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TCM and Phytotherapy: An Integrative Challenge

By Todd Luger, L.Ac., PCOM Faculty Member, Department of Herbology

With the approval of doctoral programs at several of the most prestigious schools of acupuncture in the US, Pacific College is about to embark upon a new ear in the evolution of the American practice of Traditional Chinese Medicine (TCM). This is a development that presents us with both a great opportunity and also a great responsibility with regard to the practice of herbal medicine. Since acupuncture is licensed in almost all 50 states, acupuncturists will soon be the only professionals practicing legally nationwide who have doctoral level training in both medicine and Chinese herbology. We will not have physician status everywhere, but we will be the de facto experts by virtue of our recognition and educational standards. The only other federally recognized doctoral level profession that has extensive training in herbology is naturopathic medicine and they are licensed in only 13 states, mostly in the west. In order to meet this challenge, it is vital that advanced training in herbology incl udes a solid background in modern principles of phytotherapy as well as TCM. In order to be taken seriously by the burgeoning movement towards Integrative Medicine, it is necessary that we establish ourselves as the subject matter experts in all aspects of the subject.

What do I mean by phytotherapy? Phytotherapy simply means the use of plants as medicine. While Chinese medicine is not limited to phytotherapy, plants do comprise the bulk of the medicinals used in daily practice. Phytotherapy is based upon both traditional and modern uses of herbs and explains their actions in terms of their phytochemistry, which is an aspect of pharmacognosy (the pharmacological study of medicinal agents derived from nature). Phytochemistry is based upon the idea that there are several classes of archetypal plant constituents that are the biochemical effectors of herb action. These archetypal constituents either directly affect the body after entering the bloodstream or after being changed by the body into an active secondary metabolite. Plants have multiple constituents that work together in various ways to affect potency. In some cases, constituents increase each other's effect by a summation of similar effects on the body. In other cases, the "inert" ingredients alter absorption rates and other factors that allow much smaller amounts of the "active" constituents to cause an effect than a similar amount of an isolated drug. There is a considerable body of research in this area. Being familiar with this information can be an invaluable asset when communicating with mainstream healthcare providers. It can also be useful for predicting possible drug/herb interactions, designing research and developing antidotes to toxicity.

There are several reasons why I think the study of phytochemistry and pharmacognosy is very important. First, there is considerable concern among medical doctors about the growing use of herbs by laypersons. There are fears about drug/herb interactions, toxic effects and overdoses. While much of this is hysteria and largely supported by actual incidents, the concern is not completely unreasonable. As herb use grows exponentially, there are bound to more, not fewer, problems. And herbs are not inherently safe, just generally more safe than drugs when taken at recommended dosages under the supervision of a licensed healthcare professional trained in herbology. In order to assuage these fears and insure that we will retain access to our entire pharmacopoeia, we must demonstrate to authorities that we can be trusted as guardians of this modality. So far, we have our safety record, but that will not be enough. If we are ever to be recognized as physicians nationwide, we must have the authority of modern science behind us as much as we have the authority of 2000 years of TCM. It is not one or the other. It must be both. We can be the leaders in the global renaissance of phytotherapy if we seize this opportunity.

There are a number of critical issues in herbology that can only be addressed by the scientific method and a knowledge of phytochemistry. These include research, standardized dosage, comparison of forms of delivery, herb purity and potency. I do not propose that the scientific method be used as the sole or even the main criteria in the application of Chinese herbs. The TCM method is well established by historical precedence and appears to be safe in numerous scientific Chinese studies. Many studies suggest the TCM method of pattern differentiation yields better results than treatment based upon disease diagnosis alone. I propose here only that the scientific method be used to demonstrate the safety and efficacy of the medicinal products used in our profession. This will eventually be demanded by regulators and insurers, when the latter decide to cover herbal supplements. It is best to set our own guidelines before they are imposed by outside forces. In order to have the authority to set our own saf ety guidelines it is vital that we are trained appropriately. We can't expect to decide our own fate if we don't even know the terms of the debate. And for better or for worse, the terms of the current debate are determined by the mainstream scientific community.

Many of the key issues for the acceptance of Chinese herbal remedies center around safety and reliability. Three independent organizations are now certifying herbal supplements sold through health food stores. Companies that submit to this process get a seal guaranteeing that the product has in it what it says on the label. If the consumer supplement industry is willing to meet this challenge, we would be well advised to do the same before someone else's standards are imposed upon us. In ancient times, the herbalist probably handled the herbs and was able to make judgments based on organoleptic qualities, such as taste and smell. Today, when using finishing products, it is not possible to evaluate the quality of the raw ingredients by organoleptic methods, since the prescriber never gets to see the raw materials in most cases. Thus, we must depend on an objective method of demonstrate that herbs of consistent quality are used in the manufacturing process. Many researchers, practitioners and consume rs also went to know the level of active constituents in any given product. All these parties should be able to compare the dosage of different forms of product using internationally accepted standards. This is so accurate comparisons can be made when doing research as well as for those who feel more comfortable with some objective guarantee of quality for their dispensed products (including insurers). Who should set these standards? Hopefully a committee that includes fully trained doctors well versed in both classical and modern TCM, but also modern phytochemistry.

The doctoral degree will be what is called the terminal degree in our field. It will denote the highest level of education for clinicians practicing TCM. If we are to be solidly positioned in the 21st century healthcare system, then those achieving the bestowal of this highest title should be thoroughly prepared. There is no doubt that only by having enough scholars and clinicians who read Chinese and do translation can we sufficiently deepen our understanding of the roots and context of TCM. Thus, the study of medical Chinese, basic translation and selected classical texts is essential at the doctoral level so that we may cultivate these scholars. At the very least, all who reach this pinnacle should be given the tools to access the entire body of Chinese medical literature, including cutting edge work in phytochemistry that is only available in Chinese. But as with medical Chinese, it is equally true that we need to give all our doctoral candidates the tools necessary to do research and evaluate biomedical information, including phytochemistry, if we are to take this great body of wisdom into the future. Some may even use their DAOM degree as a foundation to pursue research or phytochemistry as a career option. For instance, in the field of product development, advancements in the most convenient and effective way to deliver Chinese medicinals will require those who have knowledge of both TCM and phytochemistry.

WE don't expect everyone to become fluent in medical Chinese, nor do we expect everyone to become fluent in pharmacology and phytochemistry. But whatever we end up doing, we are all practitioners of phytotherapy. And there are worldwide standards evolving regarding safety and reliability of herbal medicines. We can help bring the United States in line with other developed countries on this matter, while at the same time protecting our patients and our pharmacopoeia. Accredited TCM colleges at the Master's level are already required to include in their curriculum training drug-herb interactions, toxicology, and the principles of phytochemistry/pharmacognosy. Thus, the foundation for deepening one's knowledge in this area will already be laid prior to entering the doctoral program. This foundation can be reinforced in both classes and clinic throughout the doctoral program. It is not necessary to have a separate program or course in phytochemistry at this level, but rather to incorporate this informa tion in academic presentations and clinical discussions. The best doctoral programs will fully embrace this integrative model and create the leaders necessary to implement these diverse goals.