Raw, Concentrated powder, Patents,..What do you use? Why? Clinical results?

What type of herbs do you use in your practice? What do your friends say about their products? How clinically effective are the different preparations? Is Raw really the best when there is so much uncertainty about its quality? Should we use herbs from China? Can you really get enough dosage with concentrates? Are tablets difficult to absorb with the binders? What type of preparation has the highest level of patient compliance?

Please, this is a path to some sort of loose standardization so needed in the use of Herbals (medicinals) in TCM. Express your thoughts, opinions, concerns, and questions.

Also, click here to vote in a poll on this issue: http://www.chinesemedicinetools.com/poll/what-preparation-of-herbals-do-you-use-most

We have both KPC granule and bulk herb pharmacies and use both interchangeably with patients based on complaint, travel schedule etc. We have found that bulk herbs are clearly stronger and certain conditions simply don't respond well enough with granules (such as fibroids, certain types of cancer, nodulations in general). If a patient is committed to getting better compliance with bulk herbs is a non-issue. Sensitive patients fare better with granules since we can dose them considerably lower and they don't spoil if we do so; they get dosages ranging from 2 - 6 g/day while less sensitive patients can receive up to 10 g/day.

What do others experience?

Dagmar Ehling

Hey everyone,

This is an interesting thread. I should preface my comment by saying that I'm only a 3rd year student.

At NCNM we are taught that we use decoctions when an illness is acute, granules when it is less so and honey pills or other slow release methods when it is a very mild, chronic condition or the patient is weak. In practice, many of our doctors use granules (KPC or Evergreen) much of the time, due to patient request.

However a decent number of patients do enjoy the ritual of boiling their raw herbs. Our doctors who adhere most closely to classical methods work closely with the patients to increase compliance on bulk herbs because they find them to be superior. Personally, I always use bulk herbs unless the doctor strongly recommends otherwise.

Eric Grey
3rd year student of Classical Chinese medicine
National College of Natural Medicine (Portland, OR)
http://www.deepesthealth.com

What do you do when you are prescribing raw herbs and your patients ask about safety and all the crap that seems to be coming out of China?

When we first started specializing in women's health and infertility, we used raw herbs almost exclusively. We had a few patients with persistent dysmenorrhea and some of the milder blood moving herbs just weren't cutting it. I made one patient a formula containing Ru Xiang, Mo Yao, and Wu Ling Zhi and the smell and taste was SO DISGUSTINGLY IMPALATABLE, that I decided to tincture it. Because it was in a liquid suspension, I also added Wu Gong and Quan Xie.

You can imagine the horror of trying to decoct and drink this mixture of squirrel shit and dessicated centipedes and scorpian carcasses!! So, this pain relief formula ended up launching our tincture line. Since that time, we have proceded to tincture an entire line of commonly used formulas and now prescribe tinctures almost exclusively. I often mix tinctured formulas together in varying proportions to adjust their function and moderate their potency.

It's been a lot of fun to process the substances into tinctures, and our patient compliance is outstanding. On a business note, I think it has also been more profitable than selling raw herbs, and it is A LOT less labor intensive to fill tinctured prescriptions than raw formulas in a very busy clinic.

David J. Karchmer
The Texas Center for Reproductive Acupuncture
Austin - San Antonio - Texas
www.texasfertilityacupuncture.com

Erin,

I know quality control is a big issue. I get my herbs from some fellow practitioners here in town who speak fluent Chinese and have travelled to China to visit the sites where the herbs are processed. They tell me that the facilities are up to snuff, and I just take it at that. I know it is not a rigorous process........but that's the landscape we're in.

As far as making tinctures goes, I think Bob and folks at Blue Poppy have published some info on that. Is that true Bob?

Bob? Are you still reading this thread?

David

David J. Karchmer
The Texas Center for Reproductive Acupuncture
Austin - San Antonio - Texas
www.texasfertilityacupuncture.com

Hello Jason

have you had similar effects with the tinctures as that of custom powders ? Using only 1oz for 2-3 weeks sounds like a horribly small amount of formula for the patient.

Thanks for your information

Ryan

I also use tinctures. I am using the K'an formulas. I have the same issue with trying to personalize the tinctures at this point. I am hoping that as time goes on and other practitioners discover how easy these formulas are to use, there will be a greater ability to personalize formulas.

I love the tinctures. I don't know if because of the way I was trained I was just using such low doses with patents or if it's that the tinctures work. At any rate, my patient formula compliance is high with the tinctures. They see results in fairly short time frames. This creates even greater compliance because the patient feels results and knows they feel better.

This is a very interesting topic and, unfortunately, one which we are taught virtually nothing about in school. The truth of the matter is that there is a 15x difference in potency across the board in Chinese herbal products. That means depending on the manufacturer your patent pills could be 15x weaker than the same formula that someone else buys. Yes, most patent formulas low ball dosage. If you look at the various products on the market you need to ask the following questions of the manufacturer to make an informed decision about what you buy.

