Whole Health

Abdelfatah MM, Beacham MC, Freedman M, Tillmann HL. Can Battlefield Acupuncture Improve Colonoscopy Experience? Med Acupunct. 2018 Oct 1;30(5):279-281. doi: 10.1089/acu.2018.1289. Epub 2018 Oct 15.

BACKGROUND

Currently, patients undergoing colonoscopy receive sedation, but pain management with acupuncture could be a safer alternative. 

CASES

This article describes 3 cases for which Battlefield Acupuncture was applied during colonoscopy to avoid using opioids for sedation. One case was a patient with a life-threating morphine allergy, and 2 other cases avoided sedation completely. 

RESULTS

Pain was reduced in all 3 cases to allow completion of colonoscopies without sedation. In Case 2, the patient also gained relief of preexisting mild joint pain. 

CONCLUSIONS

More data are needed, so potentially more patients can indeed avoid morphine/benzodiazepam-based sedation by use of acupuncture to make colonoscopies safer and more pleasant.

Baldawi M, McKelvey G, Patel VR, Krish B, Kumar AJ, Patel P. Battlefield Acupuncture Use for Perioperative Anesthesia in Veterans Affairs Surgical Patients: A Single-Center Randomized Controlled Trial. J Integr Complement Med. 2022 Aug;28(8):683-688.

Chang BH, Sommers E. Acupuncture and relaxation response for craving and anxiety reduction among military veterans in recovery from substance use disorder. Am J Addict. 2014 Mar-Apr;23(2):129-36.

Federman DG, Holleck JL.  Auricular Acupuncture and Skin-Cancer Detection: An Opportunity. Med Acupunct. 2018 Feb 1;30(1):39-40. doi: 10.1089/acu.2017.1261.

BACKGROUND

Auricular acupuncture is effective for many patients with pain. Many skin malignancies and precancerous lesions are found on the head and neck. Practitioners of acupuncture are in a unique situation to detect cutaneous malignancy at an early state.

CASE

An 83-year-old man referred for Battlefield Acupuncture was found to have a scalp lesion suspicious for malignancy as well as several precancerous lesions.

RESULTS

Referral to a dermatologist led to excision of a basal-cell cancer and treatment of actinic keratoses.

CONCLUSIONS

Practitioners of auricular acupuncture should be familiar with common skin cancers and precancerous lesions; these practitioners are in a unique situation to detect these common skin lesions.

Federman DG, Poulin LM, Ruser CB, Kravetz JD. Implementation of shared medical appointments to offer battlefield acupuncture efficiently to veterans with pain. Acupunct Med. 2018 Apr;36(2):124-126. doi: 10.1136/acupmed-2016-011315. Epub 2017 Jun 19. PubMed PMID: 28630048.

BACKGROUND

The use of prescription opioids in the treatment of pain has increased notably over recent decades. With this increase, dramatic unintended consequences have arisen. Rates of death from prescribed opioids increased fourfold between 2000 and 2014. Integrative care has been suggested as a potentially safer alternative to opioids in the treatment of chronic non-cancer pain and acupuncture has been shown to be an effective treatment for chronic pain. Battlefield acupuncture (BFA), an easily learnt subset of auricular acupuncture, has been proposed to treat a variety of painful disorders in active military members and veterans. Patients undergo insertion of five auricular semi-permanent (ASP) needles to the following traditional ear acupuncture points bilaterally: Cingulate Gyrus, Thalamus, Omega 2, Point Zero and Shenmen. While other  investigators have evaluated models for integrating medical acupuncture into practice,5 to our knowledge, there has been no evaluation of how to incorporate BFA efficiently into a busy primary care (PC) practice. Since shared medical appointments (SMA) have been shown to be helpful in chronic disease management and may decrease healthcare utilisation, we developed an SMA approach to deliver BFA in the setting of a US Department of Veterans Affairs (VA) PC practice.

Federman DG, Radhakrishnan K, Gabriel L, Poulin LM, Kravetz JD. Group Battlefield Acupuncture in Primary Care for Veterans with Pain. South Med J. 2018 Oct;111(10):619-624. doi: 10.14423/SMJ.0000000000000877. PubMed PMID: 30285269.

OBJECTIVE

To obtain preliminary data on the short- and intermediate-term effects of battlefield acupuncture (BFA) on self-reported pain intensity in a relatively large cohort of veterans to assess whether a more comprehensive clinical trial evaluation is warranted.

