Qi Spot

I know I haven’t blogged in a while – very hectic schedule and all – but I simply must greet my handful of readers a Merry Christmas and a Happy New Year!

Yes, that’s the title of an article published today in the Philippine Star.  (http://www.philstar.com/Article.aspx?articleId=630865&publicationSubCategoryId=63)

The way the headline is written, one would think that the warning issued was against Chinese Medicine as in Chinese Medicine the tradition, such as the medicine I practice.  It does not say “Warning Issued On Chinese Medicines” or “Warning Issued on Fake Chinese Medicine”.  No, it uses the general term “Warning Issued on Chinese Medicine”.

I will quote the article in full here:

MANILA, Philippines – People are urged to exercise caution when taking Chinese medicine.

Speaking to reporters, Leonila Ocampo, Philippine Pharmaceutical Association (PPA) president, said many Chinese medicinal and herbal products are not registered with the Food and Drug Administration (FDA).

Therefore they are considered counterfeit, although legitimate in the country where they were manufactured, she added.

Under Republic Act 8203, or the Special Law on Counterfeit Drugs, fake medicine pertains to unregistered imported drug products, Ocampo said.

Dr. Minerva Calimag, Philippine Medical Association (PMA) food, drugs and cosmetics committee chairman, said security in the country’s coasts is weak, enabling smugglers to bring in counterfeit medicine.

“If fake drugs are coming from outside (the country), our problem is how to secure the borders because there are many channels through which it could come into the market,” she said.

The government must be able to prevent the entry of counterfeit drugs into the country, Calimag said.

The PPA and PMA are members of Samahan Laban sa Pekeng Gamot.

It has been estimated that one of every 10 drugs in the country is fake, based on the cases reported to the FDA.

The country’s pharmaceutical market is steadily growing, making it a target of counterfeiters.

In its website, Samahan has identified Binondo, Manila as among the hotspots for counterfeit medicine.

The funny part is, I actually AGREE with most of what is said in the article.

Yes, there are tons of smuggled Chinese medicine products of questionable integrity.  I am the FIRST to admit that probably half of all over the counter drugs sold in Chinese drugstores are of poor quality or fake.

But in NO WAY should that merit a headline that passes judgment on the Chinese medical tradition as a whole!

Now for the one part of the article I don’t agree with: the idea that if a Chinese materia medica does not pass through the FDA, it should not be used at all.

Hence, let’s ban drinking tea for health purposes.

Let’s ban the use of ginger tea or salabat to relieve sore throat.

Let’s ban the use of eating watermelon to keep cool.

Why? Because those are all examples of using materials in the Chinese tradition, as per my previous post.

Shall I go on?  Let’s not use tawas or alum to relieve body odor.  That’s a materia medica used in Chinese medicine, to relieve Heat which manifests as body odor.

Let’s not massage using ginger oils for body aches, let’s ban medicinal massage, let’s ban…

You get the idea.

The past month has been brutal, scheduling wise.  I shan’t bore my handful of readers with the details of the non-essentials.  One of the things keeping me busy though, is having a 4th year medical student rotate with me in Traditional and Integrative Medicine.  For a whole month, I have a future M.D. to “convert” to Chinese medicine heh heh.

Anyway, during one of our rounds, she mentions to me that the subject of Chinese herbal medicine was brought up during her rounds with another doctor.  This other doctor encouraged her to study Philippine herbs instead of Chinese herbs because obviously, using indigenous resources is more cost-efficient than importing from China.  Also, indigenous materia medica would also be more apt and appropriate for the environment in which it grows.  Ma Huang works well in northern China for example, but not in tropical Philippines.

This got me thinking.  Just what IS the essence of Chinese medicine?  When I talk to most westerners about Chinese materia medica, most people think of stuff like Ginseng or Cordyceps.  In other words, they think about the individual materials.  Some folks with more experience might think of individual formulas – I know of a local nephrologist who actually tells patients with stones to take an over the counter stone “melting” formula from China with much success.

