MDs dont own the physician title

BlueDevil,DNP, DNP, RN · Jul 10, 2013

Chiropractic "medicine" has about as much evidence as homeopathy, and has the potential to be a lot more dangerous. I can't believe insurance covers it. That anyone would give a chiropractor the time of day, much less a penny, is mind boggling. That someone would give them more credibility than a NP or PA is offensive. Might as well get treated by a witch doctor.

"That's all I have to say about that."

-Forrest Gump

IrishIzCPNP, MSN, RN, APRN, NP · Jul 10, 2013

Chiropractic "medicine" has about as much evidence as homeopathy, and has the potential to be a lot more dangerous. I can't believe insurance covers it. That anyone would give a chiropractor the time of day, much less a penny, is mind boggling. That someone would give them more credibility than a NP or PA is offensive. Might as well get treated by a witch doctor.
"That's all I have to say about that."
-Forrest Gump

Wow. I love my chiropractor. I also firmly believe in homeopathy and working on a certificate in advanced complementary and integrative therapies through a major university. It's sad that people can be so closed minded to stuff that works. I can't post articles right now but I can later. It's a shame that your opinion is so sour on things that are proven safe and things that work.

As a provider you should be aware of he positives of these therapies and not consider your opinion as fact.

PMFB-RN, RN · Jul 10, 2013

Wow. I love my chiropractor. I also firmly believe in homeopathy and working on a certificate in advanced complementary and integrative therapies through a major university. It's sad that people can be so closed minded to stuff that works. I can't post articles right now but I can later. It's a shame that your opinion is so sour on things that are proven safe and things that work.
As a provider you should be aware of he positives of these therapies and not consider your opinion as fact.

*** The great thing about homeopathy is that it is harmless. I am always amazed that people like nurses who have at least a basic education in science, and are supposed to be critical thinkers actually buy into homeopathy.

When I was a dairy farmer we had a animal homeopathy practitioner in the area. However, animals, not being able to benefit from the placebo effect, received no benefit at all.

IrishIzCPNP, MSN, RN, APRN, NP · Jul 10, 2013

*** The great thing about homeopathy is that it is harmless. I am always amazed that people like nurses who have at least a basic education in science, and are supposed to be critical thinkers actually buy into homeopathy.
When I was a dairy farmer we had a animal homeopathy practitioner in the area. However, animals, not being able to benefit from the placebo effect, received no benefit at all.

Seriously? I use it, believe in it and have seen it work. It also isn't harmless if not used properly. Do you know what homeopathy is? If you believe it is harmless it suggests you don't know what it truly is.

I would hope that somebody with the critical thinking skills of an RN would be able to see the value in methods other than modern medicine.

nomadcrna, DNP, CRNA, NP · Jul 10, 2013

We are aware. Show us the evidence. Should be a simple matter.

I practice EBM and would be happy to use it.

Wow. I love my chiropractor. I also firmly believe in homeopathy and working on a certificate in advanced complementary and integrative therapies through a major university. It's sad that people can be so closed minded to stuff that works. I can't post articles right now but I can later. It's a shame that your opinion is so sour on things that are proven safe and things that work.
As a provider you should be aware of he positives of these therapies and not consider your opinion as fact.

nomadcrna, DNP, CRNA, NP · Jul 10, 2013

Then post the evidence. That is the point. Post a scientific peer reviewed article.

You do understand EBM?

allnurses Guide · Jul 10, 2013

Homeopathy: An Introduction | NCCAM

[h=2]Key Points[/h]

There is little evidence to support homeopathy as an effective treatment for any specific condition.

Although people sometimes assume that all homeopathic remedies are highly diluted and therefore unlikely to cause harm, some products labeled as homeopathic can contain substantial amounts of active ingredients and therefore could cause side effects and drug interactions.

Homeopathic remedies are regulated by the U.S. Food and Drug Administration (FDA). However, FDA does not evaluate the remedies for safety or effectiveness.

Several key concepts of homeopathy are inconsistent with fundamental concepts of chemistry and physics. There are significant challenges in carrying out rigorous clinical research on homeopathic remedies.

[h=2]The Status of Homeopathy Research[/h]

Most rigorous clinical trials and systematic analyses of the research on homeopathy have concluded that there is little evidence to support homeopathy as an effective treatment for any specific condition.Homeopathy is a controversial topic in complementary medicine research. A number of the key concepts of homeopathy are not consistent with fundamental concepts of chemistry and physics. For example, it is not possible to explain in scientific terms how a remedy containing little or no active ingredient can have any effect. This, in turn, creates major challenges to rigorous clinical investigation of homeopathic remedies. For example, one cannot confirm that an extremely dilute remedy contains what is listed on the label, or develop objective measures that show effects of extremely dilute remedies in the human body.

References to article at the bottom.

IrishIzCPNP, MSN, RN, APRN, NP · Jul 10, 2013

Then post the evidence. That is the point. Post a scientific peer reviewed article.
You do understand EBM?

Yes, I do understand EBM. I will post later as I said...I am on my phone. Can you understand that? It amazes me how closed minded some people can be.

Did you know that NIH has a complementary and alternative medicine office? That doesn't give you some suggestion as to the benefits of these therapies?

nomadcrna, DNP, CRNA, NP · Jul 10, 2013

I'll do it for you.

Evidence-Based Clinical Decision Support at the Point of Care | UpToDate

Homeopathy is a pre-scientific practice based on two tenets: “like cures like,” which holds that the correct remedy for a patient is a substance that, when given to a healthy person, produces symptoms similar to those of the patient; and “potentization,” which holds that serial dilutions and “succussions” (shakings) render a “remedy” increasingly potent. Homeopathic preparations (“remedies”) generally begin with minerals, plants, or animal substances that are pulverized, mixed with a water-alcohol solution, and then potentized, usually well past the point at which any of the original substance remains. The resulting diluent is applied to a sucrose pill and allowed to dry.

Current evidence finds that homeopathic remedies are no more effective than placebo [1-4].

This topic will focus on the practice of homeopathy in adults. Other complementary and alternative medicine treatments are discussed separately. (See "Overview of herbal medicine and dietary supplements" and "Overview of complementary and alternative medicine in pediatrics" and "Complementary and alternative remedies in rheumatic disorders" and "Complementary and alternative therapies for cancer".)

Meta-analyses of randomized trials have failed to demonstrate that homeopathic preparations are effective treatments for any disease [1-3,52-54]. Many small randomized trials of lower quality have reported statistically significant results suggesting a modest benefit of homeopathic remedies compared to placebos [53]. The larger and more rigorous trials tend to refute these findings [2,3,53]. “Positive” results of homeopathy are more likely to be due to bias and error than to specific effects of homeopathic preparations [55,56]. Lack of reproducibility by independent investigators has been documented for several reported positive findings in homeopathic research [4,9].

Homeopathy as a whole

One meta-analysis of randomized placebo-controlled trials compared efficacy of homeopathy with conventional medicines for a broad range of medical disorders [1]. There was no statistically significant difference between homeopathic treatment and placebo, while conventional treatment was more likely to be effective than placebo.

One of the early meta-analyses to study the effects of homeopathy, which included 89 randomized trials, reported that homeopathy was more efficacious than placebo, when combining a heterogeneous group of remedies for different diseases [52]. Subsequent re-evaluations of this meta-analysis concluded that when adjustments were made for trial quality and evidence of publication bias, the apparent benefit of homeopathy over placebo was minimal to absent [2,3,53].