Firstly, demand transparency. You should know all the herbs in the formula and what the concentrations of the herbs are. Are they tea pills (which is essentially a powdered form of a decoction with 35-40% binder added to it), are they raw ground up herbs (some unscrupulous manufacturers will actually put ground up raw herbs in capsules or tablets and the potency will be very weak), are they extracts (if so what is the concentration, 5:1 is most common)? Don't buy products which list "proprietary formula" and don't give you any other information. You should know every ingredient (including the inactive ingredients) as well as the concentration of each ingredient. How else can you make a proper determination on dosage?

Tea pills manufacturers generally recommend 8 pills per dose, actual dosage should be 2 or 3 times that if you want a desired clinical response. Other pill and tablet manufacturers generally low ball numbers as well and it is difficult to generalize across the board regarding dosage. However, if they are not made with some type of extraction then the chances are they are rather weak and you will need to give more than the recommended dose. There are some exceptions to this, Secara is an excellent brand that you can actually prescribe at the recommended dose and get good results. Their labeling is also very good, so you know exactly what you are getting.

Raw herbs made into tea and powdered extracts are generally the strongest on the market. Also, know this, there is a law of diminishing returns on making extracts by boiling them in water. Most herbs will not extract at higher ratios than 5:1, and depending on the herb, 5:1 is actually unattainable with a water extract. The formulas that list their extractions at 12:1 are made with solvents like acetone and may contain residual toxins. If they have extracts like this you need to ask to see independent lab testing for levels of these toxins.

I use powdered extracts in my practice because compliance is the best and because you get the best bang for your buck in terms of clinical effectiveness. I will usually prescribe 3-4 gram spoons 3-4 times a day depending on the issue. You must, of course factor in the height and weight of the patient and determine what other medication and/or supplements they are taking because this can impact dosage on both sides of the equation.

It seems that even though pill/tablets, tinctures, etc. have their place and time, for the type of medicine that I want to practice powder/granule extracts will be the right choice. My question is, since our medicinals are not standardized and can vary in potency and quality, is there any specific company that could be recommended?

Juliette,

Thanks for your suggestions but I was looking for powder/granules herbs in "loose" form, not in tablets/capsules. I want to be able to customize my own formulas.

This topic is great and I'm glad to see so many people taking an interest in it. I have studied both TCM and the Naturopathic methods of prescribing/delivery and I have to admit still go back and forth. I agree with Bob that prepared formulas tend to be low potency and are generic in formulation but it can be cost effective and increase compliance. Bulk herbs are stronger especially if wild-crafted but please make sure it is from a sustainable practice!

Typically we dose pretty low in the West comparatively and if you are not using raw herbs it becomes difficult to do higher dosages for complex formulas especially if you give 2 weeks or more. I mainly treat chronic disease so for things like cancer I may be giving 30-50g daily. I think the Korean pressure machines are a great way to go and am considering that for myself (if anyone has a good lead I'd appreciate it).

Tinctures are great and I give them a lot for acute conditions and when I want a very specific effect. For example I give tinctures for sleep issues (as a branch treatment) so I can maintain them on an internal formula (Root treatment) without the formula needing to address so many things. The thing you need to consider with tincturing is solubility water vs ETOH vs glycerin extract different constituents. The % of ETOH also is also important. Tinctures are very easy and you can deliver a large dose quickly.

I mainly use Granules because like most people find them convenient and patients tend to be more compliant, but as someone pointed out mixing granules that have not been decocted together is different. Multiple herb interactions are still be explored.

If I had to say what is best I would say raw-whole herb decoctions (and the research supports this) but I believe good results depend on how accurate you are with diagnosis and dosage. Granules would be my second choice. Tinctures for sure, especially from good companies, Heron Botanicals produces great stuff but they are mainly western or Naturopathic herbs. One thing to consider with Raw herbs is that it requires time and effort by the patient and likely an increase in office visits (cost) to monitor/modify but this can work in your favor so patients don't have to buy a new Rx before they have finished the old one should it change.

In terms of quality...Huge issue. Lots has been said already and I agree, testing, transparency and QA all comes into play. What I would like to add is for you to consider the environmental and conservation impact when selecting a company. I worked in conservation in Asia managing 2 large projects and can say with certainty that a great deal of conservation impact is a direct result of traditional medicine and the Chinese are the enemy number 1 in this case. Ask about sourcing and harvesting practices.

Cheers,
Chris K

As a former chemist I look at this discussion differently. All the different herb preparation methods are going to result in different end results. If we assume raw herb tangs are best, than my feeling is classic teapills are the next closest in preparation. I use min shan/Plum flower, adjust the dose and make sure patients adjust their diet to get the most out of the pills. In my neighborhood it is hard to get people to eat breakfast in the morning let alone cook raw herbs. (raw herbs are valuable as office decor, even if you don't prescribe them much) I think other preparation methods are great, however we need to understand how they vary from the raw herb tangs. Decocted raw powders have an increased surface area that may affect how much of the herbs goes into solution. Raw powders taken internally basically an acid/stomach extraction would again be different. Alcohol extractions are going to extract different compounds than a water extraction. I think the 5:1 extracts can be good, I have found that they get only marginally better compliance than say raw powder decoctions. Plus I always found instant tea to be a pale substitute for freshly brewed, and it is hard not to make the comparison. I think it depends a lot on your style of practice. Find what works for you.
David Bock

My friend and colleague, Trevor, has been chatting with Eric Brand about the therapeutic dosage of using granules. In Taiwan they are regulated to be 5:1 concentration according to Bob Flaw's post. And Eric having just returned from Taiwan has shared how most doctors use 18 grams as their standard daily dosage. I know many who use KPC, Bema and Sun Tan are using about 10 grams per day. That is a far cry from how they used in Taiwan. I did not catch all of Trevor’s discussion with Eric, but it is alo my understanding that in Taiwan they mix a few formulas together whereas many in the west use the powder concentrates like we are mixing raw formulas.