METHODS

The treatment, in an outpatient group setting, consisted of up to five auricular semipermanent needles inserted into each ear at prespecified points. Efficacy of treatment was measured by self-reported pain, using the Defense and Veterans Pain Rating Scale, just before treatment and at posttreatment days 0, 1, 7, and 30.

RESULTS

A total of 112 patients attended the group clinics. The mean pretreatment pain score was 6.8, with an immediate postprocedure decrease of 2.4 points. The proportion of patients reporting decreased pain was 88.4%, 80.7%, 52.4%, and 51% at posttreatment days 0, 1, 7, and 30, respectively.

CONCLUSIONS

The short- and intermediate-term beneficial effect of BFA on chronic pain is clinically meaningful. The large proportion of patients reporting decreased pain even 30 days after treatment suggests that the long-term effect of BFA merits further investigation.

Federman DG, Zeliadt SB, Thomas ER, Carbone GF Jr, Taylor SL. Battlefield Acupuncture in the Veterans Health Administration: Effectiveness in Individual and Group Settings for Pain and Pain Comorbidities. Med Acupunct. 2018 Oct 1;30(5):273-278. doi: 10.1089/acu.2018.1296. Epub 2018 Oct 15. PubMed PMID: 30377463; PubMed Central PMCID: PMC6205767.

OBJECTIVE

The Department of Veterans Affairs trained primary-care providers to deliver Battlefield Acupuncture (BFA), a subset of auricular acupuncture, to patients. However, little is known about BFA effectiveness in group or individual sessions or repeated administrations versus singular use. The aim of this study was to examine the use and effectiveness of BFA for back pain and four pain-comorbid conditions in group and individual sessions at a large Veterans Affairs (VA) medical center.

MATERIALS AND METHODS

This cross-sectional study was conducted at the West Haven VA Medical Center, in West Haven CT. Between October 2016 and December 2017, 284 veterans with pain received BFA. The BFA was administered in group clinics or in individual encounters. The Defense and Veterans Pain Rating Scale was used to assess self-reported pain immediately before and after each BFA administration.

RESULTS

Over the study period, an average of 57 (range: 50–66) new patients per month received BFA. Of 753 total patient encounters, an immediate decrease in self-reported pain occurred in 616 (82.0%) patients, no change occurred in 73 (9.7%) patients, and an increase occurred in 62 (8.3%) patients. Decreases in pain were common in the group and individual settings, even in patients with originally high pain scores, and the effectiveness remained with repeated uses.

CONCLUSIONS

BFA can be effective for immediate relief of pain—whether the BFA is administered in a group or individual setting—for the overwhelming majority of veterans and, as such, holds promise as a nonpharmacologic pain-management intervention.

Freedman M, Bierwirth PA.  Pragmatic Use of Acupuncture in a Neurology Practice: Experience in an Outpatient VeteransAdministration Neurology Clinic. Med Acupunct. 2018 Oct

INTRODUCTION

There is a need for nonopioid alternatives for treating pain. Acupuncture is one such modality. However, institutional resistance to the use of acupuncture is common in the Veterans Administration.

OBJECTIVE

The goal of this article is to lay out the reasoning for integrating acupuncture within the VA as well as in general practice so as to be able to relieve patients' pain quickly.

CONCLUSIONS

Among the medical specialties, neurology is particularly suited to lead the way in incorporating acupuncture into daily practice. Aggressive training of physicians of at least basic acupuncture skills should be encouraged. The use of acupuncture as part of pain-control planning should be considered with more of a sense of urgency.

Flike K, St Pierre C, Howard A, Tsai J. Changes in Pain Among Housed and Unhoused U.S. Veterans After Receiving Battlefield Acupuncture at One Medical Center. J Integr Complement Med. 2023 Oct 25.

This study reports on 54 homeless and 53 stably housed veterans who received battlefield acupuncture (BFA) between September 2018 and October 2022. Linear mixed-effects regressions were used to examine change in overall pain score and how pain impacted four areas: (1) activity, (2) sleep, (3) mood, and (4) stress over the course of 8 weeks from the baseline visit at one BFA clinic. Results indicated significant reductions in the impact of pain on activity, sleep, and stress among both homeless and housed veterans. Although overall pain levels were not significantly impacted, further research on the impact of BFA on homeless populations is warranted.

Galka E, Elfessi Z, Singh T, Liu E, Turnbull C. Battlefield Acupuncture vs Ketorolac for Treating Pain in the Emergency Department. Fed Pract. 2023 Apr;40(4):110-115. doi: 10.12788/fp.0369. Epub 2023 Apr 18. PMID: 37223660; PMCID: PMC10202138.