But is that what Chinese medicine is?  The individual materia medica?  The Formulae?

No.

The World Health Organization defines traditional medicine as “the sum total of knowledge, skills and practices based on the theories, beliefs and experiences indigenous to different cultures that are used to maintain health, as well as to prevent, diagnose, improve or treat physical and mental illnesses.”  If used outside it’s indigenous culture, it is termed alternative or complementary medicine.  (http://www.who.int/mediacentre/factsheets/fs134/en/).

Hence, the idea of medicine is not the drugs, not the acupuncture, not the materia medica.  I’ve even given this example to medical students – if for example, a person takes a certain common antibiotic but uses it for “off-label” purposes (as is rampant in the Philippines), is that person practicing medicine?  Sure, that person is using a medical tool, but not based on the knowledge, skill, and practice on which the art of medicine is based.

Chinese medicine, it can be imputed, is not about the individual materia medica.  It is about the unique theory that the practice is based on.  In particular, Chinese herbal medicine is not about the individual materia, it is about how they are used and the framework in which they are used.

Ephedra has it’s specific indications in Chinese Medicine.  Weight loss is not one of them.  Therefore, using ephedra in weight loss  - even if the ephedra is a commonly used Chinese materia medica – is not practicing Chinese medicine.

American Ginseng is grown in Wisconsin in the United States.  Frankincense and Myrrh are more associated with the Middle than the Far East.  Yet all are used in Chinese herbal medicine so long as they can be made to fit within the tradition.

So how do I reconcile my student’s story with this?

Philippine herbs can be studied and classified according to the system of Four Natures and Five Tastes.  Once this is done, it is a matter of substituting appropriate local medicinals for the imported ones, but STILL WITHIN THE FRAMEWORK OF CHINESE MEDICAL THEORY.  Let’s take a formula – Dang Gui Bu Xue Tang – with two ingredients Dang Gui and Huang Qi.  What if we can find two local materials that can be used to replace either one (with dose adjustments of course).  We could help more people at less cost.

That would be a true integration of cultures.

I was referred a patient, three months pregnant, for management of migraine, nausea and vomiting.  (Note to skeptics, the patient was referred by her neurologist, which proves that there is definitely a way for east and west to team up.)  One can imagine the thoughts that ran through my mind, “time to review the so-called forbidden points”.

Common sense dictates that the management of a pregnant patient, using whatever medical tradition, requires special care.  Certain drugs can’t be given, certain manipulations are discouraged, etc.  Acupuncture wise, there are points that are traditionally forbidden as strong stimulation on them would cause uterine contractions.  I shan’t mention them here for fear that the less-than-holy might use these points to induce artificial abortions.  Sorry but I don’t want to advocate that.

Anyhow it got me thinking.  The points are forbidden because strong stimulation might cause contractions.  What if no stimulation is done?  This is not an exact science because I have sometimes elicited strong qi sensations from patients despite having just inserting a needle.  To be safe, avoid using aforementioned points then.

The second reason that some points are forbidden during pregnancy is because of anatomic location.  Granted, specialists in acupuncture anesthesia for cesarean sections are used to putting in six inch needles in the abdomen, but the general population, even of highly trained acupuncturists, would rather not risk having needles anywhere near a fetus.

Another school of thought is this: use the non-anatomic (first category) forbidden points, but keep the stimulation down (as mentioned before) and keep the number of needles down.  In other words, it’s not the individual point stimulation, but the sum total of all stimulations that are important to prevent premature uterine contraction.

To be safe, I keep the number of needles down, and avoid the “forbidden” points as much as possible.

And the patient’s symptoms are much improved, btw.

