Learning to Use Patent Medicines in a Public Health Care Setting with Limited Resources
Editor’s Note: Certain passages of this article have been edited from the original where formula names were linked to Western medical conditions. FDA regulations prohibit Mayway from making medical claims about its products or publishing information that contains medical claims about those products.
I. My Background
I founded and was director of a low-cost Chinese medical clinic in Portland, Oregon for over 15 years. This clinic is housed in a private social service agency called Outside-In that also provides public health services. Besides working with other volunteer licensed acupuncturists in treating clients, I supervised shifts of interns from the two Chinese medical colleges in Portland, the National College of Naturopathic Medicine (NCNM) and the Oregon College of Oriental Medicine (OCOM) where I remain adjunct faculty. Mayway’s donations were a great help to us at Outside-In. We also had an extensive bulk-herb pharmacy used primarily for acute conditions, and training interns in prescribing formulas.
Last year the focus of the social service agency’s medical division changed, becoming part of a larger federal program. I decided that the directorship would be better served by someone interested in that model. I continued to want to volunteer, and after a few false starts, I began practicing at a former student’s gong fu studio. On Saturdays we opened a free or by-donation clinic without restrictions. Its focus is on bodywork, but there are a few volunteer, licensed acupuncturists, besides the director himself, who provide acupuncture and prescribe herbs. We have four recliners for most patients to receive acupuncture (the community acupuncture model) and three massage tables for bodywork and acupuncture. However, because of the nature and size of the clinic, bulk herbs are impractical. Therefore, we rely on patent medicines, and again, Mayway came through with a generous donation.
While working as a supervisor, I had relatively few occasions to personally perform acupuncture. It has been enlightening to return to the “front lines” and treat many clients myself. I find that acupuncture in combination with bodywork is synergistic, and I am hopeful that Sean, the director, will write about the wonderful bodywork he and his students are doing at the clinic. Before I write about how to use patent medicines in a public health care setting with limited resources, I would like to mention a bit about my background.
II. Influences and Style
Here in Portland we are blessed with two colleges that provide disparate “styles” or schools of Chinese herbal medicine: OCOM’s Traditional Chinese Medicine (TCM) school and NCNM’s “classical” school. TCM was developed after the Chinese Communist revolution to supplement a burgeoning public health system, and is often used in combination with Western medicine. This has occasioned standardization of the medicine, with a view towards a “scientific” approach, often with reliance on Western clinical trials and Western medical thinking. Because of this focus on a scientific approach, OCOM is quite involved in Western style research on Chinese medicine, studies of the classics, astrology, demonology, and shamanic healing are not stressed (although qi gong and tai ji remain in the curriculum). Bian zheng lun zhi (ie., differentiation according to syndromes) remains the standard at OCOM, but prescriptions tend to be those of the Tai Ping Hui Min He Ji Ju Fang and other shi fang rather than jing fang (i.e., formulas from the Nei Jing, Tang Ye Jing, and the Shang Han Za Bing Lun). While OCOM’s approach has the danger of leading to inelegant prescription writing, it does lend itself to the application of patent medicines, or combinations of patent medicines.
NCNM, on the other hand, proudly includes ba zi charts as an important diagnostic tool, gives many classes on the classics and classical thinking, and insists that a lineage be maintained. Although patent medicines are available, classical formulas, especially those of Zhang Zhong Jing, are stressed. In fact, one school of thought within this classical school insists that one may not discount any passage of the classics, and that one never need study or apply any but jing fang.
I am influenced by both colleges and other schools of thought including; Wen Bing Xue (having studied in school and privately with Liu Gao Hui), the personal style of my teacher Li Wei (having written two books with her), and the Seven Forest formulations of Subhuti Dharmananda (the director of the Institute of Traditional Medicine [ITM] located here in Portland). For a complete differentiation I include the organs, six stages, or four level differentiations. Following my teachers, I always have a formula in mind (even if only for its therapeutic mechanism) when writing prescriptions or modifying that formula. I do not build up a formula starting with single herbs. I like to start with jing fang, but do not limit myself to them.
However, at my new clinic I can only use patent medicines: We have no room for bulk herbs and granules, and even monetary resources for buying patent medicines are quite limited. Mayway’s donation of Plum Flower brand patents has provided at least a few classical formulas, but many jing fang patents are difficult to acquire, and, of course, one cannot modify patent medicines themselves. How to proceed? Some solutions follow.