Randomized trials of homeopathic treatments in children and adolescents have also found no convincing evidence of therapeutic benefit beyond placebo [57].

This body of literature, together with the pre-clinical studies cited above and the extreme implausibility of homeopathic tenets, provides compelling evidence that ultra-dilute homeopathic preparations are no better than placebos.

Meta-analyses and systematic reviews have found homeopathic remedies to be ineffective for the following conditions: attention deficit/hyperactivity disorder (ADHD) [58], allergic rhinitis [59], asthma [60], fibromyalgia [61], induction of labor [62], headaches [63], the prevention and treatment of influenza [64,65], cancer treatment [66], anxiety [67], depression [68], and some dermatologic conditions (eg, atopic dermatitis, psoriasis) [69].

ContributorsDisclosures

Date

INTRODUCTION

Homeopathy is a pre-scientific practice based on two tenets: “like cures like,” which holds that the correct remedy for a patient is a substance that, when given to a healthy person, produces symptoms similar to those of the patient; and “potentization,” which holds that serial dilutions and “succussions” (shakings) render a “remedy” increasingly potent. Homeopathic preparations (“remedies”) generally begin with minerals, plants, or animal substances that are pulverized, mixed with a water-alcohol solution, and then potentized, usually well past the point at which any of the original substance remains. The resulting diluent is applied to a sucrose pill and allowed to dry.

Current evidence finds that homeopathic remedies are no more effective than placebo [1-4].

This topic will focus on the practice of homeopathy in adults. Other complementary and alternative medicine treatments are discussed separately. (See "Overview of herbal medicine and dietary supplements" and "Overview of complementary and alternative medicine in pediatrics" and "Complementary and alternative remedies in rheumatic disorders" and "Complementary and alternative therapies for cancer".)

BASIC THEORY

Homeopathy is based primarily on two tenets: “like cures like” and “potentization.”

"Like cures like"

Homeopathy was invented at the end of the 18th century by the German physician Samuel Christian Hahnemann. While translating William Cullen’s Materia Medica into German, Hahnemann was bothered by Cullen’s explanation for how cinchona bark (one of the few effective medicines at the time) cured malaria. According to Cullen, cinchona worked by the “strengthening power it exerts on the stomach” [5]. Doubting this explanation, Hahnemann decided to try some himself. He experienced palpitations, anxiety, trembling, and diffuse joint stiffness (but not fever) lasting two to three hours each time he ingested cinchona [5]. He reported feeling well afterwards. It was this experience that led Hahnemann to conclude “similia similibus curentur” or “like cures like.” Hahnemann’s explanation was that if two diseases with similar symptoms strike a patient, the “stronger” disease will invariably cure the weaker [6]. Thus, by simulating the symptoms of a disease, homeopathic medicines “substitute themselves for the natural morbid affection, and thereby deprive the latter of all influence upon the vital force.” Moreover, “all medicines cure, without exception, those diseases whose symptoms most nearly resemble their own.”

Hahnemann’s cinchona experience was his only experimental basis for “like cures like.” Subsequent discoveries have disproved his conclusion: the active therapeutic ingredient in cinchona is quinine, which kills the parasite that causes malaria [6].

Potentization

The second fundamental tenet of homeopathy, “potentization” (also called “attenuation” or “dynamization”), holds that serial dilutions and succussions (shakings) render a remedy increasingly potent, even well past the point at which a molecule of the original substance can remain. At the time of his cinchona experiment, Hahnemann was prescribing the usual doses of commonly used 18th century medicines, many of which (eg, orificenic, mercury, belladonna) were highly toxic. Their adverse effects were thought necessary to rid the body of “the poison” of various maladies. Hahnemann soon decided, in keeping with “like cures like,” that rather than elicit the usual toxic manifestations, he needed to give a dose just large enough to produce an indication of the expected “artificial malady” [5]. For unclear reasons, he subsequently reduced the doses much further and introduced the serial 10 and 100-fold dilutions that became the norm for homeopathy [7]. (See 'Preparation of remedies' below.)

Potentization lends itself to laboratory investigations comparing ultra-dilute homeopathic preparations to diluent for chemical or biological activity. A famous 1988 investigation purported to demonstrate that dilutions of anti-IgE (up to 10120), compared to diluent, led to basophilic histamine release [8]. The study was flawed, and the initial results could not be reproduced by independent research teams [9-11].

The concept of potentization violates basic scientific principles and defies logic. Any explanation of how potentization works must account for retention of a specific effect as the dilution approaches and surpasses the point at which the original substance has disappeared completely. It must also account for how that effect is transferred to a sucrose or lactose pill, which is then allowed to dry, bathed in saliva and gastric juices, transported through bowel wall into the bloodstream, and delivered to a site of therapeutic action with its specific biologic activity not merely intact, but amplified. It also must explain how the pill lacks effects referable to contaminants, which, if homeopathic theory is correct, must include every substance on the planet that has ever been in contact with the water used for dilutions.

Modern homeopaths argue that the diluent somehow retains a memory or imprint of the “formative intelligence” specific to the original substance of interest. Much effort has been spent attempting to show that liquid water has “changeable structure” or “coherence patterns” that are somehow specified by that original substance [12-14].

CLINICAL PRACTICE

After its invention in Germany, homeopathy enjoyed considerable popularity throughout the Western world for most of the 19th century, when medicine at the time was also pre-scientific and frequently harmful. With the development of scientific medicine in the late 19th and early 20th centuries, homeopathy became a fringe practice in the United States (US) [7], making a slight resurgence during the recent public interest in “alternative” treatments. One survey reported that 0.4 percent of adults in the US consulted homeopaths in 1996 [15]. Another found that 1.8 percent of adults and 1.3 percent of children in the US used homeopathic remedies in 2007, but the report did not distinguish between those who consulted practitioners and those who merely purchased “over the counter” preparations labeled “homeopathic” [16]. Homeopathy is more widely used in Europe and Asia than in the US [17,18].

Preparation of remedies

Most homeopathic preparations begin with a mineral, plant, or animal substance, which is pulverized and mixed with a water-alcohol solution [19]. Many of these substances are highly toxic in their initial concentrations. Each preparation then undergoes potentization, consisting of serial dilutions and succussions.

Dilutions range from 106-fold to 101,000,000-fold (preparations diluted beyond 1023 are called “ultra-dilute,” “ultra-molecular,” “ultra-high dilutions,” or “homeopathic potencies”). Homeopathic potencies are designated by the Roman numerals “X” or “C,” according to whether each dilution is 10-fold or 100-fold, respectively, and by a coefficient that represents the number of such steps. Thus, a 12X remedy has been diluted 1012 times; a 15C remedy has been diluted 10015 times. Once potentized, most remedies are completed by applying a drop of the liquid to a small lactose or sucrose pellet, which is then allowed to dry. The final dilution is often made with at least 70 percent alcohol, in order to avoid dissolving the pill [20]. Remedies can also be prepared and administered in injectable, liquid or topical forms.

Although the substances are usually diluted past the point of possible danger, toxins or toxic contaminants have been found in some homeopathic preparations [21-23].