BACKGROUND

Many patients arrive in the emergency department (ED) with acute pain. Battlefield acupuncture (BFA) uses small, semipermanent acupuncture needles in 5 set points anatomically located on each ear to reduce pain in a few minutes. Pain relief can last months, depending on the pathology of the pain. At the Jesse Brown Veterans Affairs Medical Center (JBVAMC) ED, ketorolac 15 mg is the preferred first-line treatment of acute, noncancer pain. In 2018, BFA was offered first to veterans presenting with acute or acute-on-chronic pain to the ED; however, its effectiveness in pain reduction vs ketorolac has not been evaluated in this patient population. The objective of this study was to determine whether BFA monotherapy was noninferior to ketorolac 15 mg for reducing pain scores in the ED.

METHODS

This study was a retrospective, electronic chart review of patients who presented to JBVAMC ED with acute pain or acute-on-chronic pain and received ketorolac or BFA. The primary endpoint was the mean difference in the numeric rating scale (NRS) pain score from baseline. Secondary endpoints included the number of patients receiving pain medications, including topical analgesics, at discharge and treatment-related adverse events in the ED.

RESULTS

A total of 61 patients were included in the study. Baseline characteristics were similar between the 2 groups except for the average baseline NRS pain score, which was higher in the BFA group (8.7 vs 7.7; P = .02). The mean difference in NRS pain scores from baseline to post-intervention was 3.9 for the BFA group and 5.1 for the ketorolac group. The difference in reducing the NRS pain score between the intervention groups was not statistically significant. No adverse events were observed in either treatment group.Conclusions: For treating acute and acute-on-chronic pain in the ED, BFA did not differ compared with ketorolac 15 mg in NRS pain score reduction. This study's results add to the limited existing literature suggesting that both interventions could result in clinically significant reductions in pain scores for patients presenting to the ED with severe and very severe pain, indicating BFA could be a viable nonpharmacologic treatment option.

Garner BK, Hopkinson SG, Ketz AK, Landis CA, Trego LL. Auricular Acupuncture for Chronic Pain and Insomnia: A Randomized Clinical Trial. Med Acupunct. 2018 Oct 1;30(5):262-272. doi: 10.1089/acu.2018.1294. Epub 2018 Oct 15. PubMed PMID: 30377462; PubMed Central PMCID: PMC6205765.

OBJECTIVE

In the United States, ∼1.6 million adults use complementary and alternative or integrative medicine for treating pain and insomnia. However, very few studies have tested the use of auricular acupuncture using a standard protocol for chronic pain and insomnia. The aims of this research were to assess the feasibility and credibility of auricular acupuncture, and to evaluate the effects of auricular acupuncture on pain severity and interference scores, and on insomnia severity over an 8-day study period.

MATERIALS AND METHODS

Forty-five participants were randomized to either an auricular acupuncture group (AAG) or a usual care group (CG) on study day 4. A standard auricular acupuncture protocol was administered, with penetrating semipermanent acupuncture needles in place for up to 4 days. The main outcome measures were feasibility of conducting the study, credibility of auricular acupuncture as a treatment modality, Brief Pain Inventory pain severity and interference scores, and Insomnia Severity Index (ISI) scores.

RESULTS

There was high interest in the study and the retention was 96%. Credibility of auricular acupuncture as a treatment was high in both groups. The use of the standard auricular acupuncture protocol in the AAG led to significant within- and between-group reduced pain severity and interference scores, compared to the CG. Both groups showed within-group decreased ISI scores. However, the AAG showed significant between-group reduced ISI severity scores compared to the CG.

CONCLUSIONS

With the heightened focus on the opioid crisis in the United States, this easy-to-administer protocol may be an option for treating military beneficiaries who have chronic pain and insomnia

Giannitrapani KF, Ackland PE, Holliday J, Zeliadt S, Olson J, Kligler B, Taylor SL. Provider Perspectives of Battlefield Acupuncture: Advantages, Disadvantages and Its Potential Role in Reducing Opioid Use for Pain. Med Care. 2020 Sep;58 Suppl 2 9S(2 9 Suppl):S88-S93.

OBJECTIVES

Nonpharmacological options to treat pain are in demand, in part to address the opioid crisis. One such option is acupuncture. Battlefield acupuncture (BFA) is an auricular needling protocol currently used to treat pain in the Veterans Health Administration. We aimed to identify the advantages and disadvantages of BFA from providers' perspectives.

