THE AVICENNA CENTRE: New Developments in the Practice and Dispensing of Chinese Medicine

This article first appeared in the November 2008 (Vol. 5) issue of the RCHM Journal (the journal of the Register of Chinese Herbal Medicine in the U.K.

THE AVICENNA CENTRE: NEW DEVELOPMENTS IN THE PRACTICE AND DISPENSING OF CHINESE MEDICINE

Interview with Mazin Al-Khafaji September 2008

Mazin Al-Khafaji is well known to RCHM readers as a gifted and innovative practitioner and author, and as a fervent advocate of raising the standards and reputation of Chinese medicine in the UK. In recent years he has carried through exciting changes in clinical organisation and dispensing practice at the Avicenna Centre for Chinese Medicine in Brighton and Hove.

Q. What does your clinic specialize in?
For many years I've held the dream of replicating what I have done in my own practice and extend it to other practitioners working at the clinic. I realized after completing my studies in China over 20 years ago that by focusing mainly on certain types of conditions (in my case particularly skin, allergic and autoimmune disease) I could develop a greater insight into treatment protocols and approaches, that would otherwise always remain elusive if I saw all-comers. I reasoned that if I could encourage others to do the same, then the standard of Chinese medicine would be raised, and we could as a group offer the very best chance of success to our patients for a whole range of conditions that I know Chinese medicine can be very effective for. So at the moment we also have practitioners who have specific experience in treating cancer and side effects of conventional cancer therapy, endometriosis, cardiac and respiratory disease as well as both male and female fertility.

We are in the process of creating our own research facility with access to our specialist library of Chinese books and medical articles. We hold regular discussion groups and have a system of mutual support amongst the practitioners who join our clinic.

We also collect clinical data (for example we have amassed a vast amount of data on liver function tests of patients undergoing treatment with Chinese herbs to assess safety) and have run simple pilot studies to attempt to ascertain the effectiveness of what we are doing.  Most recently Andrew Flower has completed the first clinical trial in the use of Chinese herbs, in which he not only explores the efficacy of Chinese herbs in the treatment of endometriosis, but is also developing protocols for researching the best approach to conducting trials without losing touch with Chinese medicine's unique approach to treatment. The plan and hope is that over the years we at Avicenna will follow this up with more research, exploring benefits of treatment for a variety of conditions.

Q. When did you start to run your own herbal dispensary?
A. I started with a small number of herbs to supply my own practice immediately after my return from China in 1987.  During my 4-year stay in China in the early eighties I visited many dispensaries and experienced at first hand how herbs were being used in hospitals and every day life. It became clear to me then that the quality and processing of the herbs are of crucial importance for running a successful practice. I wanted to make sure that my patients received the best available treatment and to optimize the chance of success - so I always aimed to source the highest quality stock available from different suppliers at the time.

Q. What is it like now?
A. As the quality of herbs and services supplied were always my highest priority I just kept on building up the dispensary to suit the development of my own practice.

Since I first started we have steadily expanded so that today we run an extensive herbal pharmacy offering additional services to cater for every aspect of our busy treatment centre.

We now almost exclusively import all our herbs directly from China and keep a permanent stock of over 450 carefully sourced and authenticated herbal ingredients. We also offer a number of specialist services geared towards enhancing clinical practice. We employ a fully qualified Chinese pharmacist who underwent specialist training for a full five years in China and amongst other things has particular expertise in pharmacognosy. We also have access to an extensive research library as well as solid links with colleagues and educational institutions in China. We are now also registered “RCHM Approved Suppliers” so that not only do we keep maintaining good working practice in our dispensary, storing the herbs correctly, monitoring temperature and humidity etc, but we can also control the quality of herbs used in the trials we plan to conduct at Avicenna in the future.

Q. Why is quality so important and how do you authenticate herbs?
A. As herbs are a natural product, there can be a vast variation in quality. For centuries the Chinese have graded medicinal ingredients to reflect this variation. Where and how an herb was originally grown, how it was harvested and processed so that it can be used medicinally is of crucial importance. In China there are five commonly marketed classes of quality for most herbs and the difference in price can be substantial, however this ultimately reflects the difference in an herb's efficacy and the results one can expect to achieve in clinical practice.

