Habituation & the Administration of Medicinals (Including Herbs !)
Posted in Bob Flaws’ Blog
by Bob Flaws
People who have heard me teach or who have read very much of what I have written know that I, like the Chinese themselves, refer to our medicinals as that – medicinals – not herbs. In the Chinese literature, the same word is used for Chinese and Western medicinals: yao ( 药 ). The only difference is that the word Chinese (zhong, 中 ) occurs before that word to denote Chinese medicinals (zhong yao, 中 药 ), while the word Western (xi, 西 ) is placed before that word to mean Western medicinals (xi yao, 西 药 ). In other words, the Chinese do not impose any metaphysical distinctions between Western drugs and Chinese medicinals in terms of the words they use to name these substances. Both are medicinals, with one not being somehow lesser than or inferior to the other. Here in the West, we tend to speak not about Chinese medicinals but about Chinese herbs, and it is my experience that, by using the word “herb,” we then do make certain metaphysical distinctions which are prejudicial to our concept of each. Some of these prejudices are that herbs are natural, safe, and better than Western medicinals (i.e., drugs), while Western drugs are unnatural, dangerous, and inherently bad.
Personally, I think such a simplistic dichotomy is naive at best and potentially dangerous at worst. In my experience, this dichotomy leads to all sorts of fuzzy thinking and romantic assumptions, some of which have definite negative clinical implications. For instance, many of us know that Western drugs often result in habituation. Habituation is the gradual adaptation to a stimulus or to the environment, with a decreasing response. It may also be described as the method by which the body reduces or inhibits responsiveness during repeated stimulation. Yet another description is that habituation is a decrease in the strength of a behavioral response that occurs when an initially novel eliciting stimulus is repeatedly presented.
In terms of the administration of medicine, habituation means that the effect of a drug taken over time in constant dosages decreases with time. This occurs for either of two possible reasons: A ) a counter-regulatory mechanism by the body is initiated which partially compensates the pharmacological action; or B ) damage to the organs involved in the effect is present, leading to decreased responsiveness. In terms of habituation to therapeutic substances, it is the first mechanism that is most commonly at work.
Therefore, when a person has to stay on a high blood pressure medication for years and years, typically the dose of that drug must be increased over time to maintain its intended hypotensive effect. However, according to Paracelsus’ law of drug reaction, eventually the dose will become high enough that the medicine causes adverse reactions, a.k.a. side effects. So there is a basic dilemma, either maintain the same dose without side effects and the blood pressure is not properly controlled or increase the dose in order to effectively control the blood pressure and risk the increasing chance that there will be unacceptable side effects. This is a dilemma routinely faced by Western physicians and their patients.
However, habituation also occurs in Chinese medicine regardless of whether we call our medicinals herbs. Therefore, I believe it is important for Western practitioners of Chinese medicine to also keep this phenomenon in mind. Although I have never heard or read any Chinese doctor in China discuss habituation to Chinese medicinals, this is a very real phenomenon which must be addressed in the treatment of all chronic conditions, and I believe Chinese doctors in China do take habituation into account when treating this kind of disease – either purposively or simply by the way they practice.
First of all, the standard of care (SOC) of professional Chinese medicine in China itself helps prevent this problem. This is because the SOC for the prescription of Chinese medicinals for remedial purposes is the individually written, bulk-dispensed, water-based decoction. In this case, the formula is typically adjusted somewhat every week or two. Because of the ever changing combination of medicinals and variation in the dosages of those medicinals, the patient does not get a chance to habituate to a single formula.
Secondly, when reading the contemporary Chinese medical literature, one commonly sees the description of administration to real patients (either in clinical trials or case histories as opposed to beginner’s textbooks) being couched in terms of courses of treatment. For instance, “The course of treatment was so-and-so many days, and two (or three, or four, etc.) successive courses were given.” In this case, typically, a rest period of several days to one week is given between each successive course or after so many courses. This rest period allows for desensitization and, therefore, freedom from habituation. As an example within my own specialty, Chinese medical gynecology, commonly the menstrual period is a de facto rest period from successive courses of medication.
Therefore, there are at least two ways that the practice of professional Chinese medicine in China prevents or mitigates the phenomenon of habituation. However, here in the West, we have a different (albeit accidental) SOC when it comes to the administration of Chinese medicinals. Based on my experience teaching all around North America, I would say that 90% of all the Chinese medicinals prescribed professionally by non-Asian practitioners is in the form of some sort of ready-made formula. That could be ready-made pills, capsules, or extract powders. Probably less than 10% of non-Asian practitioners own their own bulk medicinal dispensary and write their own individually tailored prescriptions which are then modified on a weekly basis as in China. This means that many American patients are taking the same Chinese medicinal formula day in and day out for months at a time. In fact, I have often heard from other practitioners that, after a patient has successfully taken a particular formula for some time, that formula has eventually become ineffective. While this might be because the medicinals have remedied their original pattern, I know for a fact as a clinical mentor that, in many cases, the pattern remains the same but the formula has simply ceased being effective. In such cases, this lack of effectiveness over time is due to habituation.
What this means in clinical practice is that, when prescribing a single ready-made medicine over a protracted period of time, as in rheumatoid arthritis, lupus erythmatosus, multiple sclerosis, etc., it is important to build in scheduled rest periods to allow the patient to dehabituate to the formula. Such rest periods can be as short as three days or as long as a week to 10 days. As mentioned above, because it is SOC to only treat gynecological problems at certain phases of the menstrual cycle, such rests from therapy are automatically built in. When it comes to non-gynecological conditions, rests can be given either once per month but should, in my experience, occur not less than once every three months.
So, in closing, please don’t think that because you are prescribing “herbs” you don’t need to take into account the phenomenon of habituation. Herbs or not, the human body habituates to everything. (Take the well-known phenomenon of habituating to snake venom for example.) Therefore, the wise doctor takes habituation into account when creating and administering treatment plans for chronic, enduring conditions.
1. If one wants to specifically say “herbal medicine,” then one says cao yao (草 药 ).
2. The Free Dictionary by Farflex, http://medical-dictionary.thefreedictionary.com/habituation
3. Senna and Habituation, http://content.karger.com/ProdukteDB/produkte.asp?Aktion=checkCard3&ArtikelNr=138951&Ausgabe=236506&ProduktNr=224274
4. For sure I have heard Chinese doctors in China talk about habituation and even addiction to acupuncture.