METHODS

We rely on an inductive qualitative approach to explore provider perceptions through thematic analysis of semistructured interviews with 43 BFA providers across the nation.

RESULTS

We identified the following themes. Disadvantages included: (1) clinical guidelines are insufficient; (2) patients often request multiple BFA visits from providers; (3) BFA can be uncomfortable; (4) BFA may not be an effective treatment option unless it can be provided "on demand"; and (5) BFA can promote euphoria, which can have deleterious consequences for patient self-care. Perceived advantages included: (1) BFA can simultaneously effectively control pain while reducing opioid use; (2) BFA may alleviate the pain that has been unsuccessfully treated by conventional methods; (3) BFA gives providers a treatment option to offer patients with substance use disorder; (4) BFA helps build a trusting patient-provider relationship; (5) BFA can create the opportunity for hope.

CONCLUSIONS

Providers perceive BFA to have many benefits, both clinical and relational, including ways in which it may have utility in addressing the current opioid crisis. BFA is easy to deliver and has potential clinical and relational utility. Efforts to better understand effectiveness are warranted.

Guthrie RM, Chorba R. Physical Therapy Treatment Of Chronic Neck Pain A Discussion And Case Study: Using Dry Needling And Battlefield Acupuncture. J Spec Oper Med. 2016 Spring;16(1):1-5.

PURPOSE

Chronic mechanical neck pain can have a complex clinical presentation and is often difficult to treat. This case study illustrates a successful physical therapy treatment approach using dry needling and auricular acupuncture techniques.

Case Report

A 51-year-old active-duty, male US Marine was treated by a physical therapist in a direct-access military clinic for chronic neck pain poorly responsive to previous physical therapy, pharmacologic, and surgical interventions. Needling techniques were combined with standard physical therapy interventions to address the comprehensive needs of the patient. Within five treatments, the patient reported reduced pain levels from 8-9/10 to 0-2/10, improved sleep quality, and increased function with daily activities. Over several months, the patient reduced multiple medication use by greater than 85%. The effects of treatment were lasting, and the patient accomplished a successful transition to an independent maintenance program.

CONCLUSION

Needling techniques have the potential to expedite favorable physical therapy outcomes for active-duty service members suffering from chronic mechanical and degenerative neck pain. The dramatic improvements observed in this case warrant additional exploration of treatment efficacy and delineation of best practices in the delivery of these techniques.

Halpin, S. N., Wei Huang, & Perkins, M. M. (2015). Comparisons between Body Needle Acupuncture, Auricular Acupuncture, and Auricular Magnet Therapy Given to Veterans Suffering from Chronic Pain. American Acupuncturist, 71, 7–12

No known research has investigated patients' attitudes toward different acupuncture techniques, including those that require less training to administer and potentially could be made more widely available in order to meet the growing demand for acupuncture. The aim of this study was to determine attitudes toward and expectations regarding three different types of acupuncture. The cohort included all patients (n=114) who received acupuncture treatment at the Atlanta Veterans Affairs Medical Center between May 2012 and May 2014. The patients were mailed questionnaires. Patients who agreed to be contacted by phone also participated in semi-structured telephone interviews. The respondents to the mailed surveys (n=72) varied in their demographics and attitudes toward experiences with different types of acupuncture. Of these, a subset of respondents also completed semi-structured telephone interviews (n=45). Thematic analysis of the data revealed three key themes, including (1) perceived time commitment versus return on investment; (2) anxiety, pain, and fear of needles; and (3) the importance of the patient/clinician relationship. Findings showed that the quality of the patient/clinician relationship was a critical factor that shaped the respondents' attitudes toward the different treatment options and also influenced satisfaction with treatment. Patients who were disinclined toward needles and those who wanted longer-lasting pain relief were more likely to endorse auricular magnet therapy.

Huang W, Halpin SN, Perkins MM.  A case series of auricular acupuncture in a veteran's population using a revised auricular mapping-diagnostic paradigm (RAMP-uP).  Complement Ther Med. 2016 Aug;27:130-6. doi: 10.1016/j.ctim.2016.06.002. Epub 2016 Jun 24.

OBJECTIVES

To evaluate clinical effects of auricular acupuncture treatments for pain based on a revised auricular mapping and diagnostic paradigm (RAMP-uP).

DESIGN

Retrospective chart review.

SETTING

A major US Veterans Affairs Medical Centre located in the Southeaster United States.