Authentication of herbs is clearly very important and not a simple matter. It takes a lot of practical experience and training to be able to authenticate herbs and differentiate superior quality, and it is for this reason that I went out of my way to find a fully trained pharmacist to be in charge of our dispensary.

Q. Do you only prescribe raw herbs?
A. Yes, I only use raw herbs. In my experience the results achieved by using raw herbs far surpass any other form of administration such as powders, granules or pills in ready-made formulae.

The main advantage to patent remedies is that of course you retain the supremely important ability to alter a classical formula by adding or removing ingredients to better suit the exact pattern manifesting in the patient being treated. Whilst the major advantage over granules and powders, is the extraction that occurs with the cooking process.

The heat applied acts as a catalyst that binds the various active ingredients together, thus forming a myriad of new substances that are literally more than the sum of the original parts. In essence a chemical reaction takes place when the herbs are cooked, and new synergistic actions between the ingredients are then produced, which is where the true magic of herbal medicine comes into play.  

You can usefully draw a parallel with cooking of food.  Imagine the result of taking the desiccated ingredients of a recipe and simply adding water to rehydrate them. You certainly won't end up with the same flavors that you would do if you cooked the ingredients together from the beginning.

Q. How is your dispensary different to a commercial herb supplier?
A.  Our priorities are completely different; our first concern is not commercial interest, but the enhancement of the therapeutic. We combine ordinary dispensing of dry herbs with all sorts of specialist services that I have introduced over the years to benefit the daily clinical practice at Avicenna. We pursue the methods that we know from experience produce results.

This ranges from the frequent use of “pao zhi” to our modern decoction service to the daily manufacturing of bespoke herbal products for individual requirements.

It is of the utmost importance that we know what we prescribe and that what goes into our medicines is what we think it is, and of course that it is of the best available quality for the purpose.

For instance, as we import our own stock, we authenticate all herbs in China at the point of sale, then again as they come into this country, where we immediately reject inferior stock. Several of our herbs are stocked in varying processed forms depending on individual requirements — and we use a number of different preparation methods (“pao zhi”) to alter the main actions and properties of certain herbs thereby changing their function and indication.

Q. Tell us more about pao zhi
A. Even though pao zhi is a major element within TCM, unfortunately it seems to hardly feature in the practice of herbal medicine in the West. It is now a dying art and yet it is an integral part of traditional Chinese Medicine.

In essence pao zhi is used to alter or enhance the function of an ingredient by processing it before it is decocted. The methods used vary enormously and include baking, dry frying, frying in sand, frying in a variety of liquids with honey or wine, infusion in vinegar or alcohol, steaming, boiling or simmering with oil, calcining and many others.

These processes produce changes that are not just of marginal benefit, they really do represent a whole new level of sophistication to an already elaborate and intricate system of understanding of ingredients and how they interact with each other and the human body.

For example we all use Huang Bai (Cortex Phellodendri) to treat damp heat in the lower jiao as well as for clearing xu heat. Actually the former function is achieved by using the unprocessed Huang Bai (Sheng Huang Bai), whereas if we wished to clear xu heat, Chinese medicine teaches us that we should never use Sheng Huang Bai, because it's far too bitter and will in fact injure the fluids and in time desiccate the yin. To bring into play its function of controlling the ministerial fire and subduing xu heat, only salt fried Huang Bai (Yan Chao Huang Bai) should be used.

On a very real level you can experience this for yourself by tasting the two types of Huang Bai. The Sheng Huang Bai is very bitter and unpleasant when chewed, whereas the simple process of soaking the bark in salt water for a short while, before dry frying it, will alter the taste completely, so that there is almost no bitter flavor remaining.

As if that's not enough, countless generations of doctors have discovered that by soaking the self same bark in yellow alcohol before dry frying or baking, will alter Huang Bai's (now known as Jiu Chao Huang Bai) function so that it excels in entering the blood level and clearing damp heat from the upper Jiao, making it an extremely effective medicine for treating eczema of the face and ears.

By stocking dozens of pao zhi medicines, or performing this processing ourselves we have the flexibility to maximize the use of the ingredients we use, and further enhance the synergistic action of various herbs, exploiting the full range of their interactions for the benefit of our patients.