III. Using Patent Medicines
1. Use several patent medicines at once. - Although I have been fortunate enough to have worked under or study with practitioners who rely on giving two, three, or even more patent medicines at the same time and achieve notable results, I am not inclined to use this approach. My years working with a bulk pharmacy gave me the flexibility to use just the herbs I wanted, I don’t like giving unnecessary herbs, and I worry that this broad approach dilutes the effectiveness of the treatment. However, with the patient’s needs foremost, using several patent medicines at once sometimes proves necessary. To help minimize duplication of herbs, practitioners can modify the central or primary formula with small patent formulas that contain only a few herbs (one to four). These smaller formulas can be thought of as a way to modify or add functional blocks to the primary formula being used to treat patients without adding more herbs than necessary.
I would advise practitioners that use patents familiarize themselves with the following small formulas from Mayway:
Single herb patents:
- Huang Lian Su Wan/Coptis Teapills - Ingredient: Huang Lian. TCM Functions: Clears Heat, Transforms Dampness, Expels Toxic-Heat.
- Jie Geng Wan/Platycodon Teapills - Ingredient: Jie Geng. TCM Functions: Descends and Disperses Lung Qi, Expels Phlegm, Benefits the Throat, Directs Herbs to the Chest and Throat.
- Qi Ye Lian Tablets - Ingredient: Qi Ye Lian. TCM Functions: Dispels Wind-Damp, Invigorates the Blood, Removes Blood Stasis, Opens the Channels and Collaterals.
- Jiao Gu Lan Wan/Panta Teapills - Ingredient: Jiao gu lan. TCM Functions: Strengthens Zheng Qi, Enhances Yin, Supports Yang, Moistens the Lungs, Nourishes Body Fluids, Expels Phlegm, Clears Heat, Expels Toxic-Heat, Invigorates the Blood.
- Shou Wu Pian - Ingredient: He shou wu. TCM Functions: Tonifies Blood, Nourishes Liver and Kidney Yin, Replenishes Jing-essence, Moistens the Intestines.
- Tian Qi Teapills - Ingredient: Tian san qi. TCM Functions: Invigorates the Blood.
Two herb patents:
- Xiang Lian Wan/Auklandia Coptis Teapills - Ingredients: Huang lian, Mu xiang. TCM Functions: Clears Heat, Transforms Dampness, Moves Qi.
- Yan Huo Suo Zhi Tong Wan/Great Corydalis Teapills - Ingredients: Yan hu suo, Bai zhi. TCM Functions: Invigorates the Blood, Moves Qi, Guide herbs to Tai Yang channel.
- Shen Qi Da Bu Wan/Abundant Qi Teapills - Ingredients: Dang shen, Huang qi. TCM Functions: Tonifies Spleen Qi, Tonifies Lung Qi, Tonifies Wei Qi
- Shao Yao Gan Cao Wan/Peony & Licorice Teapills - Ingredients: Bai shao, Zhi gan cao. TCM Functions: Softens the Liver, Nourishes the Sinews, Calms Spasms.
Three herb patents:
- Chuan Xin Lian Pian - Ingredients: Chuan xin Lian, Pu gong yin, Ban lan gen. TCM Functions: Clears Heat, Expels Toxic-Heat, Cools the Blood.
- Da Huang Jiang Zhi Wan/Rhubarb Teapills - Ingredients: Da huang, Jiao shan zha, Chao mai ya. TCM Functions: Purges Accumulation, Clears Heat, Invigorates the Blood.
- Sheng Mai San Wan/The Great Pulse Teapills - Ingredients: Dang shen, Mai men dong, Wu wei zi. TCM Functions: Tonifies the Qi, Preserves the Yin, Nourishes Body Fluids, Moistens Dryness, Astringes the Leakage of Fluids.
- Yu Ping Feng San/Jade Screen Teapills - Ingredients: Huang qi, Bai zhu, Fang feng. TCM Functions: Tonifies Wei Qi, Strengthens the Spleen, Stabilizes the Exterior.
Four Herb Patents:
- Si Ni San Wan/Four Pillars Teapills - Ingredients: Bai shao, Chai hu, Zhi shi, Zhi gan cao. TCM Functions: Moves Liver Qi, Regulates Liver and Spleen, Clears Heat from the Interior.
- Cang Er Zi San Wan/Upper Chamber Teapills - Ingredients: Cang er zi, Bai zhi, Xin yi hua. TCM Functions: Dispels Wind, Benefits the Nose.
- Tong Xiao Yao Fang Wan/Calm Wind Teapills - Ingredients: Chao bai shao, Chao bai zhu, Chao chen pi, Fang feng. TCM Functions: Regulates the Liver, Tonifies the Spleen.
- Si Miao Wan/Four Marvel Teapills - Ingredients: Huang bai, Yi yi ren, Cang zhu, Huai niu xi. TCM Functions: Clears Heat, Resolves Dampness.