MAIN OUTCOME MEASURES

Pain and efficacy rating scores based on visual analogue scales during each clinical visit. Duration of acupuncture treatment effects based on clinic notes documentation.

RESULTS

Patients' average pain score decreased by almost 60% (p<0.0001). The treatment effects lasted 1-3 months (47%). The overall efficacy reported by most patients was helpful (83.6%).

CONCLUSION

The observed clinical effects of auricular acupuncture based on RAMP-uP are promising. Further research is needed to assess its feasibility to generalize and generate clinical effects in randomized controlled clinical trials.

King CH et al. J Holist Nurs. (2016). Exploring Self-Reported Benefits of Auricular Acupuncture Among Veterans With Posttraumatic Stress Disorder.

PURPOSE

Auricular acupuncture treatments are becoming increasingly available within military treatment facilities, resulting in an expansion of nonpharmacologic treatment options available to veterans with posttraumatic stress disorder (PTSD). This study aimed to explore the self-reported benefits of auricular acupuncture treatments for veterans living with PTSD.

DESIGN

A qualitative research methodology, thematic content analysis, was used to analyze data.

METHOD

Seventeen active duty veterans with PTSD provided written comments to describe their experiences and perceptions after receiving a standardized auricular acupuncture regimen for a 3-week period as part of a pilot feasibility study.

FINDINGS

A variety of symptoms experienced by veterans with PTSD were improved after receiving auricular acupuncture treatments. Additionally, veterans with PTSD were extremely receptive to auricular acupuncture treatments. Four themes emerged from the data: (1) improved sleep quality, (2) increased relaxation, (3) decreased pain, and (4) veterans liked/loved the auricular acupuncture treatments.

CONCLUSIONS

Veterans with PTSD reported numerous benefits following auricular acupuncture treatments. These treatments may facilitate healing and recovery for veterans with combat-related PTSD, although further investigations are warranted into the mechanisms of action for auricular acupuncture in this population.

King CH, Moore LC, Spence CD. Exploring Self-Reported Benefits of Auricular Acupuncture Among Veterans With Posttraumatic Stress Disorder. J Holist Nurs. 2016 Sep;34(3):291-9. doi: 10.1177/0898010115610050. Epub 2015 Nov 3. PMID: 26530240.

King HC, Spence DL, Hickey AH, Sargent P, Elesh R, Connelly CD.  Auricular acupuncture for sleep disturbance in veterans with post-traumatic stress disorder: a feasibility study. Mil Med. 2015 May;180(5):582-90. doi: 10.7205/MILMED-D-14-00451.

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. 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 post-traumatic stress disorder. Future, large-scale, prospective clinical trials are needed to examine AA effects on sleep.

Madsen C, Koehlmoos T.  Acupuncture: Bridging the Gap Between the Military and Veterans' Health Systems.  Med Acupunct. 2018 Oct

This research brief describes the use of acupuncture as a mechanism for the development of crossagency knowledge translation and evidence-based practices in order to ensure the best possible care for the nation's veterans.

McNamara CF, Kravetz JD, Federman DG. Cessation of group battlefield acupuncture visits due to COVID-19: a pilot study. Acupunct Med. 2022 Oct;40(5):470-473. doi: 10.1177/09645284221104833. Epub 2022 Jun 28. PMID: 35765785.

Montgomery AD, Ottenbacher R. Battlefield Acupuncture for Chronic Pain Management in Patients on Long-Term Opioid Therapy. Med Acupunct. 2020 Feb 1;32(1):38-44.

OBJECTIVES

Battlefield Acupuncture (BFA) is a unique auricular acupuncture procedure utilized by many Veterans Affairs Healthcare Administration facilities. Several previous studies have shown an immediate reduction in pain for up to 2 weeks post BFA. The long-term effects of BFA and its potential to decrease opioid use had yet to be analyzed. This study was conducted to analyze the effectiveness of BFA to decrease chronic pain immediately and 6 months after treatment and to decrease the number of opioids needed for management of chronic pain.

MATERIALS AND METHODS

This was a retrospective cohort study comparing veterans who received BFA and were prescribed opioids for their chronic pain to veterans who did not receive BFA. The treatment group included 24 veterans who received BFA and had opioid contracts. The comparison group consisted of 23 randomly selected veterans who had opioid contracts but did not receive BFA. A numeric rating scale (NRS) was used to measure pain before and after treatment, as well as 3 months prior and 6 months post. The average morphine mg equivalents for opioids 3 months prior and 6 months post treatment were also compared. Differences between groups were statistically analyzed by an analysis of variance and a Student's t-test.