"Provings"

Assertions of useful homeopathic preparations are based on “provings” (also known as “homeopathic pathogenic trials”): a homeopath gives a preparation to one or more healthy subjects who each keep a detailed diary of every sensation, feeling, mood change, and physical change that occurs over the next several days to months. All such symptoms, no matter how vague or seemingly trivial, are presumed to have been caused by the remedy that preceded them. Hahnemann performed his first few provings with undiluted substances, but eventually used “homeopathic potencies,” which continue to be the norm. To a homeopath, “symptoms” are quite different from what modern clinicians might expect. Examples include “dreams which are not remembered” or a “tickling sensation on the palm which obliges a person to scratch” [24].

Such symptoms are compiled and the aggregate result is published in a Materia Medica, in which remedies are listed alphabetically and matched to corresponding symptoms. There are typically thousands of symptoms reported for each substance. About half of the 1300 entries in the US Homeopathic Pharmacopoeia are based on “provings” that occurred during the 19th century; about 65 are attributable to Hahnemann himself, including most of those commonly prescribed by homeopaths today [20].

Provings, a sine qua non of homeopathic practice, suggest that “provers” ought to be able to distinguish between a homeopathic preparation and a placebo. Several randomized trials have failed to support this hypothesis [25-29].

Choosing remedies

The inverse of the Materia Medica is the Repertory, in which symptoms are listed alphabetically and matched to corresponding remedies. Repertories are no less voluminous than are Materia Medica. The practicing homeopath, after eliciting a litany of symptoms from a patient, determines the correct remedy by finding the most closely matching symptom group in a Materia Medica, aided by a Repertory. This process is the basis for homeopaths’ assertion that they treat the individual rather than the disease. Thus homeopaths are likely to choose any one of several different remedies for what modern physicians would recognize as the same disease [30].

The following treatments are examples from an abbreviated Materia Medica for earache [30]:

Belladonna — “for the earache that comes on suddenly and with great intensity. The fever can be as high as 104 degrees with a bright red, hot, flushed face and dilated pupils…there can also be delirium during sleep, with nightmares, especially of animals, causing the child to cry out.”

Chamomilla — “The child is extremely irritable and changeable, not knowing what he wants…the only thing that will calm him down is to be carried back and forth continually…green stools are a common accompanying symptom, especially in cases of otitis that are associated with teething.”

Hepar Sulphur — “indicated in a child who is very chilly…the ear pain is…a sticking or poking pain…worse from exposure to cold air…also indicated in cases of earache from referred pain from the throat.”

Some homeopaths have argued that such individualized treatments make both regulation and research of homeopathy unfeasible because “there is no real unanimity of opinion among homeopathists as to what remedies are specific for a particular symptom complex” [31]. If the homeopathic prescribing scheme is valid, there should be some agreement among experienced homeopaths regarding choices of remedies, but studies have shown poor interrater reliability [32,33].

Contemporary homeopathy

Other than gradual additions to the homeopathic pharmacopoeia, homeopathy has changed little since the time of Hahnemann.

The influences of two other 19th century homeopaths, however, are worth mentioning. Constantine Hering (1800-1880), the “father of American homeopathy,” is usually credited with having promulgated “Hering’s Law of Cure” [34]:

The human body seeks to externalize disease and dislodge it from more serious internal levels to more superficial external levels. Thus, someone with asthma may develop an external skin rash as part of the curative process.

Healing progresses from the top of the body to the bottom. Thus, someone with arthritis in many joints will generally notice relief in the upper part of the body before the lower part.

Healing proceeds in the reverse order of the symptoms. Thus, the most recent symptoms will generally be the first to be healed, and in the process of cure a person may re-experience previous symptoms.

Hering’s “third law” is the basis for the common homeopathic claim that an “aggravation” occurring shortly after a patient takes a remedy is not to be viewed as evidence of treatment failure, but as proof that the remedy chosen must have been the correct one [35]. A systematic review of placebo-controlled trials, however, found that aggravations are uncommon and are no more likely to be found in the homeopathic treatment group than in the placebo group [36]. Hering also introduced what would become known as “isopathy,” which is the use of potentized venoms or “nosodes” (diseased animal parts) to cure or prevent diseases [37]. Hering was the first homeopath to declare his opposition to vaccination, which he called “poisoning” [38]. Opposition to immunizations remains widespread among homeopaths [39-42].

James Tyler Kent (1849-1916) popularized homeopathic “constitutional remedies” based on stable patient characteristics such as body type, eating preferences, and personality, rather than on acute symptoms [43]. Hering and Kent added the necessary bases for homeopathy’s current claim to be a “whole medical system” that not only cures acute diseases, but also prevents infectious diseases and promotes general health [44,45].

Large variation currently exists in how homeopathy is practiced. Many contemporary homeopaths have promoted homeopathic methods for preventing or curing numerous infectious diseases, including influenza, small pox, anthrax, malaria, gonorrhea, syphilis, tuberculosis, and AIDS [46-49]. Some homeopaths consider themselves to be “classical” homeopaths, practicing according to Hahnemann’s rules of never mixing homeopathy with other medicine and never giving more than one medicine at a time. Others assert that homeopathy may be combined with modern medicine [30]. Still others, including many chiropractors and most naturopaths, use homeopathy along with other alternative treatments. All naturopathic schools stress homeopathy in their programs, and many naturopaths are primarily homeopaths [50,51].

CLINICAL EVIDENCE

Meta-analyses of randomized trials have failed to demonstrate that homeopathic preparations are effective treatments for any disease [1-3,52-54]. Many small randomized trials of lower quality have reported statistically significant results suggesting a modest benefit of homeopathic remedies compared to placebos [53]. The larger and more rigorous trials tend to refute these findings [2,3,53]. “Positive” results of homeopathy are more likely to be due to bias and error than to specific effects of homeopathic preparations [55,56]. Lack of reproducibility by independent investigators has been documented for several reported positive findings in homeopathic research [4,9].

Homeopathy as a whole

One meta-analysis of randomized placebo-controlled trials compared efficacy of homeopathy with conventional medicines for a broad range of medical disorders [1]. There was no statistically significant difference between homeopathic treatment and placebo, while conventional treatment was more likely to be effective than placebo.

One of the early meta-analyses to study the effects of homeopathy, which included 89 randomized trials, reported that homeopathy was more efficacious than placebo, when combining a heterogeneous group of remedies for different diseases [52]. Subsequent re-evaluations of this meta-analysis concluded that when adjustments were made for trial quality and evidence of publication bias, the apparent benefit of homeopathy over placebo was minimal to absent [2,3,53].

Randomized trials of homeopathic treatments in children and adolescents have also found no convincing evidence of therapeutic benefit beyond placebo [57].

This body of literature, together with the pre-clinical studies cited above and the extreme implausibility of homeopathic tenets, provides compelling evidence that ultra-dilute homeopathic preparations are no better than placebos.

Specific diseases

Meta-analyses and systematic reviews have found homeopathic remedies to be ineffective for the following conditions: attention deficit/hyperactivity disorder (ADHD) [58], allergic rhinitis [59], asthma [60], fibromyalgia [61], induction of labor [62], headaches [63], the prevention and treatment of influenza [64,65], cancer treatment [66], anxiety [67], depression [68], and some dermatologic conditions (eg, atopic dermatitis, psoriasis) [69].

