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March 2019
National Evaluation of the Effectiveness and Implementation of Battlefield AcupunctureCIHEC, based in Los Angeles and Boston, works to improve Veterans’ health and experiences of care through increased availability and the use of evidence-based CIH approaches. Among the 5.7 million unique patients seen annually within the VA healthcare system, more than half experience chronic pain. In 2017, VA and the DoD published an updated guideline on opioid therapy for chronic pain that strongly recommends against the initiation of long-term opioids – but does recommend alternatives, including non-pharmacologic therapy (i.e., acupuncture, yoga, cognitive behavioral therapy). In addition, the American College of Physicians1 and The Joint Commission2 issued guidelines for pain management that focused on non-drug therapies (i.e., acupuncture, massage, spinal manipulation). Pain was the most frequent reason Veterans gave for using several of these therapies in a study conducted by investigators from QUERI’s Complementary and Integrative Health Evaluation Center (CIHEC). Among a national sample of 3,346 Veterans, study findings showed that at least half of these Veterans were interested in trying and/or learning more about six complementary and integrative health (CIH) approaches, including acupuncture (56%).3 Investigators from CIHEC also conducted two studies to better understand the effectiveness of a novel pain innovation—battlefield acupuncture (BFA). One study was at a high-volume BFA site at the VA in West Haven, CT. Between October 2016 and December 2017, 284 Veterans with pain (71% had been previously diagnosed with a chronic musculoskeletal condition) received BFA. Results showed that BFA was highly efficacious in immediately reducing pain for a significant majority of Veterans in this study (82%).4 BFA is a rapid protocol-based, five-point (10 needle), auricular (ear) acupuncture therapy developed by Dr. Richard Niemtzow in 2007 and intended to be delivered alongside other treatments for chronic pain. It is noted for its ease of administration and ability to be learned by a wide variety of providers to administer without requiring training in comprehensive acupuncture techniques.5 CIHEC investigators are also examining BFA’s effectiveness nationally. They found that nearly 60% of 11,406 Veterans, who had pre- and post-BFA treatment pain scale rating data recorded in VA’s electronic health record, reported experiencing a clinically meaningful decrease in pain. Overall, patients reported an average immediate decrease in pain intensity when initially treated with BFA, and an average improvement at subsequent BFA treatments. BFA was nearly universally effective across a wide range of Veterans with many having pre-existing chronic pain, or physical or psychological comorbid conditions. 6 Given the anecdotal evidence that BFA can reduce pain in the short-term, VA has trained more than 2,400 clinicians to deliver BFA as a promising pain management option. As such, the QUERI investigators also examined BFA’s implementation by conducting telephone interviews with 62 VA providers at 55 VA medical centers across the VA healthcare system—in both urban and rural settings—on BFA implementation facilitators and barriers, successful strategies to overcome those barriers, and provider perceptions of BFA.7 Findings Providers reported multiple challenges to implementing BFA, such as: gaps between BFA training and practice, resource limitations, low-provider self-efficacy, and negative provider beliefs about BFA effectiveness and experience. Strategies used to overcome these challenges included:
Providers reported that having an effective treatment (e.g., BFA) that appears to relieve pain in real time for some patients, and can facilitate trust, patient- provider communication about pain, and patient openness to trying other therapies, has the potential for reducing the use of opioids. Providers also reported that BFA can be painful for some patients and the benefits may not last long, but that BFA is easy to deliver and low-risk for patients. Conclusions BFA is a promising, innovative non-pharmacological approach to pain management. It faces many of the implementation challenges that other novel clinical innovations do. However, some implementation facilitators, challenges, and strategies to address those challenges appear somewhat unique to BFA. For example, it appears that having an in-office BFA therapy that allows providers to help their patients experience immediate pain relief can facilitate the development of a stronger patient-provider relationship, with increased openness and trust. Strengthening this relationship may support patient openness to opioid tapering. Implications Opioid use and chronic pain are two of the most widespread epidemics affecting Americans. Strategies to facilitate decreased opioid use societally, while still addressing patient pain concerns are sorely needed. As BFA is easy to deliver, is low-risk, and appears to have clinical and relational utility, efforts to reduce barriers to implementing this promising CIH treatment option for pain are warranted. For more information about CIHEC or the studies mentioned in this article, please contact Stephanie Taylor, PhD (Los Angeles) at Stephanie.Taylor8@va.gov or A. Rani Elwy, PhD (Boston) at Rani.Elwy@va.gov .
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