德国也能看中医?医保能不能报销?在德国药房建立中药部是一种什么体验?都在这篇别错过~

书友讲坛(总第133期)

时间:2020年11月15日

形式:ZOOM 在线讲座

参与人数:大约27人左右

主题: 中医药在德国

主讲嘉宾

主讲嘉宾:孙雨田先生

中国执业药剂师,1987年毕业于上海医科大学药学专业,1990年来德国从事中医药行业,在Hirsch apotheke等药房建立中药部。2002 年成立Sinoherb GmbH, 从事中药进出口。与Angela Körfers 编写德语书籍《Traditionelle Chinesische Medizin》,2009年由德国药剂师出版社出版。

随着时代发展,中药制作也和传统有了很大区别。中药如何保证质量?德国的中药认可程度以及中医药发展现状如何?参与讲座的书友们来自各行各业,都对中医药很感兴趣。

有人喜欢学习健康养生,修心养性的知识,有人喜欢听黄帝内经的有声书,有人曾用中医药调理身体,甚至有人来自中医世家,也有人认为中医药是宝贵的财富,想写文章向外发扬,给德国人介绍中医药。一起来听听孙雨田老师给大家带来的讲座吧。

中药如何保证质量

(以当归为例)

我出国前在上海医药保健品公司做过进出口的工作,从事中药的采购和外销员工作,在德国由于在不同的中药房建立中药部门,也在杜塞尔多夫有实际接触病人,开方抓药,从这段经历,我发现中药的质量对于疗效有直接的影响,还有剂量和毒副作用等等。

今天来分享中药的制成方式与质量鉴定,有三个方面,

1. 传统的经验鉴定(外观,颜色,质地,香味,还有某些特定的结构特征来判断质量)需要数十年的经验积累才能做到。

2. 化学分析的检验报告,德国的药房特别注重这个部分,但是这个检验报告的标准也有一些问题。稍后会做具体分析。

3. 药经过疗效评估,这个也是比较有争议的,最好要有一个大数据来看。

以岷当归传统采收的过程来举例,当归采出,捋条,初步晾晒3-4天后堆塔风干(2-3月),然后手工去沙,剪到15厘米左右。当归部位划分是当归头,当归身,和当归尾。头和身是质量最好的。当地农民其实不太愿意剪裁当归的细根(去掉50%左右),觉得很可惜。买到药房之后,要进行切片。

当归最好的部分就是当归中的油性挥发物质,好的当归摸起来是非常好的,香味好,留香时间也很长,煎煮的时候满室飘香,这就是挥发油含量高的表现。

中国的当归现在质量有些问题,因为我们买当归是买原型的当归,收藏时候既要考虑要通风,又要养护,这样的要求是有点矛盾的,所以用硫熏来避免虫蛀。而发生过部分农民不合规矩的晒,就放在地上随便晒,(导致当归身体干了,但是当归的头还没有干燥),甚至有的农民出采后直接用机器把整个当归压扁(压片当归),连当归须也没有去掉,但是用机器压会破坏了当归植物保存油分的植物细胞构造,导致保存不住原有的挥发油,如果是保存的好的当归,香味保存5-6年是基本的,保存良好的当归20年后拿出来都可以比刚刚粗制滥造的压片当归还要香。压片当归用硫熏,质地也变了,发亮发红,虫不吃也不会发霉,但是虫不吃的劝人也别吃比较好。

成本上也考量,有检验报告的当归会贵很多(贵2-3倍),但是没有检验报告又怕有问题。就像挥发油有是有标准的,有些欧洲的当归硫熏很严重了。当归如果从种植,采收到加工就会出现很多问题,需要依靠检验报告来筛选。(检验报告项目:品种鉴定,农残,重金属,微生物,黄曲霉素,水分,灰分,摄取物,成分,挥发油,硫熏-目前绝大多数没有检测)

中国药典要求:当归挥发油(ätherische Öl )含量不得少于0.4 % (ml/g),阿魏酸(trans-ferulic acid)不得少于 0.05% (ml/g), 这是两个关键问题。压片当归其实是符合药典要求,但是不符合中药的制药要求。

当归是血药之圣,医谚云“血药不容舍当归“,当归具有补血,活血,调经止痛,润肠通便的功能。(许多妇人都有补血方面的需求。)注意事项:剂量不要太高(6-12 g 即可),会造成出血过多,腹泻人禁用。

问答环节

中医在德国的接受程度究竟如何?德国似乎也有不少草药有利于治疗某些病症,这跟咱们的传统中医有何异同?

