It’s hard to see how this could be a patentable idea, or even truly original apart from the unsubstantiated general claims about the links between gene sequences and health, but again I’m not expert in patent law. And despite a list of scientific papers included with the patent application (but not used as specific citations to support particular claims), it’s not clear that there is an actual preventative or therapeutic healthcare intervention here.

So how has Nestle-Purina allegedly violated the ownership of this very general idea? That’s not entirely clear from the complaint either. The allegation is that,

Purina has infringed and continues to infringe the ’343 patent by its manufacture, use, sale, importation, and/or offer for sale of its products and services developed using molecular nutrition or ‘-omics platforms,’ including Purina’s Veterinary Diet JM and OM products.

Again, it appears that the basis of the complaint is that Hemopet owns the idea of nutrigenomics and that Nestle-Purina has stolen this idea by utilizing this method which, from a scientific point of view, doesn’t really exist yet. Nestle-Purina does claim on its website to use nutrigenomics in developing its diets:

Nestlé Purina scientists use molecular and functional genetics to help them understand the “why” behind dog health. Our goal is to impact the processes through nutrition.

Nestlé Purina scientists use molecular nutrition to identify gene-expression changes related to specific health conditions and examine how nutrition can help manage canine health. Whether scientists are studying the nutritional management of obesity, joint conditions, or food allergies, molecular nutrition helps them to fully understand the biological context of certain changes and how they can be used in order to benefit dogs.

How exactly the company does this given the embryonic, even blastocystic, state of current knowledge about genes and nutrients, isn’t explained.

So we have a theoretical approach to health and nutrition which has not yet been validated scientifically. Hemopet claims to own it. And Nestle-Purina claims to use it in developing its pet foods. You might think Dr. Dodds would approve of this, given her apparent lack of confidence in the healthfulness and safety of current commercial foods and her belief that nutrigenomics is the right way to approach nutrition, but apparently not. In any case, it’s a bit baffling how these two organization can compete for ownership of an idea which doesn’t really exist in a tangible form yet.

I’ve written before about the fact that the legal system has very different priorities than the systems of science. Malpractice lawsuits involving alternative medicine, for example, rarely hinge on whether the practice being challenged is scientifically legitimate or can be shown to be safe or effective. The lawyers and judges involved seem more interested in the balance of state power and individual liberty than whether the therapy at issue is legitimate or pseudoscientific nonsense. And individuals often and easily get away with egregiously ridiculous medical practices entirely incompatible with science despite laws that sound like they should protect the public from such people. And securing a patent has more to do with proving an idea is original that proving it is true or actually works, as evinced by the weird and clearly implausible things that can be patented.

So I suppose it shouldn’t be a surprise that Hemopet can claim to essentially own the concept of nutrigenomics and choose to sue Nestle-Purina for claiming to use it. It does seem, however, like putting the cart before the horse, since who gets to profit from a new approach to health and nutrition should at least have something to do with whether the approach actually works and who has done the work to demonstrate this. But maybe that’s why I’m a scientist and not a lawyer.

 Addendum-

A reader was kind enough to point out that Hemopet is also suing Hill’s Pet Food for apparently the same violation of its ownership of the idea of nutrigenomics. Here’s the complaint:

Hemopet vs.Hills Pet Nutrition

Hill’s does also claim to use nutrigenomics, though again it isn’t clear what exactly that means.

 

 

 

 

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