Pain--a simple four-lettered word that complicates people's lives every day. According to the Centers for Disease Control and Prevention, "Chronic pain affected about 20 percent of the U.S. adults in 2016…that translates into 50 million people with chronic pain." The associated costs are just as astounding as shown by the same CDC study, "Chronic pain contributes to an estimated $560 billion each year in direct medical costs, lost productivity, and disability programs." (https://www.cdc.gov/mmwr/volumes/67/wr/mm6736a2.htm)

Pain has significant ramifications for the military, and chronic pain is a serious problem for combat veterans and Soldiers. In a sample of 2,597 Soldiers, who had served in Afghanistan and Iraq, 44 percent reported pain lasting for more than three months, half of whom reported pain for one year or more.1 Additionally, 25 percent of military personnel are purported to have an addiction to narcotics due to pain.2

The good news is that pain is manageable, and does not always require medication--specifically opioids or narcotics to manage it. There are other therapeutic options which may help to alleviate pain. One such alternative is acupuncture.

In 2002, retired Air Force Col. Richard Niemtzow, MD, PhD, a radiologist oncologist, started the first full-time acupuncture clinic for the U.S. Air Force at Andrews Air Force Base (now Joint Base Andrews).3

Dr. Niemtzow was instrumental in getting auricular (ear) acupuncture adopted into the armed forces for use in battlefield situations, hence it being called battle field acupuncture, or BFA. The benefits included, "being easy to use and to teach, no associated side effects or infections, patients that complained of acute pain (Emergency Room visit) experienced 23 percent reduction in pain, and the cost comparisons defined substantial cost savings. For example, the weekly cost of acupuncture needles was $1.82 versus $10.08 for weekly ibuprofen (such as Motrin�) and $20.58 for weekly celecoxib."4 Another benefit is the added value to pilots who cannot take ibuprofen because of the tendency to cause blurred vision. Dr. Niemtzow highly recommends BFA for those who do not respond to Western medicine, particularly for migraines, chronic low-back pain, surgical pain, procedure-related anxiety; and mood and depression to name a few.

Today, Dr. Niemtzow's concept has become a teaching tool for healthcare providers across the Armed Forces. September is celebrated as National Pain Awareness Month, and the military healthcare professionals gather annually at the National Capital Region's Pain Care Skills Training. 2018 marked the eighth year, and the gathering was held at the prestigious U.S. Air Force Academy, in Colorado Springs, CO. where four notable physicians provided BFA training to more than one-third of the participants at this year's training.

Dr. Nathan Evans, Col. Joel Tanaka, and Maj. Yin-Ting Chen, all from Evans Army Community Hospital, as well as Maj David Djuric, from Brooke Army Medical Center, provided didactic and hands-on training as part of the U.S. Air Force Acupuncture Certification Training Program, Joint Initiative Funding project sponsored by the Department of Defense and Veterans Affairs. Each participant is required to pass a written exam and correctly locate all five relevant ear points, then accurately insert the needles before being awarded certificates.
Dr. Patrick Sonnenberg, who also attended the conference and is the lead acupuncturist at Brooke Army Medical Center's Pain Management Department, stated, "The Acupuncture Semi-Permanent needles are entirely different from the needles used in standard acupuncture." The BFA needles (more accurately described as tiny conical darts) pierce the ear in designated locations in a particular order. They stay in place until they fall out typically within 3--4 days.5 There were volunteers that had the BFA procedure performed on them.

It's important to understand the differences between BFA and traditional acupuncture. Dr. Sonnenberg is a physician of Oriental Medicine and had this to say about the significant differences between the two:

"BFA certainly has benefits, chiefly powerful pain relieving potential in addition to brief treatment times, sustained effect, simplicity of placement, and being easily taught to providers. Standard acupuncture treatment has been in constant use as a medical modality for thousands of years and is perhaps the most well-known component of the Traditional East Asian Medical model.

"BFA is a valuable auricular-based acupuncture technique prevalent in military medicine. Auricular acupuncture itself is considered a microsystem within the acupuncture field; BFA has a limited protocol based on five points within the auricular system.

"Standard acupuncture treatment has the potential to activate significant functions of the nervous system's healing mechanisms within the body, which cannot be stimulated using BFA or other acupuncture needle-based therapies."

In comparison to BFA, standard acupuncture uses thin needles which can vary in diameter and length but are uniform in diameter throughout the length of the selected needle gauge. The needle is inserted and stimulated within a patients comfort level to achieve the desired response. Typically they feel what is described as a heavy, achy, dull sensation but can vary since many sensations are associated with various nerve and muscle fibers. It stimulates a healing response in the tissue local to the needle insertion point by increasing blood flow and triggering an anti-inflammatory response. The benefits have been demonstrated, frequently adopted and modified by other professions such as orthopedics, sports medicine and physical therapy.

It is important to educate patients and providers that a lack of response to BFA does not constitute a "failure" of acupuncture as a whole, nor even BFA. It also needs to be understood that patients who do not benefit from or tolerate BFA may better tolerate and or benefit from standard acupuncture. While some patients obviously will not respond to either BFA or standard acupuncture, there are other complimentary alternatives to consider, such as yoga, physical therapy, chiropractic therapy, and massage to name a few.

It is vitally important to ensure the acupuncturist is well trained, certified and credentialed:
licensed acupuncturists (L.Ac.) have a professional degree and licensure, it is the profession with the highest level of training in the application and use of acupuncture. All licensed acupuncturists within federal employment have at a minimum completed a four-year master's degree program which provides extensive training in the use of acupuncture. Those with the advanced or professional standard have a doctoral degree.

Acupuncture is suitable for most patients, but there are some associated risks for specific patients, and therefore it's important to discuss it with your primary care manager.

If you are interested in trying out BFA or standard acupuncture for yourself, or would like more information about how to become certified as a BFA practitioner, please use the links below for more information.

If you are a beneficiary interested in receiving acupuncture, please contact your nearest military treatment facility or Primary Care Manager to find out if it is available at your MTF or in your local area.

If you are a Department of Defense (DoD) provider and interested in finding out more about BFA please contact Richard Niemtzow at JB Andrews, BFA.Acupuncture@mail.mil

If you are a provider in the VHA system and would like more information about BFA, please contact Belinda Collingborne at vhabfasupport@va.gov

References:
1 & 5 Battlefield Acupuncture: An Emerging Method for Easing Pain
Levy, Charles, E., MD; Casler, Nicholas, BS; FitzGerald, David, B., MD
American Journal of Physical Medicine & Rehabilitation: March 2018 - Volume 97 - Issue 3 - p e18--e19
doi: 10.1097/PHM.0000000000000766
https://journals.lww.com/ajpmr/fulltext/2018/03000/Battlefield_Acupuncture___An_Emerging_Method_for.16.aspx

2, 3, 4 JOURNAL OF ALTERNATIVE AND COMPLEMENTARY MEDICINE
DoD--NCCAM/NIH Workshop on Acupuncture for Treatment of Acute Pain
Emmeline Edwards, Jean Louis Belard, John Glowa, Parap Khalsa, Wendy Weber, Kristen Huntley
J Altern Complement Med. 2013 Mar; 19(3): 266-279.
doi: 10.1089/acm.2012.9229.dod PMCID: PMC3608148
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3608148/