答:德国有1.5万个西医具有针灸A和B执照(能针灸和拔火罐),专门做中药的不足1000人,大概德国有100多家药房兼营中药。中医做得好的话,医生写信跟保险公司说中药可以治好这个病时,医保是可以报销的。

德国也是有民间草药但是用的是类似西医的消炎,止痛,利尿的标准,没有自己的理论体系,所以是不给报销的。用德国的药理来开药,其实不对,报告中讲单服当归会造成过敏。其实不是的,这其实是硫熏的副作用,而硫熏是为了方便保存。

我们药房一般会做成传统的丸散膏丹,从德国买到的药材来开始处理,这样很大程度免去了患者自行煎药的麻烦,也让口感更好,便于服用,携带,和保存,所以接受度更好。现代中成药在德国是灰色地带。德国药房是不喜欢用的动物类的药和濒危植物的药,动物药像蝎子,蜈蚣(虫子看到就怕),蝉蜕(包在药包里像虫子的腿),鹿茸(血淋淋锯下来,残忍)是接受度比较低的。

环境的破坏,导致种植中药药材中的疗效减弱?这对现代中医医师有什么挑战?是否中成药也会受到影响?

答:不合乎种植规范的中药,用过量农药(农残超标),化肥,或种植年限不够,都大大降低了中药的疗效,很多公司用硫熏中药材,不仅破坏了中药原有的芳香,还造成患者肝肾损害和腹泻。很多中医师都因为药材质量差而使得药效打折扣。硫熏的问题许多药商都打马虎眼,但是不硫熏又很难保存,微生物和虫会来吃。

据说古代一个优秀的中医医师其实也是一个优秀的中药药剂师?这样说是正确的吗?

答:是的,优秀的中医也是优秀的中药药剂师,都会经过品尝,采挖,加工的训练,懂得药物品质,才会根据药物质量和病人的病情来开方,如果一个药房的药师没有好的中医的理论训练,而按照西医的药理研究,那会毁了中医的。

单味药,用当归来抗凝血,结果造成过敏,其实不是当归的问题,而是硫熏制程的问题,非常刺激消化道,肠胃道。

如何让我们的中医,中医药和国际慢慢接轨,让新一代的年轻人接受相关文化和科学的传承?

一步步来,由点到面推广。疗效是硬道理。就比如当归是补血活血,让脸色有灰黄的人到气色红润,例如给血虚的患者喝八珍汤。月经等太久才来,就用温经汤慢慢调。

想问下欧洲的Chiropractor(脊椎按摩师)和中医药有什么联系吗?

中医的正骨按摩,是有自己的一套的理论,非常好的,像椎间盘突出用手法就可以治疗好,佝偻病(驼背),这些中医都有手法可以来帮忙的,可惜很多东西都失传了,传统中医的很多技术都失传了。

中医药在德国遇到的问题?

药材不纯,例如北柴胡,95%都不正宗了(正宗的做法耗时太久)。从药材开始,例如压片当归是赚钱的(三天就能弄好),正规处理的药材是不赚钱的。

德国每年都有中医大会。

德国自然医疗师(Heilpraktiker)要求的德语门槛是很高的,可以针灸开药,但是公保一般是不报销的,除非你要求私人保险增加Heilpraktiker的治疗额度,或者如果有医生专门说要中药来辅助,那公保就给报销。

另类疗法是很多的,例如印度的阿育吠陀疗法,顺势疗法,德国的香精疗法,和草药天然疗法。

国内三证(医师证)德国不认可。理论上可以用药,但是不能卖药的。所以有些医生会把药费放在治疗费里面。

德国西医的医生,可以自己做针灸,只要参加时长750小时的培训,这样的有问题的训练,其实对中医药也是一种伤害,有问题的药,用西药典开的药,其实都不是很合适。

市面上许多质量不合格的草药,结果让本来对中药很有兴趣的德国人对中药的研究偏向了分析中草药的副作用的报告了。

在德国可以买到免煎颗粒吗?

