Pharmacists working with Holistic Medical Providers Kerry Niebrzydowski

Pharmacists working with Holistic Medical Providers Kerry Niebrzydowski ND MSOM LAc.

Overview Professional Background – Naturopathic Doctor, Masters of Oriental Medicine, Licensed Acupuncturist Lay practitioners vs. Licensed credentialed practitioners Philosophical differences between Holism and the Conventional Medical Paradigm Strengths and Pitfalls of the current medical literature How to best serve our patients by working collaboratively

Holistic Medical Philosophy “Bohm (a quantum physicist, University of California Berkeley) says that everything in the universe is a part of a continuum. Despite the apparent separateness of things at the explicate level, everything is a seamless extension of everything else, and ultimately even the implicate and explicate orders blend into each other. Take a moment to consider this. Look at your hand. Now look at the light streaming from the lamp beside you. And at the dog resting at your feet. You are not merely made of the same things. You are the same thing. One thing. Unbroken. One enormous something that has extended its uncountable arms and appendages into all the apparent objects, atoms, restless oceans, and twinkling stars in the cosmos ” – The Holographic Universe, Michael Talbot 1

Holistic Medical Philosophy We are more than the sum of our parts, we are a whole system of interacting parts. When 1 part of us gets sick it effects the whole, when 1 part of us gets well, the whole system benefits. “To see a world in a Grain of Sand And a Heaven in a Wild Flower, Hold Infinity in the palm of your hand And Eternity in an hour. ” – William Blake Every part of us is connected. Nothing is separate. When we give medicine it effects the whole. Not just one isolated part. All of us need individualized care

Holistic Medical Philosophy In Holistic medical systems like Ayurveda (traditional medicine in India), Chinese Medicine and Naturopathy the philosophical precept of the macrocosm/ microcosm is utilized. Much like the golden spiral, the whole body is a homunculus. The health of one cell represents the health of the whole organism. Examples – the pre and post central gyrus, the ear has over 300 acupuncture points to treat the whole body, the Korean system of acupuncture utilizes the hand to treat the whole body. Definition of wellness - ". . . a state of complete physical, mental, and social well -being, and not merely the absence of disease or infirmity. " - The World Health Organization Some functional medicine providers incorporate holism, many practice green allopathy. Using herbs, nutrients to treat symptoms.

Holistic Medical Philosophy – Western Ideological Bias Modern Bias – Cartesian philosophy – The mind and body are separate has been the foundation of medical thought over the last several hundred years in the west. Yet, there is much evidence that speaks to the contrary. When we treat the body it affects the mind, when we treat the mind, it affects the body. Newtonian philosophy – Cause and effect relationships direct mechanisms of action – acupuncture and Holistic medical practices effects are more complex.

Holistic Medical Philosophy – Naturopathic Tenants Treat the whole person. Evaluate all systems together. This can get missed as patients go from specialist to specialist. Example – Case – 42 yo female with chronic R shoulder pain progressing to adhesive capsulitis. Pt had seen many providers, primary care, a pain management specialist, physical therapist, chiropractor and eventually acupuncture. The obstacle to cure was dietary. It was an autoimmune adhesive capsulitis that was triggered by improper diet. Evidence in medical literature for increased patient outcomes Complementary therapy in chronic wound management: a holistic caring case study and praxis model. 2

Holistic Medical Philosophy – Naturopathic Tenants Vis Medicatrix Naturae – The healing power of nature. All whole systems have self organizing and healing mechanisms. When people move toward greater wellness this inherent ability is engaged. Our bodies house extraordinary power to heal, holistic medicine embraces this power within. Do No Harm – Due to safety for patients and less side effects, Herbs and nutrients should be initiated before medications.