REGULATION AND CREDENTIALING

The regulation of homeopathy varies widely throughout the world [70,71]. The US Food and Drug Administration (FDA) officially recognizes the drugs and standards in the Homeopathic Pharmacopeia of the United States (HPUS) [31,72]. The FDA has the authority to require the same pre-market demonstrations of safety and effectiveness for homeopathic preparations as it expects for drugs, but so far has declined to do so. Rather, it relies on homeopaths themselves to judge safety and effectiveness. Until 1980, this was done by the American Institute of Homeopathy; since then it has been the responsibility of the Homeopathic Pharmacopoeia Convention of the United States (HPCUS) [73]. In the US, three states (Arizona, Connecticut, and Nevada) have boards of homeopathy, whose licensees are limited to medical doctors (MDs) and doctors of osteopathy (DOs).

There are several homeopathic certification boards in North America that appear to have no formal legal status. The Council for Homeopathic Certification (CHC) offers the Certified in Classical Homeopathy (CCH) designation to “lay” practitioners [74]. Practitioners certified by the CHC can also become members of the North American Society of Homeopaths (NASH), and include the designation “RSHom(NA)” after their names (Registered with the Society of Homeopaths North America) [75]. The American Board of Homeotherapeutics offers the Diplomate of Homeotherapeutics (D. Ht) certificate to MDs or DOs, and the Homeopathic Academy of Naturopathic Physicians offers the Diplomate of the Homeopathic Academy of Naturopathic Physicians (DHANP) certificate to naturopaths in North America [76]. Almost all naturopathic physicians in the US and Canada practice homeopathy [77]. Homeopathy is usually not covered by Canada’s provincial health care programs [70,71]. An unknown number of chiropractors practice homeopathy. There is no formal regulation of “lay” homeopaths in the US.

Nations in the European Union vary in their willingness to pay for homeopathic treatments through national health programs, but most accept homeopathy as a fact of their cultures. In the United Kingdom (UK), where the royal family has endorsed homeopathy, many general practitioners use homeopathy, although this practice is declining [78]. All medicines in the UK, including homeopathic preparations, are licensed by the Medicines and Healthcare products Regulatory Agency (MHRA), which is charged to ensure that medicines meet acceptable standards on safety, quality and efficacy [79]. The MHRA, however, does not require homeopathic medicines to meet any standards on efficacy [80].

Homeopathy is also part of the national health care systems of India, Mexico, Brazil, Pakistan, and Sri Lanka [71].

SUMMARY AND CONCLUSIONS

Homeopathy is based on two tenets: “like cures like,” which holds that the correct remedy is one that produces symptoms similar to those of the patient; and “potentization,” which holds that serial dilutions and succussions (shakings) render a remedy increasingly potent. Subsequent discoveries have disproved the theory of “like cures like,” and there is no evidence that “ultra-dilute” homeopathic remedies have specific biologic activity. (See 'Basic theory' above.)

Most homeopathic preparations begin with a mineral, plant, or animal substance, which is pulverized and mixed with a water-alcohol solution. It then undergoes serial dilutions and succussions, usually leaving none of the original substance. (See 'Preparation of remedies' above.)

Homeopaths state that they treat the individual rather than the disease. This is the reason that homeopaths choose among numerous different remedies for the same disease. The practicing homeopath, after eliciting a list of symptoms from a patient, determines the remedy by finding the most closely matching symptom group. There is poor inter-rater reliability among experienced homeopaths in selecting remedies. (See 'Choosing remedies' above.)

The totality of the evidence finds that homeopathic remedies are no more effective than placebos. There is no role of homeopathy for the prevention or treatment of any disease. (See 'Clinical evidence' above.)

References

Shang A, Huwiler-Müntener K, Nartey L, et al. Are the clinical effects of homoeopathy placebo effects? Comparative study of placebo-controlled trials of homoeopathy and allopathy. Lancet 2005; 366:726.

Linde K, Scholz M, Ramirez G, et al. Impact of study quality on outcome in placebo-controlled trials of homeopathy. J Clin Epidemiol 1999; 52:631.

Ernst E. A systematic review of systematic reviews of homeopathy. Br J Clin Pharmacol 2002; 54:577.

Ernst E. Homeopathy: what does the "best" evidence tell us? Med J Aust 2010; 192:458.

Cullen W. Materia Medica. In: History of Homœopathy: its Origin; its Conflict, Ameke, WE (Eds), Gould & Son, London 1885. p.103.

Hahnemann, SC. Organon of Medicine, 5th ed, Dudegeon 1833. Organon paras 52-53 (Accessed on November 11, 2010).

Fishbein M. The Rise and Fall of Homeopathy. In: Fads and Quackery in Healing, Fishbein M (Ed), Blue Ribbon Books, Inc., New York 1932. p.19.

Davenas E, Beauvais F, Amara J, et al. Human basophil degranulation triggered by very dilute antiserum against IgE. Nature 1988; 333:816.

Maddox J, Randi J, Stewart WW. "High-dilution" experiments a delusion. Nature 1988; 334:287.

Ovelgönne JH, Bol AW, Hop WC, van Wijk R. Mechanical agitation of very dilute antiserum against IgE has no effect on basophil staining properties. Experientia 1992; 48:504.

Hirst SJ, Hayes NA, Burridge J, et al. Human basophil degranulation is not triggered by very dilute antiserum against human IgE. Nature 1993; 366:525.

Jonas WB, Jacobs J. Healing with Homeopathy: the Doctors’ Guide. New York, NY: Warner Books, 1996. P. 21

Roy R, Tiller WA, Bell I, Hoover MR. The Structure Of Liquid Water; Novel Insights From Materials Research; Potential Relevance To Homeopathy. Materials Research Innovations Online. 2005. Accessed 5/110 at: http://www.rustumroy.com/Roy_Structure%20of%20Water.pdf

Elia, V, Baiano, S, Duro, I, Napoli, E, Niccoli, M, Nonatelli, L. Permanent Physio-chemical Properties of Extremely Diluted Aqueous Solutions of Homeopathic Medicines, Homeopathy, 93, 2004:144-150.

Druss BG, Rosenheck RA. Association between use of unconventional therapies and conventional medical services. JAMA 1999; 282:651.

Barnes, PM, Bloom, B, Nahin, R. CDC National Health Statistics Report #12. Complementary and Alternative Medicine Use Among Adults and Children: United States, 2007. December 2008. 2007 Statistics on CAM Use in the United States | NCCAM (Accessed on November 11, 2010).

Tuffs A. Three out of four Germans have used complementary or natural remedies. BMJ 2002; 325:990.

Prasad R. Homoeopathy booming in India. Lancet 2007; 370:1679.

Kayne, SB. Homeopathic Pharmacy. Elsevier Ltd, Philadelphia 2006. p.93. Homeopathic Pharmacy: Theory And Practice - Steven B. Kayne - Google Books (Accessed on November 11, 2010).

Shelton JW. Homeopathy: How it Really Works, Prometheus Books, Amherst, NY 2004. p.110.

Pettypiece, S. Smell-Loss Drug Escaped FDA Review Under Homeopathic Label. Smell-Loss Drug Escaped FDA Review Under Homeopathic Label - Bloomberg (Accessed on November 11, 2010).

Chakraborti D, Mukherjee SC, Saha KC, et al. orificenic toxicity from homeopathic treatment. J Toxicol Clin Toxicol 2003; 41:963.

Tumir H, Bosnir J, Vedrina-Dragojević I, et al. Preliminary investigation of metal and metalloid contamination of homeopathic products marketed in Croatia. Homeopathy 2010; 99:183.

Kent, JT. Lectures on Homepathic Philosophy, 6th, B. Jain Publishers Ltd, New Delhi 2005. p.121.

