For those of you who missed my class on herbs in a community acupuncture clinic at the conference, these notes will help. You can also download a word doc of the course notes. Below are the notes, with some more elaboration similar to that which was discussed in class.
Clinical relevance: Why
- Stronger treatment than acupuncture alone for
moderate to severe internal medicine conditions (i.e. for the conditions listed below)
- Faster results than acupuncture alone (i.e. a condition can resolve or greatly improve within 24-48 hoursor over the course of a week whereas with acupuncture alone it could likely take several weeks or more)
- Good for people who can’t come in frequently (i.e. for those with very busy schedules)
- Much more efficient and useful for patient to
have herbs for immediate use vs. sending to an outside pharmacy to fill
(i.e. have them in your clinic rather than relying on a school pharmacy or herb company pharmacy that ships it – especially for acute issues like common cold/flu/cough/stomach bug)
Conditions in which
herbs make a substantial difference:
- GYN: menses (dysmenorrhea, amenorrhea, oligomenorrhea, PMS), menopause (night sweats, hot flashes, insomnia, anxiety, irregular menses etc.) and infertility
- Digestion: diarrhea, constipation, sluggish/incomplete BM, gas/bloating, IBS, heartburn, acid reflux, abdominal cramps, etc.
- Respiratory: common cold, sinus problems, cough,
allergies, phlegm, asthma, etc.
- Dermatology: acne, psoriasis, eczema, etc.
- Depression and anxiety: moderate to severe with
or without western meds.
- Migraines: good for stubborn cases
- Insomnia: good for stubborn cases
- Combinations of any/all of the above – often times there are complex cases where a person complains of something such as depression and has trouble with headaches, digestion, sleep, fatigue, etc. and herbs can address all of it
Patents only vs. custom formulas:
- Easy to administer off the shelf
- Can have on display – easy to sell and people
can pick them up for their own medicine cabinet and when having an acute
condition, i.e. yin qiao for common cold and curing pills for stomach
problems, are convenient and easy to take. Often recommend higher doses than the box suggests if they aren’t very strong (i.e. Mayway Yin Qiao – I recommend double the dose)
- Downside: can’t modify – may not have appropriate patent
or may have to combine patents to match a health need
- Not as strong as powder formula or raw formula
- Patient may not need entire package
- Custom formulas:
- Can make exactly what would be good for a
patient in terms of ingredients and dose
- Can adjust dose and length of amount to take –
i.e. a half week, a week, two weeks worth
- Can adjust with each visit so body doesn’t
adapt to formula and change of herbs can adapt to body’s changes as they occur
- Stronger than patents
- Downside: does take time from schedule to make – or you
can have staff person make it
- Can make exactly what would be good for a
Supplies: stocking an herbal pharmacy, patents and prep materials
- Herb pharmacy can be expensive to start.Would recommend beginning with
approx. 100 herbs – the most commonly used.Start with 1-3 bottles of each depending on how
commonly used and quantity used – i.e. Dang Shen 3 bottles, Chen Pi 2 bottles, Da Huang 1
- Patents – choose ones you would use most commonly
– i.e. yin qiao, curing pills, xiao yao wan, cang er zi wan
- Other supplies:a gram measuring scale, plastic ziplock sandwich bags,
large cup, long spoon and sticky labels.Measure powder herbs in large cup on the scale, mix with
spoon, put in plastic bag with a little measuring spoon (these come from
the herb company).Make
sticky labels to put on bag.
- Example labels – front and back to stick on the bag of herb formula:
Directions:Take _____ level spoons _____ times
Total:______ grams for _______ days.
If you feel you are coming down with a cold or
Timing of herbal
consults, formula writing and preparations in a community acupuncture clinic –
how to balance it all:
acupuncture/herb appointment for 30 minutes (can do less if you have staff to fill formula and can write a formula very quickly)
o10 minute consult (or less), 5
mintutes for acupuncture tx., 15 for herbal write-up and prep. (Consult time must be very well targeted so that you get the important information quickly – that can be the tricky part, depending on the patient. After subsequent visits it gets easier b/c you know your patient better than the first time you meet them).
oIf you have staff, you
can teach them how to prepare the formula and just write it up for them to fill
– just be sure to check all ingredients before they fill it
oMuch like acupuncture
done quickly, you need to be able to come up with an herbal formula quickly
oStart with one week’s worth,
see how patient responds, then next time if patient had no side-effects (typically digestive disturbance if not balanced properly) make 2
weeks worth at that time.If
adjustment is needed try one week again.For acute/fast-moving conditions such as common cold, make half a week’s
Pricing of Chinese
·Decide what seems fair
and comparable to what it would cost them for acupuncture only, with more
acupuncture/herb follow-up (cost for time to do herb consult and prepare herbs)
plus the herbs themselves vs. acupuncture follow-up.
·Consider how often they
will come when using herbs vs. without – i.e. they may come once a week along
with herbs or even just once every two weeks, but without herbs would be
getting acu 2-3 times per week.Price
for herbs + acu/herb visit could be in the ballpark of what it would take to
have 2 acu tx. per week.
·Example – at my clinic
acupuncture follow-up is $20-40.Acu-herb follow-up is $30 (flat fee) and herbs cost $20/weeks
worth.If a patient gets 1 week
herbs + 1 acu/herb follow-up it’s $50 – that’s like having 2 tx/week at $25
each. If they have 2 weeks worth of herbs filled and come in once every two weeks that is $70 for two weeks. The actual cost of a week’s
worth of herbal formula cost me about $7-8, so there’s a $12-13 mark-up.
