A Blue Poppy blog post by Bob Quinn
A year ago I gave a Scholar’s Hour talk at NUNM in Portland, OR with this—The Hobgoblin of Dose—as the working title. I want to come back to this topic in this blog post, in part because I am working on a review of Stephen Birch’s new edition of Shonishin, and in this book he gives a great presentation of Dr. Yoshio Manaka’s dose model, but also because of a recent interaction with a patient, an interaction I have experienced many times with many patients over the years. By the way, I recommend this new edition of Shonishin—it is an improvement on a book that was already stellar.
Let me start with the patient, a 40-year old woman with chronic digestive complaints. I switched her custom formula and after a few days she reported some side effects. They were not major, but they did alert me that something was not quite right. Rather than change the formula, I changed the dose. In fact I lowered the dose by 30%, and the result was a solid improvement in her symptoms. To a practitioner following normal TCM dosing guidelines, her dose would seem almost silly. She now takes just two scoops a day of a granule formula, one scoop AM, and one PM. But this patient is very slender, maybe just 105 pounds or so, and extremely sensitive, the canary-in-the-coal-mine type of patient. I have learned to be flexible in how I dose herbs with this sort of patient.
I have studied Kanpo (Kampo) with Nigel Dawes. This is the art and science of herbal medicine in Japan. There the doses commonly used are quite small when laid alongside current prescribing habits in the PRC. Yet, these are often the very same formulas. It is interesting that both systems, TCM and Kanpo, claim positive effects with these radically different dose levels. In mainstream biomedicine it would be highly unusual to have a drug dosed one way in Country A, while people in Country B get less than half the dose of the same drug. This can be carried across to Western herbal medicine in the US and Europe as well. Here the dosages almost never approach the levels regularly used in China. Some well-regarded Western herbal practitioners even use just a few drops of tincture in water as a dose and claim good results. What is going on with this hobgoblin of dose; is there no solid ground on which to stand?
This dose issue pops up regularly on the shifts I supervise at NUNM in Portland, OR. For instance, imagine a patient comes to the clinic with an acute headache. The student intern and I will agree on an understanding of the case and on which acupuncture points to treat. Usually this is more often the result of careful palpation than of “thinking our way” to a set of points, but clearly some sort of thinking has to take place as well. What happens then when the intern comes back to me 20 minutes later (I have up to 6 rooms to keep an eye on, so that I rarely have the opportunity to witness and help with an entire treatment) and says the patient still has the same level of pain? In many instances I add no more needles. Those already inserted might well be sufficient, but they had not been made to work; perhaps the angle of insertion was a bit off or a needle was too deep or too shallow. The point is the intern comes with the idea that we need to add more needles, and that might not be the case at all. It might be, but it might not be. A careful inspection of the pulse in these instances is usually what guides me in deciding what to do—do I take a new approach and insert a few more needles or do I use the ones already in.
Back to Dr. Manaka’s dose model: This is a brilliant piece of work that conceptualizes an issue that is not often discussed in TCM, at least not sufficiently so. Dr. Manaka posits what we can call a “therapeutic threshold,” a level of stimulation beyond which our treatment must reach, if we are to achieve a desirable therapeutic outcome. He also posits an “overdose threshold,” beyond which undesirable outcomes start to occur. In average patients there is a comfortable amount of room between these two dose thresholds, i.e., wiggle room and room for style differences.
If we quickly insert a number of strong needles, we run the risk of not monitoring closely enough the level of stimulation we have achieved—the stimulation may for instance have travelled well over the therapeutic threshold on past the overdose threshold without us being aware of it. In a case like this we could expect the patient to report poor outcomes, e.g., adverse effects to sleep, energy levels, appetite, and so on; these are not life-threatening of course, but from the patient’s point of view, undesirable. In the Manaka model those sorts of unwanted outcomes are explained as “overtreatment.” Our goal should be to keep our level of stimulation between those two thresholds. It is quite possible that many patients who come for one or two acupuncture visits never to return were over treated in this manner. This is particularly true of the type of patient I described above as the extremely sensitive, canary-in-the-coal-mine type. Dr. Manaka explains that these sensitive patients (children as well would ALL be considered to be in this category) have both a lower therapeutic threshold and less space between this threshold and the overdose threshold than normal patients. It is easier, in other words, to over treat this type of patient; they have less wiggle-room.
What does this have to do with Blue Poppy herbal products? What I am suggesting is that you might well have chosen the correct formula for your patient who is now reporting either no effect or adverse effects. Of course go back to the drawing board in those instances and re-inspect your diagnosis and analysis of the case, but ALSO consider your dose. It might simply need an adjustment up or down. If you are dealing with one of these sensitive types, then my advice is to try reducing the dose. If there is still no positive shift in the complaint at the lower dose, then a higher dose can be tried. And it might need to go quite bit higher in some cases; I am aware of this and don’t want to be misunderstood as saying that in all instances we need to do less. That is certainly not true. There is a place in herbal medicine and in acupuncture for doing more—even at times a good bit more. We just have to be wise about when we deliver more stimulation. It should not be a knee-jerk reaction or a default setting that we always revert to.
We at Blue Poppy go to great lengths with our sourcing practices and the quality control and testing of our products; they really are products you can rely upon. And the herbal education in this country has improved a great deal in the last 20 years, so there is every chance, if you follow what you have been taught, that you can arrive at a helpful formula for a given condition. My point here is that the question of dose is stickier and is tougher to teach than the other aspects of herbal medicine. All that can be presented are traditional guidelines; beyond that we have to be willing to tinker a bit. Take note of the constitution of the patient in front of you. Is this a canary-in-the-coal-mine type? If so, proceed with caution.
As for regulating dose with acupuncture, what can be done beyond inserting fewer needles? Let me cite one example from a few years ago here in Portland. A friend’s husband went to an herbalist-acupuncturist for treatment for lung cancer. This practitioner is known in town as someone who focuses in the area of supportive care for cancer. I asked my friend how her husband responded to the acupuncture, and the reply was that for 3-7 days after a treatment he did not have the energy to get out of bed. Something is wrong, horribly wrong, in this picture! Clearly these treatments were overshooting the overdose threshold! Can we be so blind that we miss something like this; and this was from a practitioner with over 30 years of experience! The Blue Poppy Tempo brand of needles features gauges (42 and 44) not commonly used in China. The needle body of these Japanese-style needles is incredibly smooth, making for an easy, painless insertion.