Brien S, Lewith G, Bryant T. Ultramolecular homeopathy has no observable clinical effects. A randomized, double-blind, placebo-controlled proving trial of Belladonna 30C. Br J Clin Pharmacol 2003; 56:562.

Walach H, Köster H, Hennig T, Haag G. The effects of homeopathic belladonna 30CH in healthy volunteers -- a randomized, double-blind experiment. J Psychosom Res 2001; 50:155.

Vickers AJ, van Haselen R, Heger M. Can homeopathically prepared mercury cause symptoms in healthy volunteers? A randomized, double-blind placebo-controlled trial. J Altern Complement Med 2001; 7:141.

Vickers A, McCarney R, Fisher P, van Haselen R. Can homeopaths detect homeopathic medicines? A pilot study for a randomised, double-blind, placebo controlled investigation of the proving hypothesis. Br Homeopath J 2001; 90:126.

Dantas F, Fisher P, Walach H, et al. A systematic review of the quality of homeopathic pathogenetic trials published from 1945 to 1995. Homeopathy 2007; 96:4.

Jonas WB, Jacobs J. Healing with Homeopathy: the Doctors’ Guide, Warner Books, New York 1996. p.170.

Junod SW. An alternative perspective: homeopathic drugs, Royal Copeland, and federal drug regulation. Food Drug Law J 2000; 55:161.

Vickers AJ, van Haselen RA, Pang L, Berkovitz S. Inter-rater reliability of symptom repertorisation: a pragmatic empirical study. Br Homeopath J 2000; 89:188.

Brien S, Prescott P, Owen D, Lewith G. How do homeopaths make decisions? An exploratory study of inter-rater reliability and intuition in the decision making process. Homeopathy 2004; 93:125.

Barrett, S. Homeopathic Glossary. HomeoWatch website. Revised March 26, 2009. Homeopathic Glossary (Accessed on January 31, 2011).

Jonas, WB, Jacobs, J. Healing with Homeopathy: the Doctors' Guide, Warner Brooks, New York 1996. p.21.

Grabia S, Ernst E. Homeopathic aggravations: a systematic review of randomised, placebo-controlled clinical trials. Homeopathy 2003; 92:92.

Little, D. Nosodes in Homeopathy. Simillimum.com; Homeopathic Online Education website. 2007. [Homoeopathic Online Education, David Little] Nosodes in Homoeopathy (Accessed on January 31, 2011).

Hering, C. The Homoeopathic Domestic Physician, 7th ed, Boericke, FE (Ed). Hahnemann Publishing House, Philadelphia 1883. p.387. The Homoeopathic Domestic Physician - Constantine Hering - Google Books (Accessed on November 11, 2010).

Ernst E, White AR. Homoeopathy and immunization. Br J Gen Pract 1995; 45:629.

Schmidt K, Ernst E. MMR vaccination advice over the Internet. Vaccine 2003; 21:1044.

Lee AC, Kemper KJ. Homeopathy and naturopathy: practice characteristics and pediatric care. Arch Pediatr Adolesc Med 2000; 154:75.

Minutes of a meeting of the Connecticut Homeopathic Medical Examining Board, March 12, 2003. http://www.ct.gov/dph/lib/dph/phho/homeopaths/minutes/homeopathic_medical_examining_board_minutes_2000-2006.pdf (Accessed on January 31, 2011).

Natural Alternative website. Homeopathy—Constitution Types. Homeopathy - Constitution Types | Homeopathy (Accessed on November 11, 2010).

NCCAM website. What are the major types of complementary and alternative medicine? Updated Feb 2007. Complementary, Alternative, or Integrative Health: What's In a Name? | NCCAM (Accessed on January 31, 2011).

Ullman, D. Prophylaxis. In: A Homeopathic Perspective on Infectious Disease: Effective Alternatives to Antibiotics. Homeopathic Educational Services website. Homeopathic.com Page Not Found (Accessed on November 11, 2010).

Barrett, S. Stay Away from Homeopathic Flu Vaccine "Substitutes." HomeoWatch website. 2004. Stay Away from Homeopathic Flu Vaccine "Substitutes" (Accessed on January 31, 2011).

Barrett, S. Bogus Homeowpathic "Smallpox Shield" Stopped. HomeoWatch website. 2003. Bogus Homeopathic "Smallpox Shield" Stopped (Accessed on January 31, 2011).

Garsombke, K. Alternative Remedies for Anthrax: Homeopathy provides options. Utne Reader Online. November 2, 2001. Utne Reader Online: Society (Accessed on January 31, 2011).

Ghosh, P. Homeopathic practices 'risk lives'. BBC News. 13 July 2006. BBC NEWS | UK | Homeopathic practices 'risk lives' (Accessed on January 31, 2011).

Association of Accredited Naturopathic Medical Colleges website. Academic Curriculum. Association of Accredited Naturopathic Medical Colleges - Academic Curriculum.

Homeopathic Academy of Naturopathic Physicians website. Homeopathic Academy of Naturopathic Physicians : Welcome to the HANP : About the HANPThe Homeopathic Academy of Naturopathic Physicians (HANP) is a specialty society within the profession of naturopathic medicine, and is affiliated with the American (Accessed on January 31, 2011).

Linde K, Clausius N, Ramirez G, et al. Are the clinical effects of homeopathy placebo effects? A meta-analysis of placebo-controlled trials. Lancet 1997; 350:834.

Linde K, Melchart D. Randomized controlled trials of individualized homeopathy: a state-of-the-art review. J Altern Complement Med 1998; 4:371.

Lüdtke R, Rutten AL. The conclusions on the effectiveness of homeopathy highly depend on the set of analyzed trials. J Clin Epidemiol 2008; 61:1197.

Ioannidis JP. Why most published research findings are false: author's reply to Goodman and Greenland. PLoS Med 2007; 4:e215.

Beyerstein, BL. Social and Judgmental Biases that Make Inert Treatments Seem to Work. Scientific Review of Alternative Medicine 1999; 3:20. Available at: http://www.sram.org/0302/bias.html (Accessed on January 31, 2011).

Altunç U, Pittler MH, Ernst E. Homeopathy for childhood and adolescence ailments: systematic review of randomized clinical trials. Mayo Clin Proc 2007; 82:69.

Coulter MK, Dean ME. Homeopathy for attention deficit/hyperactivity disorder or hyperkinetic disorder. Cochrane Database Syst Rev 2007; :CD005648.

Passalacqua G, Bousquet PJ, Carlsen KH, et al. ARIA update: I--Systematic review of complementary and alternative medicine for rhinitis and asthma. J Allergy Clin Immunol 2006; 117:1054.

McCarney RW, Linde K, Lasserson TJ. Homeopathy for chronic asthma. Cochrane Database Syst Rev 2004; :CD000353.

Perry R, Terry R, Ernst E. A systematic review of homoeopathy for the treatment of fibromyalgia. Clin Rheumatol 2010; 29:457.

Smith CA. Homoeopathy for induction of labour. Cochrane Database Syst Rev 2003; :CD003399.

Ernst E. Homeopathic prophylaxis of headaches and migraine? A systematic review. J Pain Symptom Manage 1999; 18:353.

van der Wouden JC, Bueving HJ, Poole P. Preventing influenza: an overview of systematic reviews. Respir Med 2005; 99:1341.

