best prescribing?

[Guest guest]

Brian Carter wrote this in Acupuncture today this month. In the article,

he admits his view is controversial and he invites debate.

 

" I believe combinations of classical formulas [combinations of prepared or

patent medicines in powder or liquid form] are the best answer for most

acupuncturists. If you look at the first list in this article (best to

worst in ideal herbal medicine), you'll see I put personalized

prescriptions first. The learning curve, the unwillingness of most

acupuncturists to commit to them, and the perils to the patient's health

and pocketbook knock them down a notch for most.

 

In fact, I use classical combos when the personalized prescription seems

too complicated, or if I suspect the patient's health might be too

sensitive to accommodate an imperfect formula. I also rely on classical

combos in cases where the diagnosis is not clear after the initial intake

and treatment, and I expect we may go through a bit of " diagnosis by

treatment. " I do that because the effect of these time-tested formulas is

better known, so the risk of a negative response is lower. If the results

aren't great, I at least know it's not a problem of formula design, but of

diagnosis, and I can use their response to refine my diagnosis. "

 

He states the main reasons as:

 

" 1. Reliability. Each of these formulas has proven over time to work well.

If it ain't broke?

2. Simplicity. No worries about subtracting the wrong single herb. When you

fiddle with your personal prescription, eliminating various seemingly

redundant herbs, you sometimes thwart the whole prescription: Problems pop

up, and the whole thing becomes an incomprehensible puzzle. "

's response: The idea that personalized classical rx are best is

timely given the current debate on CHA. Perhaps this view is historically

inaccurate and essentially incorrect. What about Kanpo and condition based

tx as Felt has elaborated?

 

The idea that combining classical patents is somehow safer because they are

" time-tested " and you don't have to worry about creating a dangerous or

ineffective variant by adding or subtracting single herbs or dui yao. I

would suggest that combining classical rx without doing additions and

subtractions is what is really risky to one's patient. If one uses full

dose formulas of decoction equivalence, the inclusion of an herb that

should have been deleted is actually far more problematic than the deletion

of one that should have been included. As for being time-tested, that is

not quite true. As far as I can tell, prepared unmodified classical

formulas were mainly used by laypeople and illiterate doctors in low

potency forms. Elite professional practice in China for hundreds of years

has relied on physician modified rx (though admittedly most people only had

access to the other types of docs). Most elite docs do not put much stock

in the low dose patents. And since most such docs modified their full

strength decoctions, there really is no history in china of using full

strength unmodified formulas. So perhaps placebo versions (low dose

patents) of unmodified rx have withstood a test of time (but who cares),

while the actual practice of herbal med has not undergone this test. I

would wager that most herbalists who write personalized rx would strongly

disagree with Brian's contention.

 

Brian then goes on to propose a solution to this dilemma, which is to

purchase custom liquid combinations from a new virtual pharmacy. What he

fails to mention is that he founded this pharmacy and it is now owned by

his wife. In order to further make the case for using his pharmacy, he

provides the following practice tip:

 

" It costs money. A full liquid pharmacy costs from $5,000 to $10,000, and

a granular pharmacy of 400 single herbs about $2,000. If you want 100

granular classic formulas to combine, that will cost an additional $1,000

or so. "

 

I believe these prices are overstated. A fully functional starter pharmacy

from springwind costs about $1000 or less and one is able to make three

payments. It is hardly necessary to have 400 herbs and 100 formulas, but

only an experienced prescriber would know that one typically uses more like

the same 100 herbs and 25 formulas over and over again. The herbs have

great shelf life and this cost should be well within the reach of any

startup clinic. While a liquid pharmacy costs much more, the question is

whether such products are in any way equivalent to decoctions and thus an

adequate substitute. If we are comparing apples and oranges, then the

entire debate becomes pointless. There is NO research or history backing

up the use of low dose liquid extracts for ANYTHING. We make a big

assumption when we extrapolate the modern research and historical use of

decoctions in something wholly other. It is just bad science.

 

 

Chinese Herbs

 

 

" Great spirits have always found violent opposition from mediocre minds " --

Albert Einstein

 

 

 

[Guest guest]

, wrote:

> I would wager that most herbalists who write personalized rx would

strongly disagree with Brian's contention. >>>

 

:

 

This would be a foregone conclusion. As someone who has worked with

herbs in all the different ways Brian mentions, I don't see much

problem with any procedure as long as it creates an effective

treatment strategy. My formulas now are often compounded from

several classical formulas with additions and subtractions depending

on the pathology of the disorder rather than individual

symptomology. Many of these formulas have more than 30 herbs so

reactions to individual herbs are no problem; effectiveness is

maintained not by the quantity of a particular ingredient but by

synergy.

 

Where Brian's argument breaks down is where he is not diagnosing

effectively ( " I expect we may go through a bit of 'diagnosis by

treatment' " ) or when things become " an incomprehensible puzzle " . I

do not think that " reliablity " or " simplicity " are inherent to any

one way of prescribing herbs. They are a function of the person

doing the writing.

 

 

Jim Ramholz

[Guest guest]

I don't think there is an either-or scenario between prepared and raw

prescriptions. Clearly, the raw/modified prescription is the standard

for the practice of Chinese herbal medicine, but there is certainly

room for the use of prepared medicines, in significant dosages, to

treat disease patterns.

 

Xu Da-chun addresses this in " Forgotten Traditions of Ancient Chinese

Medicine " , where makes the case for prepared medicines, with the caveat

that physicians should prepare them by themselves, which allows for

modifications in batches. There is also a tradition of combining

prescriptions for complex or combined patterns, and if one looks at

many of the Blue Poppy textbook translations, that seems to be a fairly

predominant methodology. There is also discussion of different

treatment methods in Hua To's " Classic of the Central Viscera/Zhang

Zhong Jing " .

 

The problem I think is in patient education and compliance. In my one

semester clinic shift, I helped the interns write raw prescriptions for

almost every patient, but the compliance was quite poor from what I

could see. I do write raw prescriptions for my own patients, but they

seem to prefer the liquid extracts, which are quite potent and seem to

work very well.

 

I agree with you, that one should have a definitive diagnosis

before administering any herbal treatment. I don't think Brian is

correct in giving herbs to people without a correct diagnosis.

 

 

On Friday, October 17, 2003, at 09:21 AM, wrote:

 

> Elite professional practice in China for hundreds of years

> has relied on physician modified rx (though admittedly most people

> only had

> access to the other types of docs). Most elite docs do not put much

> stock

> in the low dose patents. And since most such docs modified their full

> strength decoctions, there really is no history in china of using full

> strength unmodified formulas. So perhaps placebo versions (low dose

> patents) of unmodified rx have withstood a test of time (but who

> cares),

> while the actual practice of herbal med has not undergone this test. I

> would wager that most herbalists who write personalized rx would

> strongly

> disagree with Brian's contention.