RESULTS

Significant average decreases of 1.3 points on the NRS occurred in 66.1% immediately after the procedure. No significant decreases in pain were found. No significant changes of the average number of opioids over the 9 months analyzed were found.

CONCLUSIONS

BFA is effective for immediate pain reduction. Further research with a randomized controlled trial in a larger population is needed to assess BFA effects on chronic pain and opioid dependency.

Niemtzow R, Baxter J, Gallagher RM, Pock A, Calabria K, Drake D, Galloway K, Walter J, Petri R, Piazza T, Burns S, Hofmann L, Biery J, Buckenmaier C 3rd.  Building Capacity for Complementary and Integrative Medicine Through a Large, Cross-Agency, Acupuncture Training Program: Lessons Learned from a Military Health System and Veterans Health Administration Joint Initiative Project. Mil Med. 2018 Nov 1;183(11-12):e486-e493. doi: 10.1093/milmed/usy028.

Complementary and integrative medicine (CIM) use in the USA continues to expand, including within the Military Health System (MHS) and Veterans Health Administration (VHA). To mitigate the opioid crisis and provide additional non-pharmacological pain management options, a large cross-agency collaborative project sought to develop and implement a systems-wide curriculum, entitled Acupuncture Training Across Clinical Settings (ATACS).

ATACS curriculum content and structure were created and refined over the course of the project in response to consultations with Subject Matter Experts and provider feedback. Course content was developed to be applicable to the MHS and VHA environments and training was open to many types of providers. Training included a 4-hr didactic and "hands on" clinical training program focused on a single auricular acupuncture protocol, Battlefield Acupuncture. Trainee learning and skills proficiency were evaluated by trainer-observation and written examination. Immediately following training, providers completed an evaluation survey on their ATACS experience. One month later, they were asked to complete another survey regarding their auricular acupuncture use and barriers to use. The present evaluation describes the ATACS curriculum, faculty and trainee characteristics, as well as trainee and program developer perspectives.

Over the course of a 19-mo period, 2,712 providers completed the in-person, 4-hr didactic and hands-on clinical training session. Due to the increasing requests for training, additional ATACS faculty were trained. Overall, 113 providers were approved to be training faculty. Responses from the trainee surveys indicated high satisfaction with the ATACS training program and illuminated several challenges to using auricular acupuncture with patients. The most common reported barrier to using auricular acupuncture was the lack of obtaining privileges to administer auricular acupuncture within clinical practice.

The ATACS program provided a foundational template to increase CIM across the MHS and VHA. The lessons learned in the program's implementation will aid future CIM training programs and improve program evaluations. Future work is needed to determine the most efficient means of improving CIM credentialing and privileging procedures, standardizing and adopting uniform CIM EHR codes and documentation, and examining the effectiveness of CIM techniques in real-world settings.

Prisco MK, Jecmen MC, Bloeser KJ et al.  Group auricular acupuncture for PTSD-related insomnia in veterans: a randomized trial. 17 Dec 2013https://doi.org/10.1089/acu.2013.0989

OBJECTIVES

This study examined how group auricular acupuncture may influence sleep quality, sleep patterns, and hypnotic medication use associated with PTSD-related insomnia in Operation Enduring Freedom and Operation Iraqi Freedom veterans.

DESIGN

This study was a randomized controlled trial with sham acupuncture and wait-list controls.

SETTING

This study took place at the Washington, DC, Department of Veterans Affairs (VA), Medical Center.

SUBJECTS

Thirty-five subjects were randomized to participate in the study, but only 25 subjects completed the study.

INTERVENTIONS

Subjects were randomized to one of three groups: (1) true group auricular acupuncture; (2) sham auricular acupuncture; or (3) wait-list control.

OUTCOME MEASURES

The primary outcome measure was perceived sleep quality (as measured by Insomnia Severity Index (ISI) questionnaires and Morin Sleep Diaries [MSDs]). Secondary outcome measures were total sleep time (TST), sleep efficiency, sleep latency, naps (as measured by MSD and wrist actigraphs [WAs]), hypnotic medication use, veteran satisfaction, and attrition rates.

RESULTS

Subjects in the true auricular acupuncture group had a statistically significant improvement (p=0.0165) in sleep quality as measured by the ISI at time (t)=1 month. This group had a trend toward lower MSD TST at t=2 months (p=0.078), lower WA TST at t=1 month (p=0.0893), and toward higher MSD nap times than the other two groups post-treatment (p=0.0666). No statistically significant association between group assignment and hypnotic medication use and satisfaction scores were noted.