Vickers AJ, Smith C. Homoeopathic Oscillococcinum for preventing and treating influenza and influenza-like syndromes. Cochrane Database Syst Rev 2006; :CD001957.

Milazzo S, Russell N, Ernst E. Efficacy of homeopathic therapy in cancer treatment. Eur J Cancer 2006; 42:282.

Pilkington K, Kirkwood G, Rampes H, et al. Homeopathy for anxiety and anxiety disorders: a systematic review of the research. Homeopathy 2006; 95:151.

Pilkington K, Kirkwood G, Rampes H, et al. Homeopathy for depression: a systematic review of the research evidence. Homeopathy 2005; 94:153.

Smolle J. Homeopathy in dermatology. Dermatol Ther 2003; 16:93.

Wikipedia contributors. Regulation and prevalance of homeopathy. Wikipedia, The Free Encyclopedia. May 28, 2010. Available at: Regulation and prevalence of homeopathy - Wikipedia, the free encyclopedia (Accessed on January 31, 2011).

World Health Organization website. "Legal Status of Traditional Medicine and Complementary/Alternative Medicine: A Worldwide Review" World Health Organization. 2001. http://whqlibdoc.who.int/hq/2001/WHO_EDM_TRM_2001.2.pdf (Accessed on November 11, 2010).

FDA Compliance Policy Guide 7132.15 for Homeopathic Products. Revised March 1995. Homeopathy: FDA Compliance Policy Guide (Accessed on June 10, 2010).

The website of the Homeopathic and Integrated Medicine website. RegisterÂ |Â LoginÂ |Â Edit Acco.

Council for Homeopathic Certification website. http://www.homeopathicdirectory.com/ (Accessed on June 01, 2010).

NASH website. http://www.homeopathy.org/index.html (Accessed on June 01, 2010).

HANP website. Homeopathic Academy of Naturopathic Physicians : Welcome to the HANP : About the HANPThe Homeopathic Academy of Naturopathic Physicians (HANP) is a specialty society within the profession of naturopathic medicine, and is affiliated with the American (Accessed on July 01, 2010).

American Association of Naturopathic Physicians website. What is Nautorpathic medicine? American Association of Naturopathic Physicians (Accessed on June 01, 2010).

BBC News online. Homeopathy prescriptions falling. July 2008. BBC NEWS | Health | Homeopathy prescriptions falling.

MHRA website. What we regulate: Medicines. Page last modified 01 October 2005. Available at: Error: Page cannot be displayed (Accessed on January 31, 2011).

House of Commons. Science and Technology Committee. Evidence Check 2: Homeopathy. Fourth Report of Session 2009-10. Printed 8 February, 2010. Science and Technology Committee - UK Parliament (Accessed on January 31, 2011).

nomadcrna, DNP, CRNA, NP · Jul 10, 2013

I'll do it for you.

Evidence-Based Clinical Decision Support at the Point of Care | UpToDate

Homeopathy is a pre-scientific practice based on two tenets: "like cures like," which holds that the correct remedy for a patient is a substance that, when given to a healthy person, produces symptoms similar to those of the patient; and "potentization," which holds that serial dilutions and "succussions" (shakings) render a "remedy" increasingly potent. Homeopathic preparations ("remedies") generally begin with minerals, plants, or animal substances that are pulverized, mixed with a water-alcohol solution, and then potentized, usually well past the point at which any of the original substance remains. The resulting diluent is applied to a sucrose pill and allowed to dry.

Current evidence finds that homeopathic remedies are no more effective than placebo [1-4].

This topic will focus on the practice of homeopathy in adults. Other complementary and alternative medicine treatments are discussed separately. (See "Overview of herbal medicine and dietary supplements" and "Overview of complementary and alternative medicine in pediatrics" and "Complementary and alternative remedies in rheumatic disorders" and "Complementary and alternative therapies for cancer".)

Meta-analyses of randomized trials have failed to demonstrate that homeopathic preparations are effective treatments for any disease [1-3,52-54]. Many small randomized trials of lower quality have reported statistically significant results suggesting a modest benefit of homeopathic remedies compared to placebos [53]. The larger and more rigorous trials tend to refute these findings [2,3,53]. "Positive" results of homeopathy are more likely to be due to bias and error than to specific effects of homeopathic preparations [55,56]. Lack of reproducibility by independent investigators has been documented for several reported positive findings in homeopathic research [4,9].

Homeopathy as a whole

One meta-analysis of randomized placebo-controlled trials compared efficacy of homeopathy with conventional medicines for a broad range of medical disorders [1]. There was no statistically significant difference between homeopathic treatment and placebo, while conventional treatment was more likely to be effective than placebo.

One of the early meta-analyses to study the effects of homeopathy, which included 89 randomized trials, reported that homeopathy was more efficacious than placebo, when combining a heterogeneous group of remedies for different diseases [52]. Subsequent re-evaluations of this meta-analysis concluded that when adjustments were made for trial quality and evidence of publication bias, the apparent benefit of homeopathy over placebo was minimal to absent [2,3,53].

Randomized trials of homeopathic treatments in children and adolescents have also found no convincing evidence of therapeutic benefit beyond placebo [57].

This body of literature, together with the pre-clinical studies cited above and the extreme implausibility of homeopathic tenets, provides compelling evidence that ultra-dilute homeopathic preparations are no better than placebos.

Meta-analyses and systematic reviews have found homeopathic remedies to be ineffective for the following conditions: attention deficit/hyperactivity disorder (ADHD) [58], allergic rhinitis [59], asthma [60], fibromyalgia [61], induction of labor [62], headaches [63], the prevention and treatment of influenza [64,65], cancer treatment [66], anxiety [67], depression [68], and some dermatologic conditions (eg, atopic dermatitis, psoriasis) [69].

ContributorsDisclosures

Date

INTRODUCTION

Homeopathy is a pre-scientific practice based on two tenets: "like cures like," which holds that the correct remedy for a patient is a substance that, when given to a healthy person, produces symptoms similar to those of the patient; and "potentization," which holds that serial dilutions and "succussions" (shakings) render a "remedy" increasingly potent. Homeopathic preparations ("remedies") generally begin with minerals, plants, or animal substances that are pulverized, mixed with a water-alcohol solution, and then potentized, usually well past the point at which any of the original substance remains. The resulting diluent is applied to a sucrose pill and allowed to dry.

Current evidence finds that homeopathic remedies are no more effective than placebo [1-4].

This topic will focus on the practice of homeopathy in adults. Other complementary and alternative medicine treatments are discussed separately. (See "Overview of herbal medicine and dietary supplements" and "Overview of complementary and alternative medicine in pediatrics" and "Complementary and alternative remedies in rheumatic disorders" and "Complementary and alternative therapies for cancer".)

BASIC THEORY

Homeopathy is based primarily on two tenets: "like cures like" and "potentization."

"Like cures like"

Homeopathy was invented at the end of the 18th century by the German physician Samuel Christian Hahnemann. While translating William Cullen's Materia Medica into German, Hahnemann was bothered by Cullen's explanation for how cinchona bark (one of the few effective medicines at the time) cured malaria. According to Cullen, cinchona worked by the "strengthening power it exerts on the stomach" [5]. Doubting this explanation, Hahnemann decided to try some himself. He experienced palpitations, anxiety, trembling, and diffuse joint stiffness (but not fever) lasting two to three hours each time he ingested cinchona [5]. He reported feeling well afterwards. It was this experience that led Hahnemann to conclude "similia similibus curentur" or "like cures like." Hahnemann's explanation was that if two diseases with similar symptoms strike a patient, the "stronger" disease will invariably cure the weaker [6]. Thus, by simulating the symptoms of a disease, homeopathic medicines "substitute themselves for the natural morbid affection, and thereby deprive the latter of all influence upon the vital force." Moreover, "all medicines cure, without exception, those diseases whose symptoms most nearly resemble their own."