I’m a bit tired so I’ll just quote this article and comment on it:

Outrage over Acupuncture Evidence Attacks NIH (http://www.healthcmi.com/index.php/acupuncturist-news-online/291-outrageacupunctureproofnih)

Doctors from the University of Maryland School of Medicine, Baltimore and the University of Vermont College of Medicine, Burlington published a case vignette in the New England Journal of Medicine recommending acupuncture for the treatment of lower back pain. The article cites that patients with lower back pain account for over $90 billion in annual health care expenses in the US. The doctors conclude that acupuncture is an effective means for treating lower back pain based partly on a recent study of 6,359 patients published in Spine1. For the lower back pain patient in the case study presented, 10-12 acupuncture treatments over an 8 week period are recommended.

Hmmm, why do these names sound familiar?  Oh I recall!  I had cited the University of Maryland Medical Center for it’s excellent website resource on astragalus root (Huang qi) research.  (http://qi-spot.com/2009/10/20/astragalus-root-for-swine-flu/).   Apparently, those guys are quite open minded.

So anyway, what this means is that some doctors published their opinions that acupuncture should be recommended.  Fair enough.  Everyone’s entitled to an opinion, right?  If it’s wrong, let it be proven wrong through tact and reasoning.

NOT.

The pro-acu docs cite extensive evidence:

The doctors cite physiological phenomena that measure the effects of acupuncture. Local anesthesia at needle insertion sites block the the analgesic effects of acupuncture showing that acupuncture is dependent upon neural innervation2. Acupuncture has been proven to cause the release of endogenous opioids in brain-stem, subcortical, and limbic structures3,4. Acupuncture has also been proven to induce the secretion of adrenocorticotropic hormone and cortisol from the pituitary gland thereby creating a systemic anti-inflammatory response5. Functional MRI studies in humans reveal that acupuncture stimulates limbic and basal forebrain areas involved in pain processing6. PET scan MRIs (positron-emission tomography) show that acupuncture increases opioid binding potential in the brain for several days7. Acupuncture has also been proven to mechanically stimulate connective tissues8, release adenosine at the site of needle stimulation9, and increase local blood blow10. The doctors then cite clinical trials showing the efficaciousness of acupuncture in the treatment of thousands of patients10-15.

So what do some skeptics do?  Do they try to base their argument on refuting the evidence?

Despite this overwhelming evidence proving the mechanisms of action and efficaciousness of acupuncture, skeptics were outraged at the publication of an article supportive of acupuncture in the venerable New England Journal of Medicine. An article recently posted in the Forbes “science business” section stated that the article is “embarrassing” and that acupuncture “infiltrates” the University of Maryland Medical School. In the article, the author calls acupuncture “pseudoscience” and states that it is based on “magical thinking of non-existent life-force.” The skeptic author’s only proof of his theory is that one of the many studies cited in the article found that acupuncture was only 47.6% effective for the treatment of lower back pain and that sham acupuncture was 44.2% effective. Therefore, the author concludes that using “toothpicks” randomly on the human body will have the same pain relieving effects as acupuncture. What the author fails to mention in the Forbes attack article is that conventional western medicine therapy (a combination of drugs, physical therapy, and exercise) was only 27.4% effective in that very same study. Should we therefore abolish western medicine by MDs and call it pseudoscience? Acupuncturists have noted that the success of sham acupuncture noted in that particular study of 1,162 patients in Germany reveals that poorly placed acupuncture needles also derive benefit for the patient.

I have already blogged at length on the physiologic differences between sham and real acupuncture (http://qi-spot.com/2010/04/30/definite-proof-acupuncture-more-than-placebo/) and why it SEEMS that acupuncture is hard to validate using holy grail of western medicine studies – the double blind study (http://qi-spot.com/2010/03/30/how-to-research-acupuncture/).

What I also find interesting is the insistence of skeptics that acupuncture works by balancing Qi or something.  That is the lynchpin of their argument.  I can hear it now:

Skeptic: “They believe in some quasi mystical energy flow!  That means acupuncture MUST be quackery!”