Q. Tell us more about the decoction service?
A. During one of my visits to China a few years ago, I became aware that this was now the preferred method of preparing herbs in Chinese hospitals and recognized immediately that this method would overcome many of the problems traditionally associated with patients having to prepare their own herbs as well as delivering outstanding and consistent treatment outcomes.

At Avicenna we have now successfully been offering this option to our patients since 2003 when we imported the machinery used to decoct and pack the herbs.

In essence the herbs prescribed (anything between 1 to 6 weeks worth) are thoroughly mixed, placed in a muslin bag and soaked for an hour in the pressurized chamber of the machine. The lid is secured and heat applied. Since the vessel is totally enclosed, the steam formed will build up the pressure so that the water will boil at around 125-130° C, rather than the normal 100° C. Once the cooking process is complete (usually 20 minutes), the pressurized liquid is sent to a second machine where it is immediately vacuum packed in sachets. Each sachet (ranging is size from 50 ml for babies and children, to 280 ml, and everything in-between) is then preserved for up to 2-3 month with no deterioration in its contents without the need for refrigeration.

Q. Where are the herbs decocted?
A.  In our on-site dispensary. We have our own processing facility where we prepare all our decoctions. Currently we have a dozen or so such machines. Individual decoctions are custom-made and dispensed in predetermined sized portions within a couple of hours from receipt of prescription. Decocted herbs can be collected by the patient or be sent out to them if they live further afield on the same day and delivered within 24 hours.

Q. What are the benefits of decocted herbs?  
A. There is considerable research and clinical data from trials in Chinese hospitals to endorse the benefits and superior results of decocted herbs under high pressure, as opposed to them being cooked on a stove at home. The high pressure and temperature controlled decoction method extracts significantly higher proportions (as high as 30-40%) of the active ingredients of the herbs thereby making the formula much more powerful and effective and enhancing the synergistic effect of the ingredients.

For example one study by Zhe Jiang Chinese Medicine Research Institute (repoted in Zhe Jiang Zhong Yi Za Zhi, Vol-9. 2005; Weiqing Liang, Junxian Zheng, Jinbao Pu, Kemin Wei) looked at a variety of components such as flavonoids, alkaloids, polysaccharides extracted in order to compare potency of the traditional method of decocting the herbs on a stove with the high pressure method when using the decoction machines. When they looked at flavonoids for example extraction rates in ingredients where flavonoids are considered an important component of the medicinal effect, they found the following:

	SHAN ZHA	MAI DONG	GAN CAO	CHEN PI	ZHI MU	HUANG QI
Extraction rate by machine	0.0765%	0.0651%	0.787%	3.22%	0.378%	0.365%
Extraction rate trad. method	0.0456%	0.0356%	0.563%	1.71%	0.221%	0.233

When alkaloids extraction rates where measured in ingredients where alkaloids are considered an important component of the medicinal effect, they found the following differences:

	CHUAN XIONG	GAN CAO	XU DUAN	MU XIANG
Extraction rate by machine	0.04%	0.28%	0.19%	0.094%
Extraction rate trad. method	0.025%	0.19%	0.091%	0.045

As we can see, even for ingredients with high volatile oil contents such as Mu Xiang (Aucklandiae Radix) this approach is able to maximize extraction, even though it was cooked together with the other ingredients for the full 20 minutes. Since the volatile oils cannot escape out of the pot, they are preserved. There are a few heat sensitive ingredients such as Gou Teng (Uncariae Ramulus cum Uncis) or Da Huang (Rhei Radix et Rhizoma) however that still have to be added once cooking is complete in order to retain their efficacy, but for the majority of ingredients that is not the case.

Q. Is patient compliance better?
A. Without doubt. The decocted liquid herbs actually seem more palatable, somehow smoother and therefore easier for patients to drink. And there are none of the problems traditionally associated with decocting such as the need to remember to soak and cook the herbs daily, adding ingredients at the end of cooking etc. One of the other big benefits I have heard reported by patients is the lack of smell associated with cooking the herbs at home. In my experience in the past, this could end up draining the last bit of resolve from patients who were able to cope with all the inconveniences, but finally unable to deal with the uproar from other family members because of the smell. The decocted herbs come in convenient sachets, which makes taking the herbs regularly much simpler. The sachets can easily be transported so that patients don't have to interrupt treatment when working, travelling or on holiday. Once prepared the decoction is stable and has a shelf life of up to 70 days. All this amounts to much better patient compliance and therefore better results.