Holistic Medical Philosophy. Naturopathic Tenants Tolle Causum – Identify and treat the cause. Look to the root of imbalances versus treatments based on symptom resolution. Example – 55 yo female with fibromyalgia. Cymbalta and acupuncture help manage the pain but stress reduction and an anti-inflammatory diet are the cure. Prevention – Utilizing conventional standards of care guidelines as well as developing awareness around individual health risks and mindfulness about our own biochemistry. Using that information to engage in how to take care of ourselves and take responsibility for our health.

Holistic Medical Philosophy – The Perspective of a Chinese Medical doctor

Chinese Medical Philosophy Theory of yin/yang – sunny and shady side of the mountain. “Every phenomenon in the universe alternates through a cyclical movement of peaks and bases, and the alternation of Yin and Yang is the motive force of its change and development. Day changes into night, summer into winter, growth into decay and vice versa. ” 3 Yin and Yang are mutually dependent upon another. Chinese medicine embraces the reality of constant change within human beings. We are dynamics of yin and yang. Disease comes from imbalances in yang and yin. Too much yang, not enough yang, too much yin, not enough yin.

Chinese Medical Philosophy Too much fire or heat, not enough – example would be hyper or hypothyroidism. Too much water (example damp conditions like diarrhea), not enough water (example tight wiry tendons). Yin yang theory in western philosophy is very similar to the concept of homeostasis – Chinese medicine diagnoses then treats according to create more homeostatic balance via acupuncture, herbs and dietary counseling.

Chinese Medicine Diagnosis In Ancient times, how was imbalance diagnosed in the absence of imaging techniques and labs? We are trained to look at the person as a whole as well as listen to specifics about their symptoms. We observe a person’s demeanor and body movement, personality, body constitution, complexion. We observe closely the pulse and tongue. We also diagnosis by hearing and smelling. This allows our diagnosis to be individualized for each person we treat and each time we treat that person. Something can shift between treatments and require a different treatment. Conditions have a pattern differentiation determined by individualized symptom presentation, pulse and tongue.

Pattern Differentiation in Chinese Medicine Tinnitus – ringing in the ears. Liver qi stagnation – wiry pulse, thin white tongue coating , irritability, tense muscles, PMS. Liver Yang rising – Wiry, tight pulse. Thin white tongue – red or dusky sides of tongue. High blood pressure. Irritability that borders on rage. Red face. Roaring in ears. Kidney Qi deficiency – weak, deep pulse. Pale tongue, thin white coat. LBP, high pitched ringing. Fatigue.

Chinese Medicine Pattern Differentiation Insomnia – Spleen and Heart blood deficiency - dream disturbance, shallow sleep, palpitation, dizziness, blurred vision, poor energy, poor appetite, sallow complexion Tongue: pale with thin white coat Pulse: thin and weak Liver Qi stagnation with Liver blood deficiency - hard to fall asleep and stay asleep, or dream, disturbed sleep, fullness in the chest or intercostals region, irritability, sighing a lot, finger nails pale, Tongue: red tongue with white or yellow coat Pulse: wiry and rapid Disturbance of the heart by empty fire with Liver and Kidney Yin deficiency - insomnia, restlessness, palpitation, tinnitus, dizziness, poor memory, soreness of lower back, five center heat, dream disturbance (erotic), seminal emission, thirst, difficulty falling asleep and staying asleep, menopause, hot flushes. Tongue: red with little coat Pulse: thin, rapid

Pattern Differentiation in Chinese Medicine Insomnia – Weakness of heart and gallbladder - timid (weak GB, lack of courage), easily waken and difficult to go back to sleep again, nightmare, waken up frightened, panic, paranoid, sob, poor energy. Tongue: slight pale with thin white coat Pulse: thin and wiry phlegm heat in the stomach – insomnia from overeating, heavy sensation of head, foggy mind, profuse sputum, stifle sensation in chest, anorexia, burping, nausea, acid regurgitation, bitter taste in mouth, blurred vision Tongue: yellow and greasy coat Pulse: slippery and rapid