Acupuncturist:  ”There are modern, scientifically proven phenomena that explains what we mean by qi flow.  The “needling sensation” is a result of stimulation of nerve fibers, and can be inhibited by certain drugs.  Qi can also be used to mean function, so when “qi” is deficient, one can say there may be decreased circulation to a certain area, or decreased organ function.  An excess of qi can mean a muscle is too tense… (cites more examples)”

Skeptic: (oblivious) “They believe in some quasi mystical energy flow!  That means acupuncture MUST be quackery!”

Acupuncturist:  ”Never mind.”

Seriously, I feel that way sometimes, talking to skeptics.  What’s the point?  You can treat pain in these people and they’ll assign all sorts of reasons EXCEPT the obvious – acupuncture works.

The use of the word “toothpick” also indicates a lack of even a basic awareness of how acupuncture is performed.  You don’t just “prick” people, you insert the needle and manipulate it.

Oh well…

And lastly, a list of references cited by the link I cited…

References

1. Yuan J, Purepong N, Kerr DP, Park J, Bradbury I, McDonough S. Effectiveness of acupuncture for low back pain: a systematic review. Spine 2008;33:E887-E900.

2. Wang SM, Kain ZN, White P. Acupuncture analgesia: I. The scientific basis. Anesth Analg 2008;106:602-10.

3. Han JS. Acupuncture: neuropeptide release produced by electrical stimulation of different frequencies. Trends Neurosci 2003;26:17-22.

4. Pomeranz B. Scientific research into acupuncture for the relief of pain. J Altern Complement Med 1996;2:53-60.

5. Li A, Lao L, Wang Y, et al. Electroacupuncture activates corticotrophin-releasing hormone-containing neurons in the paraventricular nucleus of the hypothalamus to alleviate edema in a rat model of inflammation. BMC Complement Altern Med 2008;8:20.

6. Dhond RP, Kettner N, Napadow V. Neuroimaging acupuncture effects in the human brain. J Altern Complement Med 2007;13:603-16.

7. Harris RE, Zubieta JK, Scott DJ, Napa- dow V, Gracely RH, Clauw DJ. Traditional Chinese acupuncture and placebo (sham) acupuncture are differentiated by their effects on mu-opioid receptors (MORs). Neuroimage 2009;47:1077-85.

8. Langevin HM, Churchill DL, Wu J, et al. Evidence of connective tissue involvement in acupuncture. FASEB J 2002;16:872-4.

9. Goldman N, Chen M, Fujita T, et al. Adenosine A1 receptors mediate local anti-nociceptive effects of acupuncture. Nat Neurosci 2010 May 30 (Epub ahead of print).

10. Sandberg M, Lundeberg T, Lindberg LG, Gerdle B. Effects of acupuncture on skin and muscle blood flow in healthy subjects. Eur J Appl Physiol 2003;90:114-9.

11. Brinkhaus B, Witt CM, Jena S, et al. Acupuncture in patients with chronic low back pain: a randomized controlled trial. Arch Intern Med 2006;166:450-7.

12. Haake M, Muller HH, Schade-Brittinger C, et al. German Acupuncture Trials (GERAC) for chronic low back pain: randomized, multicenter, blinded, paralel-group trial with 3 groups. Arch Intern Med 2007;167:1892-8. [Erratum, Arch In- tern Med 2007;167:2072.]

13. Cherkin DC, Sherman KJ, Avins AL, et al. A randomized trial comparing acupuncture, simulated acupuncture, and usual care for chronic low back pain. Arch In- tern Med 2009;169:858-66.

14. Thomas KJ, MacPherson H, Thorpe L, et al. Randomised controlled trial of a short course of traditional acupuncture compared with usual care for persistent non-specific low back pain. BMJ 2006; 333:623. 15. Witt CM, Jena S, Selim D, et al. Prag- matic randomized trial evaluating the clinical and economic effectiveness of acupuncture for chronic low back pain. Am J Epidemiol 2006;164:487-96.