CONCLUSIONS

Acupuncturists should consider incorporating sleep hygiene education into their clinical practices and/or collaborate with insomnia health care professionals when working with individuals with insomnia. This study also supports the finding that perceived sleep quality and objective WA measurements are not significantly correlated.

Shao X, Corcoran M, O'Bryan M.  The Use of Battlefield Acupuncture Prior to Botulinum Toxin A Administration: A 2-Patient Case Series. Med Acupunct. 2018 Oct 1;30(5):282-284. doi: 10.1089/acu.2018.1302. Epub 2018 Oct 15.

BACKGROUND

Botulinum toxin type A injection is a common and safe procedure used for the treatment of overactive muscles through local injection. This toxin inhibits the release of acetylcholine in the neuromuscular junction. The benefits usually last only 3-6 months; thus, repeated injections are often required. The procedure, however, can be difficult if a patient's spasticity and pain prevents access to the muscles for injection or if a patient is anxious. Battlefield Acupuncture (BFA), a technique developed by Richard C. Niemtzow, MD, PhD, MPH, in 2001, is a form of auricular acupuncture using a very specific sequence of gold Aiguille semipermanente needles inserted into the ear. BFA can be very effective for reducing pain quickly, with few potential side-effects.

CASES

BFA was performed prior to Botulinum toxin A injections on 2 patients who had either pain limitations or anxiety limitations during prior Botulinum toxin A injections. Case 1 was a 70-year-old male veteran with painful, right upper-extremity spasticity with hand contractures. Case 2 was a 69-year-old male veteran with spasticity who had anxiety related to his fear of needles.

RESULTS

Application of BFA prior to Botulinum toxin A injections enabled the 2 patients who either had pain limitations or anxiety limitations to tolerate the toxin injections much better.

CONCLUSIONS

BFA is a safe and effective treatment option for rapid pain reduction, enabling Botulinum toxin A to be administered more easily to patients who have had pain or anxiety during prior injections.

Taylor SL, Giannitrapani K, Ackland PE, Holliday J, Reddy KP, Drake DF, Federman DG, Kligler B. Challenges and Strategies for Implementing Battlefield Acupuncture in the Veterans Administration: A Qualitative Study of Provider Perspectives. Med Acupunct. 2018 Oct 1;30(5):252-261. doi: 10.1089/acu.2018.1286. Epub 2018 Oct 15. PubMed PMID: 30377461; PubMed Central PMCID: PMC6205764.

OBJECTIVE

Battlefield Acupuncture (BFA) is an auricular needling protocol for pain. More than 1300 Veterans Health Administration (VHA) clinicians have been trained in BFA delivery. However, little is known about how well BFA has been implemented at the VHA. The aim of this research was to identify the challenges providers experience in implementing BFA and to look for any successful strategies used to overcome these challenges.

MATERIALS AND METHODS

Semistructured telephone interviews were conducted from June 2017 to January 2018, using an interview guide informed by the integrated Promoting Action on Research Implementation in Health Services framework to address several implementation domains: knowledge and attitudes about BFA; professional roles and training in BFA; organization of BFA delivery and resources to provide BFA; and implementation challenges and strategies to address challenges. The interviews were analyzed, using a grounded theory-informed approach. This research was conducted at 20 VHA facilities and involved 23 VHA BFA providers nationwide.

RESULTS

Nine main implementation themes were identified: (1) providers organizing BFA delivery in various ways; (2) insufficient time to provide BFA to meet patient demand; (3) beliefs and knowledge about BFA; (4) lack of BFA indication guidelines or effectiveness data; (5) self-efficacy; (6) time delay between training and practice; (7) limited access to resources; (8) key role of leadership and administrative buy-in, and (9) written consent an unwarranted documentation burden. Providers offered some possible strategies to address these issues.

CONCLUSIONS

System- and provider-level challenges can impede BFA implementation. However, several providers discovered strategies to address some challenges that can be used within and outside the VHA, which, in turn, might improve access to this potentially promising pain-management intervention

Thomas ER, Zeliadt SB, Coggeshall S, et al. Does Offering Battlefield Acupuncture Lead to Subsequent Use of Traditional Acupuncture?. Med Care. 2020;58 Suppl 2 9S:S108-S115.

OBJECTIVES

Veterans Health Administration encourages auricular acupuncture (Battlefield Acupuncture/BFA) as a nonpharmacologic approach to pain management. Qualitative reports highlighted a "gateway hypothesis": providing BFA can lead to additional nonpharmacologic treatments. This analysis examines subsequent use of traditional acupuncture.