Acupuncture and the Concept of “Qi” The ancient Chinese physicians discovered an organized system of energy or vitality in the body – it is known as the “Qi” or “Chi”. This is organized along channels known as meridians. When there is dysfunction in the body, pain or any other symptom, it is represented in the flow of this Qi throughout the body. CT Scan Study – Xray phase-contrast CT imaging of the acupoints based on synchroton radiation. This study revealed clear distinctions between the non-acupuncture points and acupuncture point anatomical structures. Acupuncture points had a higher density of micro-vessels and involuted microvascular structures. 4

The Meridian System

Scientific Mystery Holistic Medicine, due to it’s individual assessment and diversity of treatments, Acupuncture and other holistic medical practices are difficult to assess scientifically. We are in the infancy stages in terms of evidence in the research literature. There are deep effects on the body, many of which are unknown. With Acupuncture - We have to take into account the thousands of years of empirical evidence.

Acupuncture in the Medical Literature – An Argument for Acupuncture The American Journal of Medicine. Acupuncture for Chronic Pain? Clinical Wisdom Undecided Despite Over 4000 Years of Practice Cory S. Harris, Ph. D, Michael Lifshitz, MSc, Amir Raz, Ph. DPublished Online: November 22, 20144

Why Physicians Should at Least Consider Acupuncture “Approximately one-third of Americans suffer from chronic pain, debilitated affected individuals and families and costing the US economy more than half a trillion dollars annually. 8 Million fail to find adequate relief through commonly prescribed medical interventions. Many of these treatment options, moreover, carry considerable financial costs or risk of side effects. Patients seeking relief through less expensive, less toxic, and more holistic approaches may turn to various forms of complementary and alternative medicine. And yet, such alternative interventions generally lack robust clinical evidence to support their efficacy and often extend beyond the purview of mainstream medicine. ”

Considerations for Acupuncture Consequently, many doctors hesitate to recommend such treatments, leaving patients to find care on their own. Unlike most complementary and alternative medicine options, acupuncture has been clinically ascertained as safe and effective in the relief of chronic pain as a standalone or adjunct therapy…. the Joint Clinical Practice Guideline of the American College of Physicians and the American Pain Society recognizes acupuncture as a viable treatment for several forms of chronic pain; the Canadian and European guidelines echo the same sentiment. ” 5

Acupuncture Scientific Literature – Not just chronic pain. Military Medicine. 2015 May; 180(5): 582 -90. doi: 10. 7205/MILMED-D-1400451. Auricular acupuncture for sleep disturbance in veterans with post-traumatic stress disorder: a feasibility study King HC 1, Spence DL 1, Hickey AH 2, Sargent P 1, Elesh R 1, Connelly CD 3.

Acupuncture Scientific Literature – Not just chronic pain. PTSD, Insomnia - Abstract The purpose of this study was to examine the feasibility and acceptability of an auricular acupuncture (AA) insomnia regimen among Operation Iraqi Freedom and Operation Enduring Freedom veterans with post-traumatic stress disorder and sleep disturbance. Secondarily, this study examined the effect of an AA insomnia regimen on objective sleep times by wrist actigraphy, subjective sleep times by sleep diary, and sleep quality ratings utilizing the Pittsburg Sleep Quality Index. Veterans (n = 30) were randomized to receive a 3 -week AA insomnia regimen.

PTSD, Insomnia Veterans receiving the AA insomnia regimen reported it as a more acceptable treatment for sleep disturbance than subjects in the control group (AA group median = 5 vs. control group median = 3, p = 0. 004). Significant differences between groups were found on the sleep quality and daytime dysfunction components of the Pittsburgh Sleep Quality Index (p = 0. 003, p = 0. 004). No other significant differences between groups were found for objective and subjective sleep measures. These results suggest that an AA insomnia regimen may improve sleep quality and daytime dysfunction among veterans with posttraumatic stress disorder. Future, large-scale, prospective clinical trials are needed to examine AA effects on sleep. 6

Relaxation of Acupuncture Zhongguo Zhen Jiu. 2015 Jan; 35(1): 101 -4. Mechanism on atrial natriuretic peptide receptor in anti -anxiety with acupuncture based on its tranquilizing effect. [Article in Chinese] He W, Zhou Q, Yu S, Cai D, Wang Q, Zhang X, Huang WQ.