- Si Jun Zi Wan/Four Gentlemen Teapills - Ingredients: Dang shen, Chao bai zhu, Fu ling, Gan cao. TCM Functions: Tonifies the Qi, Strengthens the Spleen and Stomach.
- Si Wu Wan/Four Substances Teapills - Ingredients: Shu di huang, Dang gui, Bai shao, Chuan xiong. TCM Functions: Tonifies and Regulates the Blood, Regulates the Liver.
- Dang Gui Wan/Angelica Dang Gui Teapills - Ingredients: Dang gui, Chuan xiong, Bai zhu, Da zao. TCM Functions: Regulates Menstruation, Nourishes Blood, Harmonizes and Invigorates the Blood, Strengthens Qi, Moistens the Intestines.
- Da Bu YinWan/Abundant Yin Teapills - Ingredients: Shu di huang, Gui ban, Zhi mu, Huang bai. TCM Functions: Tonifies Liver and Kidney Yin, Sedates Deficiency Fire, Alleviates Steaming Bone Syndrome.
- Huo Luo Xiao Ling Wan/Red Vessel Teapills - Ingredients: Dang gui, Dan shen, Ru xiang, Mo yao. TCM Functions: Invigorates Qi and Blood, Dispels Blood Stasis, Unblocks the Channels and Collaterals.
- Du Zhong Pian/Eucommia Combination - Ingredients: Du zhong, Gou teng, Xia ku cao, Huang qin. TCM Functions: Strengthens Liver and Kidneys, Calms Internal Wind, Clears Heat, Drains Dampness, Calms the Shen.
2. Focus on the disease and its main syndrome without addressing the subtleties. - While this approach is “practical” and useful, it will not achieve superior results in acute cases. One cannot be limited to a few patents for all the complicated cases of common cold and hope for quick resolution. It also requires much more time to resolve complicated diseases with multiple syndromes as one must slowly address one after another. However, most “knotty” diseases have one primary or root syndrome: if one cannot address all the syndromes at the same time, resolving or partially resolving the most primary syndrome will allow the others to be more easily treated.
For instance, a client, Ms. X, is 50 years old, and morbidly obese. Her syndrome differentiation included wei qi deficiency, qi stagnation and blood stasis in various channels, spleen qi vacuity with damp, liver qi stagnation, liver invading spleen, stomach heat, kidney and liver yin deficiency, heart heat, kidney and heart not communicating— again the list could go on. Here I chose to use Ban Xia Xie Xin Wan. In this case I felt that the root of the patient’s condition was qi blockage in the epigastrium. I did not directly address the channel blockage, wei qi deficiency or liver qi stagnation. But, by treating the root I was able to address the greatest number of symptoms and treat an aspect of her complaint that was also exacerbating other syndromes in her overall condition.
3. Use newly formulated products - The number of American companies making their own formulations seems to increase every year. A few of these companies are: Evergreen, Blue Poppy, Seven Forests, Health Concerns, and Golden Flower. Some of these companies indicate the standard formulas their newly constituted formulas rely on. Others start from scratch, sometimes using Western research on single herbs to produce a formula with Western therapeutic properties. I have found a few companies that start with standard formulas and modify them in a manner I can justify. Since I can rationalize the modifications, these are the patents I use most often.
Perhaps the most common of these newly formulated products are for pain. If one is going to use these new formulations, one must first determine whether the pain is from external contraction, internal damage, or other miscellaneous diseases such as an external invasion of evils into the channels as in bi syndrome, pain from traumatic injury, etc.; what channels, burners, and organs and humors are affected; as well as the stage of the disease process. Often the formulas contain herbs specific to broad disease categories, or mention “arthritis and rheumatism”, “traumatic injury”, and other diseases. Many just contain a few herbs that Western research has shown to have analgesic properties.
If we take traumatic injury as an example, with a view toward the stage of the disease, in an early stage often there are heat and toxins (damaged or necrotic tissue is toxic) and swelling along with the pain. One would look for a formula with heat-clearing, toxin-resolving herbs, and swelling-reducing damp-transforming herbs. The tongue is often swollen and red with a purple cast or purple stasis-speckles, the pulse is often wiry or tight. Wind-damp dispelling herbs are not as important in early stage traumatic injury. In an intermediate stage one would look for a formula with blood moving and harmonizing herbs as well as qi rectifying herbs. Here, the tongue should be less red and swollen. In a recovery stage or later stage, one would need to find a formula that included blood nourishing, qi boosting herbs. The tongue may become paler. If one sees only the sequelae of a traumatic injury, these usually include bi syndrome, and one would look for a formula that does contain wind-damp dispelling herbs. In this case, the tongue may be normal or swollen, and pulse can be tight, slippery, and or wiry.