I am curious, what dosage are others using. And how effective are you finding using concentrates. It seems that many of us in the west are using "homeopathic" dosages. Maybe it is our intentions that are doing the healing and not the herbs .... :o)

Lorne
www.acubalance.ca
www.prodseminars.com

From my understanding the corn starch is in the concentrates only as a flow agent for the manufacture, to package the herbs easier. Also when I purchase herbs I get a certificate of analysis on each herb to insure I am getting the proper item and botanical name. At times the herbs can be confusing. I purchase mostly Plum Flower and Herbal times, which all have gone through 3rd party testing. Plus the concentrates do no have any fillers, binders, or flow agents, which I have found many other companies do. I have had wonderful results, and the product comes with spoons for my clients to measure out 1 gram easily.

I am still new to using CMT, but I'm very happy to be here. :)

When I still had my practice (don't have now for various reasons, won't bore you with that now), I didn't use much herbs as I have never connected with the herbs as a practitioner.
However, I did study them and the patent formulas we have here in Israel.
Some patients of mine took the patent as they were disgusted with the raw herbs.

My own experience as a patient taught me that raw herbs are the best method to using herbs as they work fast and have a minimum of extra substances that are not the herbs.

After this experience I told my patients who used the herbs that they really should give raw herbs a go.
I was able to convert maybe 5 over the years of my practice. Then again, I didn't use them much so that doesn't say much about my ability to influence my patients. :)

Herbs from China- I'm not sure what we have in them, does anyone?
They are known for putting things inside their formulas that are not listed on the list of ingredients- at least that's what I last heard with the whole Jin Bu Huan story.

Tablets- I could never consume them, such big tablets!!!
Not user friendly at all.

Have a good day everyone,

Yael Ernst

http://www.chinesemedicinenotes.com

Doctors in Taiwan typically use granule herbs for insurance patients. They make the same amount of money for an insurance patient regardless of how much medicine they prescribe (about $4). I think there is no financial incentive for them to use 18g/day, and 18g/day is lower than the corresponding amount of raw herbs that they would typically give in the first place.

Eric

Wow, I have not seen any answers to the questions here. Just a bunch of dancing around the issues and questions. We sound like politicians.

I too am curious. What dosage do you need to use in clinic with powders do get great results... "a cure". And if you to say you have great results how do you document and monitor such great results. I loved Deadman's video on here about the story about a practitioner who thought he cured someone's hemorrhoids because the patient never came back.

Also, if dosage is so important... then how can tinctures be effective. maybe dosage is important for decoctions but the same principles do not apply for powders and tinctures?

Also, back to the filler question. What energetics does corn starch have? That is a good question. Considering so mahy have sensitivities to corn.... is it appropriate to be used on in our herbs?

"I will stick you where it counts"

Hi Lorne

I am not too aware of Bema, do they use jars to dispense herbs, if so what is the percentage of corn starch in the bottle? The lowest I have ever seen coming out of Tiawan was about 30% corn starch. I use EFong and I know they don't have any corn starch. As for dosage I use Efong herbs and put them into VCaps for patients. This ensures they take the exact dosage prescribed. If i am treating something like eczema or psoriasis then the dosage could be alot bigger say 18 to 20 grams. Body weight and constitution plays into this. More internal problems or fertility type formulas then 10 to 15 grams. Kids/children are so lucky because they can easily go below 10 grams per day.

Also another thought, Tiawan is quite south compared to most of China. Do they really grow all the traditional herbs there? In China it is common to name the herb from what province it came from, i.e. Chuan as in szechuan is where it was grown. Some herbs need or thrive off the specific environment, seasons , etc that are unique to that ground.

I am really enjoying this conversation Lorne.
I agree the pressure cookers are the ultimate. Draw backs are space and storage of herbs, unless some other company offers this service. Draw back number two is they don't test dried/raw herbs like they do for powders so the safety factors for public perception could be worse. Can you find some supplier to back their herbs? Also herbs shipped across a border (imported) are always fumigated due to the possibilty of bugs. Not my most applealing thought.

In China the cooking machine is what is used in the hospitals now not the granules, why ? Well the insurace company doesn't reimbuse granules like it does for cooked herbs.

Korea (south) may be the best source of herbs, regulations are much more strict their and the public is into organics alot.

Where did you get the liver enzyme testing unit?

You may want to try running a search for bulk herbs or bags of herbs something like that on google, looking for discount vitamins won't bring up much