Hahnemann's cinchona experience was his only experimental basis for "like cures like." Subsequent discoveries have disproved his conclusion: the active therapeutic ingredient in cinchona is quinine, which kills the parasite that causes malaria [6].

Potentization

The second fundamental tenet of homeopathy, "potentization" (also called "attenuation" or "dynamization"), holds that serial dilutions and succussions (shakings) render a remedy increasingly potent, even well past the point at which a molecule of the original substance can remain. At the time of his cinchona experiment, Hahnemann was prescribing the usual doses of commonly used 18th century medicines, many of which (eg, orificenic, mercury, belladonna) were highly toxic. Their adverse effects were thought necessary to rid the body of "the poison" of various maladies. Hahnemann soon decided, in keeping with "like cures like," that rather than elicit the usual toxic manifestations, he needed to give a dose just large enough to produce an indication of the expected "artificial malady" [5]. For unclear reasons, he subsequently reduced the doses much further and introduced the serial 10 and 100-fold dilutions that became the norm for homeopathy [7]. (See 'Preparation of remedies' below.)

Potentization lends itself to laboratory investigations comparing ultra-dilute homeopathic preparations to diluent for chemical or biological activity. A famous 1988 investigation purported to demonstrate that dilutions of anti-IgE (up to 10120), compared to diluent, led to basophilic histamine release [8]. The study was flawed, and the initial results could not be reproduced by independent research teams [9-11].

The concept of potentization violates basic scientific principles and defies logic. Any explanation of how potentization works must account for retention of a specific effect as the dilution approaches and surpasses the point at which the original substance has disappeared completely. It must also account for how that effect is transferred to a sucrose or lactose pill, which is then allowed to dry, bathed in saliva and gastric juices, transported through bowel wall into the bloodstream, and delivered to a site of therapeutic action with its specific biologic activity not merely intact, but amplified. It also must explain how the pill lacks effects referable to contaminants, which, if homeopathic theory is correct, must include every substance on the planet that has ever been in contact with the water used for dilutions.

Modern homeopaths argue that the diluent somehow retains a memory or imprint of the "formative intelligence" specific to the original substance of interest. Much effort has been spent attempting to show that liquid water has "changeable structure" or "coherence patterns" that are somehow specified by that original substance [12-14].

CLINICAL PRACTICE

After its invention in Germany, homeopathy enjoyed considerable popularity throughout the Western world for most of the 19th century, when medicine at the time was also pre-scientific and frequently harmful. With the development of scientific medicine in the late 19th and early 20th centuries, homeopathy became a fringe practice in the United States (US) [7], making a slight resurgence during the recent public interest in "alternative" treatments. One survey reported that 0.4 percent of adults in the US consulted homeopaths in 1996 [15]. Another found that 1.8 percent of adults and 1.3 percent of children in the US used homeopathic remedies in 2007, but the report did not distinguish between those who consulted practitioners and those who merely purchased "over the counter" preparations labeled "homeopathic" [16]. Homeopathy is more widely used in Europe and Asia than in the US [17,18].

Preparation of remedies

Most homeopathic preparations begin with a mineral, plant, or animal substance, which is pulverized and mixed with a water-alcohol solution [19]. Many of these substances are highly toxic in their initial concentrations. Each preparation then undergoes potentization, consisting of serial dilutions and succussions.

Dilutions range from 106-fold to 101,000,000-fold (preparations diluted beyond 1023 are called "ultra-dilute," "ultra-molecular," "ultra-high dilutions," or "homeopathic potencies"). Homeopathic potencies are designated by the Roman numerals "X" or "C," according to whether each dilution is 10-fold or 100-fold, respectively, and by a coefficient that represents the number of such steps. Thus, a 12X remedy has been diluted 1012 times; a 15C remedy has been diluted 10015 times. Once potentized, most remedies are completed by applying a drop of the liquid to a small lactose or sucrose pellet, which is then allowed to dry. The final dilution is often made with at least 70 percent alcohol, in order to avoid dissolving the pill [20]. Remedies can also be prepared and administered in injectable, liquid or topical forms.

Although the substances are usually diluted past the point of possible danger, toxins or toxic contaminants have been found in some homeopathic preparations [21-23].

"Provings"

Assertions of useful homeopathic preparations are based on "provings" (also known as "homeopathic pathogenic trials"): a homeopath gives a preparation to one or more healthy subjects who each keep a detailed diary of every sensation, feeling, mood change, and physical change that occurs over the next several days to months. All such symptoms, no matter how vague or seemingly trivial, are presumed to have been caused by the remedy that preceded them. Hahnemann performed his first few provings with undiluted substances, but eventually used "homeopathic potencies," which continue to be the norm. To a homeopath, "symptoms" are quite different from what modern clinicians might expect. Examples include "dreams which are not remembered" or a "tickling sensation on the palm which obliges a person to scratch" [24].

Such symptoms are compiled and the aggregate result is published in a Materia Medica, in which remedies are listed alphabetically and matched to corresponding symptoms. There are typically thousands of symptoms reported for each substance. About half of the 1300 entries in the US Homeopathic Pharmacopoeia are based on "provings" that occurred during the 19th century; about 65 are attributable to Hahnemann himself, including most of those commonly prescribed by homeopaths today [20].

Provings, a sine qua non of homeopathic practice, suggest that "provers" ought to be able to distinguish between a homeopathic preparation and a placebo. Several randomized trials have failed to support this hypothesis [25-29].

Choosing remedies

The inverse of the Materia Medica is the Repertory, in which symptoms are listed alphabetically and matched to corresponding remedies. Repertories are no less voluminous than are Materia Medica. The practicing homeopath, after eliciting a litany of symptoms from a patient, determines the correct remedy by finding the most closely matching symptom group in a Materia Medica, aided by a Repertory. This process is the basis for homeopaths' assertion that they treat the individual rather than the disease. Thus homeopaths are likely to choose any one of several different remedies for what modern physicians would recognize as the same disease [30].

The following treatments are examples from an abbreviated Materia Medica for earache [30]:

Belladonna-"for the earache that comes on suddenly and with great intensity. The fever can be as high as 104 degrees with a bright red, hot, flushed face and dilated pupils...there can also be delirium during sleep, with nightmares, especially of animals, causing the child to cry out."

Chamomilla-"The child is extremely irritable and changeable, not knowing what he wants...the only thing that will calm him down is to be carried back and forth continually...green stools are a common accompanying symptom, especially in cases of otitis that are associated with teething."

Hepar Sulphur-"indicated in a child who is very chilly...the ear pain is...a sticking or poking pain...worse from exposure to cold air...also indicated in cases of earache from referred pain from the throat."

Some homeopaths have argued that such individualized treatments make both regulation and research of homeopathy unfeasible because "there is no real unanimity of opinion among homeopathists as to what remedies are specific for a particular symptom complex" [31]. If the homeopathic prescribing scheme is valid, there should be some agreement among experienced homeopaths regarding choices of remedies, but studies have shown poor interrater reliability [32,33].