4. Use formulas in novel ways. - This approach follows the Nei Jing dictum, “tong bing yi zhi, yi bing tong zhi (for the same disease there are multiple methods [and formulas], the same method [and formula] can treat multiple diseases).” To me this is the most elegant way of using limited resources. TCM clinical methodology usually requires one to find the specific representative formula for the differentiated syndrome of the differentiated disease. But if specific enough, one can use any formula that addresses the differentiated syndrome, even if it was originally formulated for a different disease. A few examples follow.
Si Miao San (Mayway’s “Four Marvel Teapills”)
This formula is often given for damp-heat in the lower jiao. However, one should also consider it for the damp-heat Bi syndrome and blood stagnation affecting the lower part. Huang Bai clears damp heat and resolves toxins, Cang Zhu dries damp and expels wind, Niu Xi is an arrow to the knees and lower extremities and moves blood, and Yi Yi Ren percolates water to help resolve the rheum manifesting as swelling.
Xiao Chai Hu Tang Wan (Mayway’s “Xiao Chai Hu Teapills”)
Originally designed for Shao Yang disease, this formula has been used for a wide variety of conditions. Chai Hu addresses issues associated with liver qi stagnation and gall bladder heat. Ban Xia and Sheng Jiang strengthen the spleen and so help prevent excess and liver/gall bladder from invading the stomach. Huang Qin clears heat in the upper jiao. Ren Shen, Da Zao, and Zhi Gan Cao calm the shen, generate fluids, and strengthen the Middle Jiao. This is also an important formula for deficient patients with concurrent excess phlegm-heat. And while Xiao Yao Wan is one of the most prescribed formulas in the US, in many cases Xiao Chai Hu Tang is more appropriate, as are Ban Xia Hou Po Wan and Bu Zhong Yi Qi Wan.
Ban Xia Xie Xin Tang Wan (Available from Mayway as “Ban Xia Xie Xin San” extract powder)
For heat, toxins, and phlegm-heat in the upper jiao, with concurrent spleen deficiency with cold and damp, I have often used a combination of Ban Xia Xie Xin Tang Wan and Bi Yan Pian. In Ban Xia Xie Xin Tang Wan, Huang Lian and Huang Qin clear heat, resolve toxins, dry damp, and transform hot phlegm. Ban Xia transforms damp and phlegm and lowers qi. Ren Shen supplements the spleen and lung, and Gan Jiang warms the spleen. Bi Yan Pian is used as an arrow to benefit the nose.
Gui Zhi Tang Wan (Mayway’s “Gui Zhi Teapills”)
Gui Zhi Tang has been called the “number one illustrative formula” and the “principal Shang Han Lun formula” for the multiple mechanisms of its herbal combinations and for its symbolic harmonizing of yin and yang by harmonizing ying and wei. It is useful for many problems at the surface, including psychological “boundary issues”. Gui Zhi Tang Wan consolidates the boundary between humans and the external environment, physical or emotional.
I call the combination of He Shou Wu Pian (Mayway’s “Shou Wu Tablets”) and Gui Zhi Tang Wan “heartbreak soup”, useful for those going through emotional break ups. These patients may have a slow or fast pulse, either deep and weak or big and soft. The tongue may have a red or pale tip, and the sides may also be red. He Shou Wu supplements the essence, the deepest part of one’s being. Gui Zhi Tang not only harmonizes ying and wei securing the “boundary”, but Gui Zhi itself strengthens heart yang to increase “warrior energy”, and Bai Shao “softens and comforts” the liver to increase flexibility in the face of adversity.
Our new clinic is popular and patient outcomes often gratifying. Sean and his partner Emily continue to learn how to most effectively run the clinic, and I continue to learn how to use acupuncture and patent medicines in a public health setting.
|Bio: David Frierman, L.Ac. graduated San Francisco College of Acupuncture 1989. He opened a low-cost community acupuncture private practice in Portland Oregon called Open Gate and worked for one year at the Portland Addiction Acupuncture Center. He later established and ran a Chinese medical public health clinic at Outside-In, a private social service agency in Portland Oregon, that utilized volunteer acupuncturists, as well as interns from OCOM and NCNM. David is presently volunteering one day a week at a by-donation Chinese medical public health clinic, supervising interns at NCNM, and substitute supervising at OCOM. In 2006, he published a book through Blue Poppy with his teacher Li Wei on Diseases of the Kidney & Bladder, and is currently in the process of completing another on Thyroid Disease.|