2000 年开始有,大规模进入德国, 后来在2017年被禁止了,因为原料查不到草药的成分,只能检测到淀粉和糊精。免煎颗粒如果还是从源头质量不合格的草药开始做,那做出来的颗粒会有很大的问题。

在德国买中药贵不贵啊?

买有检验的当然比较贵,但是买没有检验的便宜的药吃了不放心,疗效也不好。用量也不好拿捏,好的黄芪,当归,柴胡,用量3-4 g就够了。汤药3-4天就能见到效果,德国人来看中医的,有一部分是西医宣布的不治之症,如果患者能看到效果,就不会觉得中药贵(平均一天10欧的药费,最重症的病人/晚期患者也就一天30欧左右的药费,只要有疗效,患者都是很感谢中药的。)

在网上哪里能买好的当归,如何挑选?

Amazon 就可以,国内京东也可以。

(孙雨田先生配合书友及时搜寻网上购物平台上的当归,对比哪些是有熏硫,哪些则没有,原则上找土黄色的是没有硫熏的,有点半透明的就可能是硫熏过的,闻起来有刺激性气味,质地也比较硬。)好的当归切开不是中空的,握起来是质地柔软的。敲在桌上是不会有响声的。

(没有硫)

(有硫过)

   太黄的当归是熏过的,跟原色来对比颜色太鲜艳漂亮,没有熏过的是有点土色,舌尖点一下是酸的,好的当归挥发油要达到1% (ml/g)以上。

亚超买的当归,作为平时食补,如何自己处理掉硫磺的问题?

这个没有办法自己去除,作为消费者,农药,和硫熏的问题我们可以解决的方法是不去买硫熏的产品,我们要去要求厂商改,大家都要求,厂商就得改。厂商之所以卖硫熏的当归,是因为如果不硫熏处理,厂商的耗损率太大,会发霉和虫蛀。

女性平时当归搭配的食谱?

非常多的搭配,四物汤,八珍汤,温经汤。平时单用的话,10g“当归加葱”一起煎一下,加点水煮开,加一勺白酒,即可服用。也可以“当归炖羊肉”,30-40 g当归加半斤羊肉,葱姜炖煮。对于补血,女性怕冷脸色苍白,用这个养血补阳气很好。

国际的中医药概况 

在新加坡开药之后,打成粉给患者回家冲服服用,这种方法不太好(只剩30-40%),传统煎药法较好(80%),但是还是比中成药好(10%)。

日本是非常推崇伤寒论的经方,在日本不需要通过药品的许可就可以使用了,只要你能保证药品的质量,(例如葛根汤,大青龙汤等等),日本的津村(Tsumura)是100多年的药厂,中药是做的非常精的,虽然药的含量不高, 但是它的药品拿出来基本算是艺术品。

病人煎药的时候,其实有40%-50%的成分是没有煎出来的,所以我们做成散剂,病人回家用水冲一下就可以了。

我的药材是日本加工再卖给我的,我们行业都知道,能给日本津村公司供药的公司是非常牛的。

患者就诊的流程?

医生或是自然疗法医师开的药方拿到,可以去任何一个药房买的。药方是中文的也是可以的。

是否是私保才给报销,公保不给报销呢?

私保可以,或者如果有医生说专门说要中药来辅助则公保也可以。

德国的中医药的未来

中医和中药应该有立法,有自己的资格考试,而不是去考Heilpraktiker。

不应该让西医来参加培训班就可以做针灸。

不应该让德国人让硫熏过的当归拿来用,药效不好,会打坏中医药的市场。

药的质量也是会影响疗效的,医生如果不了解采购来的药的质量,那患者怎么把控呢?是该听医生还是药房的?

这是一个很困难的问题,也是很混乱的。

野生黄芪6-9克其实也就够了,当归,羌胡,茯苓,都是很珍贵的,好的质量是很重要的。但是费用也会比较高。另外,炮制的方法和存放的方式,也会影响疗效和副作用,酸枣仁带皮的好保存,但是煎药的时候却要去皮,但是去皮了,皮开肉绽的酸枣仁保存不容易,也就比较没有效果了。


谢谢孙老师给大家带来中医药的宝贵知识,也谢谢大家对中医药感兴趣,我们一起支持中医药和关注中药的发展,一起监督质量,相信有一天一定能让中医药普遍进入德国的医院和诊所。孙老师补充:

https://www.tcm-apo.de

这个网址可以查到大部分做中药的药房。


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