There are many questions and some debate around choosing which way to prescribe herbal medicine, especially for the Interns during their clinic year. I urge the Interns to try different methods of taking herbs themselves so that they experience the assortment of options out there.
For our patients, different factors are at play for prescribing herbs. Cost is often a factor, along with patient compliance. For most of the history of AFEA, the dispensary consisted only of loose or bulk herbs. Students now can be hesitant to use loose herbs, and often cite that they don’t think their patients will take loose herbs. But for many years—they did.
In this blog, I’ll attempt to give pros and cons of the different styles of prescribing, including loose herbs, granulated herbs, and prepared herbs also known as patents that come in pills, tablets or capsules. Let’s compare three types of water-based herbal preparations: the loose herb decoction, granules, and patent pre-made capsules.
Loose / bulk herbs
For those herbalists who are attached to their connection to the plants or those who favor tradition, loose herbs are often a preferred way of prescribing to patients. In a class taught by Chanchal Cabrera, I learned that she gives loose herbs to her patients even if they are also getting herbs in pills or tinctures. It becomes about helping the patient connect to self-care, to cooking and taking care of themselves, and to the ritual of a hot mug of something good for them (even if it doesn’t taste like sweet tea or orange juice!) For the length of history of Chinese herbal medicine, this has been how herbs were by and large taken (although there are exceptions to this, of course). Another benefit of decoctions is that all of the herbs are cooked together, as a formula or team, enhancing their communication with each other and in turn the patient. Many feel that loose herbs are the strongest, most effective way of giving herbs to patients, as well as being the most easily digested.
A primary argument against using loose herbs is that it is too much work for the patient. For patients at the Academy, it used to be they had to spend 90 minutes cooking their herbs (two 45 minutes decoctions that were then combined), but our addition of a grinder has shortened that time to 30 minutes in most cases. As we mix a formula for a patient, the last step is to grind the loose herbs into smaller pieces. Another argument is the taste, which can be a hinderance to the standard American palate but is also one of the ways that the herbs work.
Prepared herbal formulas, aka Patents
Prepared herbs, patent herbs: These are often seen as the easiest for patient compliance. Sometimes this is a necessity—if it’s the only way we can get the herbs in the patient, then it’s what we need to use. And, for some formulas, even the ancient Chinese used pills. An example is Liu Wei Di Huang Wan, or Six Ingredient Pill with Rehmannia. A yin tonic formula, they knew that building and maintaining yin substance in the body is a long-term undertaking, and that pills are well-suited for this purpose. Pills have a longer shelf life than decoctions and loose herbs. However, some argue that it is more challenging for patients to extract and digest all of the good stuff from pills, tablets and capsules. Patients also miss the experience of the TASTE of the herbs, which is part of their medicine and their personality. We should experience all the flavors in daily life, and in American culture flavors like bitter are rarely eaten. An herbal formula may be the sole bitter flavor a patient gets in a day.
Granulated herbs are somewhat of a new thing. Coming about in the last decade or so, practitioners like Eric Brand are publishing and educating on the production and use of granules. Granulated herbs are concentrated, and in the AFEA dispensary we use 5:1 granules, meaning the granules are five times stronger than the loose herb equivalent. There are examples of when this isn’t the case, and there are always exceptions, but that’s the premise under which we operate. One caveat with granules is that patients can be allergic to the excipients in them. And, unlike how loose herbs and many patent herbs are prepared, in a dispensary like ours all the herbs are singles compounded together. They never ‘mingle’ as a formula for very long, as patients simply pour hot water over the granules, stir and drink. Is something lost by not having the formula cooked together? While it is possible to purchase formulas in granules, you might still want to modify, and carrying formulas and singles both increases cost as well as space needed for inventory.
A seven day supply of loose/bulk Liu Wei Di Huang Wan from the AFEA dispensary is a base cost of $18.00, for 240 grams. That base cost includes the shipping and handling of the herbs. That is an average dosage that we give to patients for a 7 day period. In real life, patients often forget a couple of doses or have a little too much water, so they often last 8 days. Ten is the maximum they can keep the liquid herbs before going bad. This cost is by weight—with no expensive ingredients in the formula, like Ren Shen ginseng or Mei Gui Hua rosebuds, then the formula is calculated at the average per gram cost, .075 per gram.
For granules, if giving the patients a dose of 12 grams a day (again, in the range where we most often prescribe in clinic) a day, then 120 grams of Liu Wei Di Huang Wan (3 parts Shu Di Huang with 2 parts of everything else Fu Ling, Ze Xie, Mu Dan Pi, Shan Zhu Yu and Shan Yao) is $13.50 base cost. We use KPC granules.
To give an example of prepared herbs, I picked Blue Poppy. For a bottle of 120 capsules, 500 mg each with a 10:1 concentration, one bottle would last the same as granules for approximately 10 days. The cost of a bottle is $15.95. While there are cheaper brands like Golden Flower and Great Nature, they are a lower concentration and a smaller bottle (often 7:1 concentration and a bottle of 90 capsules.) So choosing a more expensive Blue Poppy bottle actually can be less expensive in the end, because of needing to take fewer capsules per day. However, the $15.95 does not include shipping and handling, as most practitioners, whenever possible, order large quantities together.
To review: loose was $18, granules $13.50 and patent $15.95. This is before your practitioner mark-up (you know, that profit you have to make to help keep the doors open and the lights on.) These are all prices as if you were doing the work yourself. Companies like Crane Herb offer compounding pharmacies, and the prices go up significantly because you are paying their fees, plus adding in your mark-up, plus shipping to the patient. These services are incredibly convenient, however, and the practitioner has no worries about the rules and guidelines for GMPs.
I did not include tinctured herbs in this scenario because all of them are purchased as patents in our clinic at this time. There are some practitioners who are beginning to tincture Chinese herbs singles and formulas, and developing compounding pharmacies with them. Companies like Blue Poppy and Kan sell liquid versions of many formulas—a personal favorite is the tincture version of Dispel Invasion, because you want to get the herbs absorbed and working as quickly as possible. But the tincturing of Chinese and Ayurvedic herbs raises some question. There is some precedent for alcohol extraction with medicinal wines, but that is a small category. How do we know an alcohol extraction has the same medicinal benefits and actions as a water- based preparation? Do we know what we are changing when we alter the preparation? I am by no means a purist, and I rely heavily on glycerin preparations for pediatrics, but I have yet to fully embrace the trend to tinctures of Chinese herbs. Perhaps that’s another blog for another day, as I have heard talks from herbalists on both sides about tinctures.
To conclude, my thought is that the most important factor in prescribing herbs to patients is the herbalist’s personal preference. What are you enthusiastic about? What do you prefer to take? What ignites your passion for herbal medicine? How do you feel most connected to the plants and herbs you are using? Your excitement and belief in the form of herbal medicine will translate into patients acknowledging your authenticity, your belief, and will comply more readily. Our enthusiasm will shine through. So no matter how the math comes out, the most important part is getting the patient to actually take the herbs. And that has a lot to do with our connection to the botanicals.