Contemporary homeopathy

Other than gradual additions to the homeopathic pharmacopoeia, homeopathy has changed little since the time of Hahnemann.

The influences of two other 19th century homeopaths, however, are worth mentioning. Constantine Hering (1800-1880), the "father of American homeopathy," is usually credited with having promulgated "Hering's Law of Cure" [34]:

The human body seeks to externalize disease and dislodge it from more serious internal levels to more superficial external levels. Thus, someone with asthma may develop an external skin rash as part of the curative process.

Healing progresses from the top of the body to the bottom. Thus, someone with arthritis in many joints will generally notice relief in the upper part of the body before the lower part.

Healing proceeds in the reverse order of the symptoms. Thus, the most recent symptoms will generally be the first to be healed, and in the process of cure a person may re-experience previous symptoms.

Hering's "third law" is the basis for the common homeopathic claim that an "aggravation" occurring shortly after a patient takes a remedy is not to be viewed as evidence of treatment failure, but as proof that the remedy chosen must have been the correct one [35]. A systematic review of placebo-controlled trials, however, found that aggravations are uncommon and are no more likely to be found in the homeopathic treatment group than in the placebo group [36]. Hering also introduced what would become known as "isopathy," which is the use of potentized venoms or "nosodes" (diseased animal parts) to cure or prevent diseases [37]. Hering was the first homeopath to declare his opposition to vaccination, which he called "poisoning" [38]. Opposition to immunizations remains widespread among homeopaths [39-42].

James Tyler Kent (1849-1916) popularized homeopathic "constitutional remedies" based on stable patient characteristics such as body type, eating preferences, and personality, rather than on acute symptoms [43]. Hering and Kent added the necessary bases for homeopathy's current claim to be a "whole medical system" that not only cures acute diseases, but also prevents infectious diseases and promotes general health [44,45].

Large variation currently exists in how homeopathy is practiced. Many contemporary homeopaths have promoted homeopathic methods for preventing or curing numerous infectious diseases, including influenza, small pox, anthrax, malaria, gonorrhea, syphilis, tuberculosis, and AIDS [46-49]. Some homeopaths consider themselves to be "classical" homeopaths, practicing according to Hahnemann's rules of never mixing homeopathy with other medicine and never giving more than one medicine at a time. Others assert that homeopathy may be combined with modern medicine [30]. Still others, including many chiropractors and most naturopaths, use homeopathy along with other alternative treatments. All naturopathic schools stress homeopathy in their programs, and many naturopaths are primarily homeopaths [50,51].

CLINICAL EVIDENCE

Meta-analyses of randomized trials have failed to demonstrate that homeopathic preparations are effective treatments for any disease [1-3,52-54]. Many small randomized trials of lower quality have reported statistically significant results suggesting a modest benefit of homeopathic remedies compared to placebos [53]. The larger and more rigorous trials tend to refute these findings [2,3,53]. "Positive" results of homeopathy are more likely to be due to bias and error than to specific effects of homeopathic preparations [55,56]. Lack of reproducibility by independent investigators has been documented for several reported positive findings in homeopathic research [4,9].

Homeopathy as a whole

One meta-analysis of randomized placebo-controlled trials compared efficacy of homeopathy with conventional medicines for a broad range of medical disorders [1]. There was no statistically significant difference between homeopathic treatment and placebo, while conventional treatment was more likely to be effective than placebo.

One of the early meta-analyses to study the effects of homeopathy, which included 89 randomized trials, reported that homeopathy was more efficacious than placebo, when combining a heterogeneous group of remedies for different diseases [52]. Subsequent re-evaluations of this meta-analysis concluded that when adjustments were made for trial quality and evidence of publication bias, the apparent benefit of homeopathy over placebo was minimal to absent [2,3,53].

Randomized trials of homeopathic treatments in children and adolescents have also found no convincing evidence of therapeutic benefit beyond placebo [57].

This body of literature, together with the pre-clinical studies cited above and the extreme implausibility of homeopathic tenets, provides compelling evidence that ultra-dilute homeopathic preparations are no better than placebos.

Specific diseases

Meta-analyses and systematic reviews have found homeopathic remedies to be ineffective for the following conditions: attention deficit/hyperactivity disorder (ADHD) [58], allergic rhinitis [59], asthma [60], fibromyalgia [61], induction of labor [62], headaches [63], the prevention and treatment of influenza [64,65], cancer treatment [66], anxiety [67], depression [68], and some dermatologic conditions (eg, atopic dermatitis, psoriasis) [69].

REGULATION AND CREDENTIALING

The regulation of homeopathy varies widely throughout the world [70,71]. The US Food and Drug Administration (FDA) officially recognizes the drugs and standards in the Homeopathic Pharmacopeia of the United States (HPUS) [31,72]. The FDA has the authority to require the same pre-market demonstrations of safety and effectiveness for homeopathic preparations as it expects for drugs, but so far has declined to do so. Rather, it relies on homeopaths themselves to judge safety and effectiveness. Until 1980, this was done by the American Institute of Homeopathy; since then it has been the responsibility of the Homeopathic Pharmacopoeia Convention of the United States (HPCUS) [73]. In the US, three states (Arizona, Connecticut, and Nevada) have boards of homeopathy, whose licensees are limited to medical doctors (MDs) and doctors of osteopathy (DOs).

There are several homeopathic certification boards in North America that appear to have no formal legal status. The Council for Homeopathic Certification (CHC) offers the Certified in Classical Homeopathy (CCH) designation to "lay" practitioners [74]. Practitioners certified by the CHC can also become members of the North American Society of Homeopaths (NASH), and include the designation "RSHom(NA)" after their names (Registered with the Society of Homeopaths North America) [75]. The American Board of Homeotherapeutics offers the Diplomate of Homeotherapeutics (D. Ht) certificate to MDs or DOs, and the Homeopathic Academy of Naturopathic Physicians offers the Diplomate of the Homeopathic Academy of Naturopathic Physicians (DHANP) certificate to naturopaths in North America [76]. Almost all naturopathic physicians in the US and Canada practice homeopathy [77]. Homeopathy is usually not covered by Canada's provincial health care programs [70,71]. An unknown number of chiropractors practice homeopathy. There is no formal regulation of "lay" homeopaths in the US.

Nations in the European Union vary in their willingness to pay for homeopathic treatments through national health programs, but most accept homeopathy as a fact of their cultures. In the United Kingdom (UK), where the royal family has endorsed homeopathy, many general practitioners use homeopathy, although this practice is declining [78]. All medicines in the UK, including homeopathic preparations, are licensed by the Medicines and Healthcare products Regulatory Agency (MHRA), which is charged to ensure that medicines meet acceptable standards on safety, quality and efficacy [79]. The MHRA, however, does not require homeopathic medicines to meet any standards on efficacy [80].

Homeopathy is also part of the national health care systems of India, Mexico, Brazil, Pakistan, and Sri Lanka [71].

SUMMARY AND CONCLUSIONS

Homeopathy is based on two tenets: "like cures like," which holds that the correct remedy is one that produces symptoms similar to those of the patient; and "potentization," which holds that serial dilutions and succussions (shakings) render a remedy increasingly potent. Subsequent discoveries have disproved the theory of "like cures like," and there is no evidence that "ultra-dilute" homeopathic remedies have specific biologic activity. (See 'Basic theory' above.)