Q. What are the bespoke products you mentioned earlier?
A. There are two main areas really. The first is the external application of medicine and the making of creams, ointments, gels, washes, vinegar soaks etc. The biggest aspect that I have worked on has been in developing creams for the skin. You see although TCM's traditional ointments can be very effective, being in essence medicated oils (oils that have had herbs gently cooked in them thus transferring the active principles from the plants into the oil) with very finely powdered herbs and bees wax added to make ointments, they tend to be very greasy and messy, and not at all user friendly.

Creams, which are in essence the combining of a water part with an oil part using emulsifiers to bind them together are much nicer for the patient to use, and have the added advantage of not only being able to combine both water and oil extracted herbs along with the raw powdered herb that we add, but also other wonderful ingredients for the skin, such as vitamin E, A, aloe vera as well as CO2 extracts of plants that can increase the ability of the cream to for example reduce inflammation, or aid in granulation and healing of the skin in a very substantial way.

The science of making creams was never developed in traditional Chinese medicine so I have experimented by drawing upon the best from traditional and modern methods in making a product that is both effective and easy to use.

The second area is the making of pills from individual prescriptions of raw herbs in cases where administering the herbs in decoction form might be difficult or inconvenient for some reason.

Making pills is a fairly elaborate process that involves processing the herbs in a specially designed Extraction machine, which first decocts the medicine, before evaporating off the liquid to end up with a high quality concentrate of the original formula. This first procedure is exactly the same as the one used for the decoction machines that I described earlier, (i.e. cooking the herbs under high pressure and therefore high temperature where maximum extraction is achieved).

Once the used herbs are removed, instead of packing the liquid medicine in sachets, it is evaporated off by between 96 -98% in order that we end up with a very concentrated extract of the decoction. If we just slowly boiled this liquid down at normal atmospheric pressure, which means at a 100° C, much of the efficacy would be lost because prolonged simmering (several hours would be needed) would be very destructive. So the Extraction machine uses an ingenious but simple way of evaporating off the water part without compromising the efficacy of the medicine. By applying a strong vacuum to the liquid, which takes advantage of the fact that low pressure means low boiling point, the decoction is then boiled off to remove water, but not by evaporation at 100° C, but rather by simmering at 30° C or less which preserves the active principles. Once most of the water has been removed, we end up with a paste that is then mixed with some malt, honey, or starch to get the right consistency, before being put through yet another machine (very similar to a pasta making machine) which cuts and rolls the paste into small pills.

Making the pill ourselves means we don't lose the advantage of using an individual prescription tailored exactly to the patient's needs at the time of consultation.  Pills in particular can be useful where a patient has difficulty drinking the medicine or where they have a chronic condition that may require months of treatment.

Q. Is it possible for outside practitioners to use your dispensing service?
Yes, in fact we have been supplying outside practitioners for several years now. In order to be eligible, it would be necessary to register as an associated practitioner first. To sign up for this, please contact us by writing to dispensary@avicenna.co.uk or phone the clinic on 01273 776499.  

Once registration is complete, prescriptions can be faxed or emailed to us, and are processed and dispatched on the same day if received before midday.

Q. How can other practitioners learn more about your way of practicing Chinese Medicine?
We regularly organise lectures, postgraduate classes and of course the Dermatology Diploma Course through Avicenna Seminars. They are highly practice-oriented and geared towards solving real problems encountered in every day clinical environments.

The next Diploma Course is due to start again in February 2009, and later in spring we will be holding another Dispensary Day where our pharmacists will spend a day describing many aspects of pharmacy work such pao zhi, authentication, looking at the differences between good and poor quality herbs etc. You'll find details of this and other forthcoming lectures and events on our website at www.avicenna.co.uk.

We also have a forum on our website that has just opened where registered practitioners and colleagues are invited to contribute to topical discussions on Chinese Medicine.