Seeking ways to curb the use of opioid painkillers, doctors at Baltimore’s VA Medical Center started offering a version of acupuncture to treat some veterans’ chronic pain.
Two years later, the U.S. Department of Veterans Affairs has embraced the therapy based on the traditional Chinese practice of inserting needles into the body to treat maladies. The VA is using acupuncture at clinics across the country.
There is little research to support the effectiveness of acupuncture, but the federal agency now plans to study its use.
The willingness to try alternative methods of treating pain reflects the VA’s pressing need to reduce the use of addictive opioids for the thousands of men and women who leave the military with chronic pain or develop it as civilians.
Opioids have caused a nationwide epidemic of overdose, and VA doctors recognized their own addiction problem stemming from both chronic conditions and grievous mental and physical injuries. One in 10 service members returning from Iraq or Afghanistan and seen at a VA office has a problem with alcohol or drugs.
It also represents an effort across the VA health care system to focus more broadly on “wellness” and what the department calls “whole health,” with doctors and patients developing health goals such as regaining the ability to play a sport rather than simply treating one disease at a time.
For a large proportion of veterans living with chronic pain, plans often include weight loss, exercise and dietary improvements and other non-drug therapies such as massage, yoga and mindfulness training in conjunction with or instead of traditional medicine. The acupuncture treatment, piloted in Baltimore and since taken up by two dozen other VA centers, is part of that approach.
“We recognized that we were not treating chronic pain very well,” said Dr. Carol Bowman, medical director of patient and family-centered care for the VA Maryland Health Care System. “Opioid pills don’t work long-term. … We’ll continue to treat disease and sickness and other sources of pain, but we want to take a whole-health approach that teaches people how to be healthy.”
The program is aimed at patients like John DeLost, who injured his left knee cross country skiing while stationed in Alaska with the Army in the 1970s.
His over-reliance on his right knee and years of hard labor in a Curtis Bay shipyard near where he was raised left him with ongoing pain. After knee surgery, the 68-year-old couldn’t walk well and opioid painkillers were no longer helping. Ice, massage, and a big weight loss were providing only some relief. The medical marijuana he wanted to try was off limits to the VA because cannabis remains illegal at the federal level.
A recent session of acupuncture gave him little relief from pain but made him feel better in other ways.
“I feel a little more energy; I can breathe better,” said DeLost, after a Veterans Affairs doctor put five tiny needles into each of his ears. “It didn’t take the pain away, but it makes me feel good.”
DeLost said he’s still not sure how or why it works — a sentiment shared by many medical experts.
“There is no reason to think acupuncture would work,” said Steven L. Salzberg, a professor of biomedical engineering, computer science and biostatistics at the Johns Hopkins medical school. “It would be really shocking if it did.”
In Salzberg’s view, acupuncture is not only “quackery” being pushed on veterans who have real pain from medical problems and little choice of medical providers, but unethical because it carries a small risk of serious infection.
A review of published acupuncture studies by the National Center for Complementary and Integrative Health, which is part of the U.S. Department of Health and Human Services, found mixed results, with many studies either too small or too inconsistent to draw conclusions. Some studies found that acupuncture done properly — with needles placed deeply enough in specific places — was a little more beneficial for some kinds of pain than when it’s done incorrectly. But people even found improper acupuncture a little more beneficial than no treatment or a placebo pill that has no effect on bodily functions.
Andrew Vickers, a biostatistician whose studies were included in the review, concluded that acupuncture’s benefit, even if it’s just “a little,” could be beneficial for some people. For example, he said, one examination found that acupuncture reduced the number of a patient’s migraines by 22 days per year, but they still had a lot of bad headaches.
“Who defines a little or a lot and what’s meaningful to patients?” said Vickers, an attending research methodologist at Memorial Sloan Kettering Cancer Center in New York. “Whether it was worth having acupuncture or not was a subjective opinion.”
Vickers said if many veterans believe they get even some relief from acupuncture, and the cost and risk remain low, then it may be reasonable to offer it, though he said the practice should have standards and continue to be studied.
The VA is using a modified form of the therapy known as battlefield acupuncture that was developed in 2001 by an Air Force doctor who envisioned its use someday on the battlefield in place of or in addition to morphine to control pain. It involves placing five needles in each ear and leaving them in until they fall out, a few days to more than a week later. The treatment can be completed much more quickly than traditional acupuncture.
A training program was developed about two years ago at the Defense and Veterans Affairs departments. The VA couldn’t say how much it has spent on training and treatment, but it and the Department of Defense plan to spend $81 million over six years on 12 research projects to address pain and other conditions using non-drug approaches, including battlefield acupuncture.
Critics like Salzberg say the lack of evidence after so many years and so much study makes continued research wasteful and the VA’s use of acupuncture irresponsible.
And worse, he said, the VA is using a version of the centuries-old therapy that was “made up out of whole cloth” in 2001 and not yet put under any significant review.
Salzberg attributed positive stories from veterans to a conscious or unconscious desire to tell doctors or researchers what they want to hear or a desire for it to have some effect.
The VA’s Bowman countered that if patients believe that it’s helping their pain — and the bulk of her patients say that it is — then it is. And since pain is related to anxiety and depression, common among veterans, a perception that acupuncture helps also can improve mood and outcomes, she said.
From January 2016 through September 2017, the Baltimore VA reports that it has reduced use of opioid painkillers by 16 percent.
That drop is partly a result of acupuncture, but also of exercise, weight loss, counseling and other measures, said Margie Koehler, a VA pain clinic clinician.
“You are entitled to chronic pain management but not entitled to opioids because of patient safety and because of addiction prevalence and opioid misuse,” she said. “Patients decide how they can be more functional and in less pain. … Often complete eradication of pain is not realistic.”
Prince Matthews would agree. He served in the Marines in the 1980s and believes the physical strain of staying in top shape and the extensive hours he subsequently worked as a chef in commercial kitchens led to his debilitating arthritis.
Matthews, 54, said he doesn’t expect any pill or therapy to take away all his pain, but the acupuncture seems to work as well as the opioid Tramadol he also takes.
Since last year, he's been going for acupuncture sessions at a VA facility near his Perryville home. He said he noticed no difference when the pins went into his ears, but the shooting pain in his hip tended to subside about a day later, lasting until the pins fell out.
Intense pain makes people willing to try new things, Matthews said. And because he has been in recovery from alcohol addiction for 16 months, he really doesn’t want to take addictive painkillers.
Matthews also tried aromatherapy and mindfulness training, which he said also help him cope with pain better. But he said he’ll still need to use the pain medication sometimes before he’s able to have hip replacement surgery.
“Nothing is going to take away all the pain; pain is merely a symptom that something is wrong,” he said. “But I’ll try anything over taking a pill any day to manage the pain. If it works, great, if it doesn't, I’m glad I have the pills.”
DeLost, too, said he had no expectation of living pain-free and also plans to seek more surgery to help. But as he sat on a patient exam table with needles sticking from his ears, he said it’s worth the repeated trips to the VA for any relief.
“I’m not skiing no more and I probably will never play basketball again,” he said. “But I’d like to be able to walk to the store.”