RESEEARCH DESIGN

Cohort study of Veterans treated with BFA and a propensity score matched comparison group with a 3-month follow-up period to identify subsequent use of traditional acupuncture. Matching variables included pain, comorbidity, and demographics, with further adjustment in multivariate regression analysis.

SUBJECTS

We identified 41,234 patients who used BFA across 130 Veterans Health Administration medical facilities between October 1, 2016 and March 31, 2019. These patients were matched 2:1 on Veterans who used VA care but not BFA during the same period resulting in a population of 24,037 BFA users and a comparison cohort of 40,358 non-BFA users. Patients with prior use of traditional acupuncture were excluded.

RESULTS

Among Veterans receiving BFA, 9.5% subsequently used traditional acupuncture compared with 0.9% of non-BFA users (P<0.001). In adjusted analysis, accounting for patient characteristics and regional availability of traditional acupuncture, patients who used BFA had 10.9 times greater odds (95% confidence interval, 8.67-12.24) of subsequent traditional acupuncture use.

CONCLUSIONS

Providing BFA, which is easy to administer during a patient visit and does not require providers be formally certified, led to a substantial increase in use of traditional acupuncture. These findings suggest that the value of offering BFA may not only be its immediate potential for pain relief but also subsequent engagement in additional therapies.

INTRODUCTION

Given the prevalence of pain among the military and veteran populations, the U.S. Department of Defense (DoD) and Veterans Health Administration (VA) have committed to offering safe and practical nonpharmacological options for pain management. One emerging, potentially effective therapy offered in the DoD and VA settings for immediate, short-term pain relief is battlefield acupuncture (BFA).

Walker PH, Pock A, Ling CG, Kwon KN, Vaughan M. Battlefield acupuncture: Opening the door for acupuncture in Department of Defense/Veteran's Administration health care. Nurs Outlook. 2016 Sep-Oct;64(5):491-8. doi: 10.1016/j.outlook.2016.07.008. Epub 2016 Jul 20. PubMed PMID: 27601311.

Battlefield acupuncture is a unique auricular acupuncture procedure which is being used in a number of military medical facilities throughout the Department of Defense (DoD). It has been used with anecdotal published positive impact with warriors experiencing polytrauma, post-traumatic stress disorder, and traumatic brain injury. It has also been effectively used to treat warriors with muscle and back pain from carrying heavy combat equipment in austere environments. This article highlights the history within the DoD related to the need for nonpharmacologic/opioid pain management across the continuum of care from combat situations, during evacuation, and throughout recovery and rehabilitation. The article describes the history of auricular acupuncture and details implementation procedures. Training is necessary and partially funded through DoD and Veteran's Administration (VA) internal Joint Incentive Funds grants between the DoD and the VA for multidisciplinary teams as part of a larger initiative related to the recommendations from the DoD Army Surgeon General's Pain Management Task Force. Finally, Uniformed Services University of the Health Sciences School of Medicine and Graduate School of Nursing faculty members present how this interdisciplinary training is currently being integrated into both schools for physicians and advanced practice nurses at the Uniformed Services University of the Health Sciences. Current and future research challenges and progress related to the use of acupuncture are also presented

Zeliadt SB, Thomas ER, Olson J, et al. Patient Feedback on the Effectiveness of Auricular Acupuncture on Pain in Routine Clinical Care: The Experience of 11,406 Veterans. Med Care. 2020;58 Suppl 2 9S:S101-S107.

OBJECTIVES

Veterans Health Administration (VHA) launched a national initiative to train providers in a specific, protocolized auricular acupuncture treatment (also called Battlefield Acupuncture or BFA) as a nonpharmacological approach to pain management. This evaluation assessed the real-world effectiveness of BFA on immediate pain relief and identified subgroups of patients for whom BFA is most effective.

RESULTS

More than 3 quarters experienced immediate decreases in pain following administration of BFA, with nearly 60% reported experiencing a minimal clinically important difference in pain intensity. The average decrease in pain intensity was −2.5 points (SD=2.2) at the initial BFA treatment, and −2.2 points (SD=2.0) at subsequent treatments. BFA was effective across a wide range of Veterans with many having preexisting chronic pain, or physical, or psychological comorbid conditions. Veterans with opioid use in the year before BFA experienced less improvement, with pain intensity scores improving more among Veterans who had not recently used opioids.