Acupuncture for Anxiety Abstract - Anxiety disorder is one of the most common mental disorders and seriously impairs the physical and mental health of patients. Due to the efficacy of acupuncture for tranquilization, acupuncture displays its unique advantage on the treatment of anxiety disorder, but the relevant biological mechanism has not been elaborated. The modern medicine study has proved that the heart and brain have their own independent natriuretic peptide (NP) system. The dysfunction of ANP and its receptor are closely related to the occurrence of anxiety disorder. The ANP acts on antianxiety.

Acupuncture for Anxiety Hence, focusing on the three aspects, named the anti-anxiety effect of acupuncture based on its tranquilizing effect, the anti -anxiety effect of ANP and the positive regulation of acupuncture on NP, the mechanism on ANP and its receptor was explored in anti-anxiety with acupuncture based on tranquilizing effect, and the idea was put forward on that the anti-anxiety effect of acupuncture was possibly based on its action of tranquilization through regulating the ANP and its receptor. As a result, it is expected to provide theoretic support for the mechanism study on anti-anxiety with acupuncture based on its tranquilizing effect. 7

Chinese medicine for Asthma Medicine (Baltimore). 2017 Dec; 96(51): e 9291. Published online 2017 Dec 22. Traditional Chinese medicine as an adjunctive therapy to oral montelukast for treating patients with chronic asthma. Xuehui Wang, MD, Ph. D, a, ∗ Ziting Tian, BM, b Fengli Gao, MD, Ph. D, a Xia Zhang, BM, b Jianqiu Liu, MM, a, ∗ and Zhuying Li, MD, Ph. Da, ∗

Chinese Medicine for Asthma Background: This study aimed to explore the efficacy and safety of Ping Chuan Ke Li (PCKL) as an adjunctive therapy to oral montelukast compared with placebo plus montelukast for treating patients with chronic asthma (CAS). Methods: This randomized controlled trial involved 72 patients with CAS. They were randomly allocated to an intervention group or a control group, 36 subjects per group. Participants in the intervention group received PCKL and oral montelukast, while those in the control group received placebo and oral montelukast. The primary outcome was lung function, measured by forced expiratory volume in 1 second (FEV 1). The secondary outcomes included quality of life, measured by St. George's Respiratory Questionnaire (SGRQ), and adverse events (AEs).

Chinese Medicine for Asthma Results: Compared to placebo plus montelukast, PCKL and montelukast revealed greater efficacy in lung function, measured by FEV 1 (P <. 05), and quality of life, measured by the SGRQ scale (P <. 05). Additionally, no significant differences were found in AEs between the 2 groups. Conclusion: Traditional Chinese medicine PCKL as an adjunctive therapy to oral montelukast alleviated the symptoms of CAS. Future studies with larger sample sizes are still needed to verify the efficacy and safety of PCKL plus montelukast in patients with CAS. 8

Pharmacists Working with Holistic Providers Pharmacists have the opportunity to adopt a holistic approach when advising patients. Pharmacists are providers that can check in with patients readily and can inspire patients to engage in their wellness and health Pharmacists can advise patients about life style factors and behavioral modifications that may help with patients maladies as well as advising about how to utilize their medications.

Pharmacists Working with Holistic Providers Difficulties with communication – the patients often have difficulty explaining why we gave the herbs/nutrients other than if they work or not. Also, often they are not labeled with full ingredients from the offices of holistic medical providers. Often conventional providers and pharmacists due to lack of familiarity with natural medicines will advise patients to discontinue use. It is difficult to determine if a patient is taking a supplement based on true therapeutic benefit or the victim of faulty advertising.