·Herb patents don’t
require a consultation and can just be given over the counter when a patient comes for a regular
acupuncture follow-up.They can be
priced a few dollars more per package than they are purchased for so there’s
some mark-up.For example I offer
Mayway patents for $8 or $9/bottle and these typically cost me approx. $5 each
to purchase (the company actually suggests selling them at an even higher price, but I didn’t want to go that high).
On a first visit I rarely give herbs, because my first visits are 20 minutes on the schedule. If my schedule isn’t full and I know I’ll have time to fill a formula AND it seems either urgent (for an acute condition) or that the patient could really use it and wants it (i.e. for a woman w/ amenorrhea), I will try and fill it that day – if I don’t have time and it’s not urgent, I tell them that I will do it for them the next appointment. If their condition is one that seems it could benefit with herbs but acupuncture alone would likely be helpful, and/or they don’t seem particularly interested in trying herbs right away, I have them just start with a course of acupuncture (i.e. let’s try 2x/week for 3 weeks and see how you’re doing at that point) and then if things aren’t shifting as much as we’d like, I recommend trying herbs and book them an acu-herb visit.
As far as the way I write formulas and dose, I practice based on the model I learned from the herbalist who I studied with beyond my training at NESA (I did 4 post-grad internships with it so that I would really feel comfortable writing and preparing formulas – the training at school was entirely insufficient for me to be able to practice). There are still conditions which I would refer out for rather than treat myself and I feel that is okay (i.e. gallstones). I use Blue Light/Treasure of the East herbs, all single herbs in a granular form of 5:1 potency. Almost all of my formulas are 98 grams per week, so I just charge $20/week’s worth. Once in awhile I make a smaller dose like 86 grams/week, or rarely a higher dose such as 114 g/week. I make formulas that are well-balanced and use 15-20 herbs most of the time. This is in contrast to the way many textbooks suggest formulas be written, but it is my feeling (based on my training, discussion with other acupuncturists/herbalists) that people are rarely, if ever, straight up deficient or excess so writing more balanced formulas is essential. Also, higher doses really work better than lower doses, so these 98 gram per week, 14 gram per day formulas translate to 70 g raw herbs per day. This is just how I practice, so you get a chance to see – but your way may be quite different.
EXAMPLE: For a patient who complains of depression that is moderate with low motivation and low energy, cloudy/foggy headedness, dull headaches, mild gas and bloating in the lower abdomen, sluggish/incomplete formed bowel movements once daily, pms irritability, painful periods, insomnia a few times a week with waking in the middle of the night and a dull pale/purple tongue with a thin white coat I might give something like (herbs and their doses in grams):
Tao Ren 7
Hong Hua 7
Dang Gui 7
Shu Di Huang 5
Chuan Xiong 6
Chao Bai Shao 5
Huang Qi 8
Dang Shen 8
Yu Jin 5
Yuan Zhi 5
Suan Zao Ren 6
Jie Geng 3
Chen Pi 4
Hou Po 3
Zhi Ke 4
Shi Chang Pu 6
Chuan Niu Xi 4
Yan Hu Suo 5
This formula starts with a base of Tao Hong Si Wu Tang to move blood, also has some qi tonifiers and qi movers based on the Xue Fu Zhu Yu Tang formula, and herbs to help the middle and lower warmer digestive function, sleep and pain.
I would recommend this patient take herbs and get acupuncture once a week. If they were receiving acupuncture only, I’d recommend 2-3x/week and would expect a slower improvement, as there are many parts to treat – most likely with acupuncture the sleep and headaches would improve first, the mood and energy would more slowly change and the digestion and periods also slowly – whereas with herbs, these things could change more dramatically even within just a week or two.
Two examples of patients who have done well on herbs and I think would have not had as good results with acupuncture alone:
-a 33 year old woman w/ main complaint of infertility/no periods since stopping birth control pills 8 months prior to seeing me. Had no period since ending the pill, even with provera (medication progesterone from her doctor). No other health complaints and otherwise was quite healthy. Within one month of taking herbs she got her period. She is being treated with herbs through 3 cycles to try and have them occur on time.
-a woman with severe sinus congestion and constipation for 20+ years. Sinuses get blocked with a lot of pressure, can’t breathe through nose, ears get blocked, and she has a bowel movement only once every 2-3 days which is hard and incomplete and her lower abdomen is bloated. Also complains of a lot of skin itching and dryness especially in the winter and has had a very pale tongue, slightly purple and a thin yellow coat in the back (it is still pale-purple but less so than when she started). Herbs have gotten her to have less problems with her sinuses and having bowel movements one to two times a day, complete and easy to pass and formed, and her skin hasn’t itched all winter. She has been on herbs for about a year which is a long time, but with her long history and severity and also her vegetarian diet (which I think is very likely contributing to these problems) and intolerance of dairy, she would likely be able to get off herbs earlier and easier if she changed those habits (lots of blood deficiency).
Of course there are lots of other conditions I’ve treated along the way. I only give herbs to about 15-20% of my patients but for those who I do treat they have had a lot of improvement.
If you’d like more notes on herbs from me with sample formulas for certain conditions and individual herb indications, please email me at firstname.lastname@example.org and I’ll happily send them to you.