Pharmacists Working with Holistic Providers Clinical Pharmacists should consider giving nutrients or herbs before pharmaceuticals because they generally have less adverse events. Why not try a gentler, less invasive approach first? Lifestyle modifications with diet and exercise before medication.

Pharmacists working with Holistic medical providers – Pitfalls in Research Utilize databases like Natural Medicine Database to determine interactions. These databases are often over cautious. Herbs and nutrients are generally not as strong as pharmaceuticals and can be used in combination with medications safely. Patients are often misreporting to doctors and pharmacists about natural medicines because of fear of bias. This is dangerous because there could be true interaction.

Pitfalls in Research – Difficulties with herb and drug interaction Example – Berberine - bitter-tasting, yellow-colored, alkaloid that is found in the roots, rhizomes, and stem bark of various plants, including goldenseal, goldthread, Oregon grape, European barberry, phellodendron, and tree turmeric Very effective for lowering blood sugar in diabetics 9, blood sugar dysregulation and obesity in PCOS 10, hyperlipidemia 11, H. Pylori as an herbal antibiotic 12, Clinically I have seen it helpful in SIBO and recurrent diverticulitis.

Pitfalls in Research – Difficulties with herb and drug interaction ANTIDIABETES DRUGS Interaction Rating = Major Do not take this combination. Severity = High • Occurrence = Probable • Level of Evidence = A Clinical research suggests that berberine can lower blood glucose levels (20579, 34247, 34265, 34282). Theoretically, berberine might have additive effects when used with antidiabetes drugs and increase the risk of hypoglycemia. Some antidiabetes drugs include glimepiride (Amaryl), glyburide (Diabeta, Glynase Pres. Tab, Micronase), insulin, pioglitazone (Actos), rosiglitazone (Avandia), and others.

Pitfalls in Research – Difficulties with herb and drug interaction Contradiction - Taking berberine in combination with oral hypoglycemic drugs appears to lower FPG (fasting plasma glucose) by 0. 67 mmol/L, PPG (postprandial plasma glucose) by 0. 98 mmol/L, and Hb. A 1 c by 0. 58% compared to treatment with hypoglycemic drugs alone. 13 Safe? I have given berberine with metformin and have had multiple patients have more effectively managed blood sugars. Many drug – herb, herb- herb interactions are not reported. Clinically, I have seen unreported interactions.

In Conclusion May we work collaboratively for the better health and wellness of all human beings. Including ourselves. Research is a guideline for clinical effectiveness but must be tempered by individual assessment. Pharmacists can be included in a holistic medical approach to patient management.

The Invitation by Oriah Mountain Dreamer It doesn’t interest me what you do for a living. I want to know what you ache for, and if you dare to dream of meeting your heart’s longing. It doesn’t interest me how old you are. I want to know if you will risk looking like a fool for love, for your dream, for the adventure of being alive. It doesn’t interest me what planets are squaring your moon. I want to know if you have touched the center of your own sorrow, if you have been opened by life’s betrayal or have become shriveled and closed from fear of further pain. I wat to know if you can sit with pain, mine or your own, without moving to hide it or fade it or fix it. I want to know if you can be with joy, mine or your own, if you can dance with wildness and let the ecstasy fill you to the tips of your fingers and toes without cautioning us to be careful, to be realistic, to remember the limitations of being human.

It doesn’t interest me if the story you are telling me is true. I want to know if you can disappoint another to be true to yourself; if you can bear the accusation of betrayal and not betray your own soul; if you can be faithless and therefore trustworthy. I want to know if you can see beauty, even when it’s not pretty, every day, and if you can source your own life for its presence. I want to know if you can live with failure, yours and mine, and still stand on the edge of the lake and shout to the silver of the full moon, “Yes!” I doesn’t interest me to know where you live or how much money you have. I want to know if you can get up, after the night of grief and despair, weary and bruised to the bone, and do what needs to be done to feed the children. I doesn’t interest me who you know or how you came to be here. I wat to know if you will stand in the center of the fire with me and not shrink back. It doesn’t interest me where or what or with whom you have studied. I want to know what sustains you, from the inside when all else falls away. I want to know if you can be alone with yourself and if you truly like the company you keep in the empty moments.

References 1. Talbot, M (1992). The Holographic Universe. New York, NY: Harper Perennial. 2. Popoola MM. Complementary therapy in chronic wound management: a holistic caring case study and praxis model. Holistic Nurs Pract. 2003 May-Jun; 17(3): 152 -8 3. Maciocia, G(1989). The Foundations of Chinese Medicine. New York, NY: Churchill Livingsone. 4. Chenglin, Liu, Weang Xiaohu, Xu Hua, Liu Fang, Dang Ruishan, Zhang Dongming, Zhang Xinyi, Xie Honglan, and Xiao Tiqiao. Xray phase-contrast CT imaging of the acupoints based on synchroton radiation. Journal of Electron Spectroscopy and Related Phenomena (2013) 5. Cory S. Harris, Ph. D, Michael Lifshitz, MSc, Amir Raz. Acupuncture for Chronic Pain? Clinical Wisdom Undecided Despite Over 4000 Years of Practice The American Journal of Medicine. Ph. DPublished Online: November 22, 2014 6. King HC 1, Spence DL 1, Hickey AH 2, Sargent P 1, Elesh P 1, Connelly CD 3. Auricular acupuncture for sleep disturbance in veterans with post-traumatic stress disorder: a feasibility study. Military Medicine. 2015 May; 180(5): 582 -90. doi: 10. 7205/MILMED-D-1400451.

References 7. Zhou Q. Yu S, Cai D, Wang Q, Zhang X, Huang WQ. Mechanism on atrial natriuretic peptide receptor in anti-anxiety with acupuncture based on its tranquilizing effect. [Article in Chinese] Zhongguo Zhen Jiu. 2015 Jan; 35(1): 101 -4. 8. Xuehui Wang, MD, Phd, Ziting Tian, BM, Fengli Gao, MD Phd, Xia Zhang, BM, Jianqiu Liu, MM, and Zhuying Li MD Ph. D. Medicine (Baltimore). Traditional Chinese medicine as an adjunctive therapy to oral montelukast for treating patients with chronic asthma. 2017 Dec; 96(51): e 9291. Published online 2017 Dec 22. 9. Zhang Y, Li X, Zou D, et al. Treatment of type 2 diabetes and dyslipidemia with the natural plant alkaloid berberine. J Clin Endocrinol Metab 2008; 93: 2559 -65. 10. Wei, W. , Zhao, H. , Wang, A. , Sui, M. , Liang, K. , Deng, H. , Ma, Y. , Zhang, H. , and Guan, Y. A clinical study on the short-term effect of berberine in comparison to metformin on the metabolic characteristics of women with polycystic ovary syndrome. Eur J Endocrinol. 2012; 166(1): 99 -105.

References 11. Kong, W. , Wei, J. , Abidi, P. , Lin, M. , Inaba, S. , Li, C. , Wang, Y. , Wang, Z. , Si, S. , Pan, H. , Wang, S. , Wu, J. , Wang, Y. , Li, Z. , Liu, J. , and Jiang, J. D. Berberine is a novel cholesterol-lowering drug working through a unique mechanism distinct from statins. Nat Med 2004; 10(12): 1344 -1351 12. Hu, F. L. [Comparison of acid and Helicobacter pylori in ulcerogenesis of duodenal ulcer disease]. Zhonghua Yi. Xue. Za Zhi. 1993; 73(4): 217 -9, 253 13. Jun. Yin, Huili. Xing, Jianping Ye. Efficacy of berberine in patients with type 2 diabetes mellitus. Metabolism. Volume 57, Issue 5, May 2008, Pages 712 -717