Perceptions of the Impact and Utility of Battlefield Acupuncture Among Veterans Experiencing Homelessness: A Qualitative Pilot Study

Abstract

Purpose

The purpose of this study was to understand homeless veterans’ perspectives on the utility and impact of Battlefield Acupuncture (BFA).

Design

A qualitative study among veterans with chronic pain who were experiencing homelessness.

Methods and Participants

A subset of twelve Veterans who participated in a in weekly BFA sessions for up to 12 weeks at one VA medical center participated in semi-structured interviews conducted between September 2022 and March 2023. Qualitative thematic analysis was used to analyze the data.

Results

The average number of BFA visits among participants was 10.8. Thematic analysis revealed three themes (1) Prior experiences with chronic pain, where Veterans often reported having pain for years with limited relief, (2) Appeal of a non-pharmacologic treatment, and (3) BFA had a positive impact on health and well-being. Overall, participants reported BFA to be a brief, convenient, and effective non-pharmacological treatment for their chronic pain. Many described how they had exhausted most other traditional treatments for their chronic pain and saw BFA as an acceptable and effective alternative treatment.

Conclusions

Our results indicated Veterans appreciated BFA as an alternative approach toward the treatment of their chronic pain beyond what is typically offered in conventional health care, the convenience of short appointment times, and accessible services. Our findings support the VA continuing to offer BFA as a Complementary and Integrative Health modality, particularly for high acuity populations like Veterans experiencing homelessness.

Introduction

Battlefield Acupuncture (BFA) is a type of acupuncture that was developed by an Air Force Surgeon and Acupuncturist, Richard Niemtzow ¹ in 2001 to provide a protocol to treat pain in soldiers on the front lines of battle. BFA is a protocol of auricular acupuncture with 5 specific sites of treatment located in the ear. This type of acupuncture treatment requires a minimal amount of equipment (which can be carried on a person) and therefore was a reasonable type of treatment to be used on the front lines of battle.

Historically, acupuncture is based on an Eastern philosophy of medicine which differs from Western philosophy and its biomedical approach to medicine. For example, in Western philosophy, if a patient has musculoskeletal pain the affected areas (ie, knee, back, etc.) are assessed, and if needed, more diagnostic tests such as x-rays, CAT scans or MRI, may be ordered and reviewed before a diagnosis and treatment is initiated. Often, the traditional approach to treatment for most musculoskeletal pain includes rest, ice, heat and over the counter medications such as Ibuprofen or Acetaminophen as needed. Visits may take 30 min or longer, depending on whether or not testing is involved.

Alternatively, BFA visits offered in the U.S. Department of Veterans Affairs (VA) healthcare system are typically shorter, lasting 15-20 min. A typical BFA appointment includes a pain questionnaire at the beginning of each visit. Once completed, BFA provider reviews the patients’ responses on the questionnaire regarding their pain levels and the treatment begins with the placement of small BFA needles for a total of 10 needles (5 in each ear). After the BFA needles are placed, patients are again asked to rate their pain prior to leaving the visit. Patients are generally seen weekly for their chronic pain treatment. This type of treatment is more holistic and can reduce pain quickly and it is not necessarily limited to only one area of the body. For some patients, it can reduce or eliminate their pain in several areas of the body. BFA has been shown to be effective in the treatment of many different types of musculoskeletal pain including headaches, back and extremity pain.^2-4

BFA is offered nationally in the VA healthcare system, which is the largest integrated healthcare system in the US. A number of studies of BFA in the VA have been conducted. One study, which evaluated over 750 patients being treated in a BFA clinic, found that 82% of participants reported an immediate decrease in pain after the BFA procedure.^2,5 Another large scale retrospective study which included over 11 000 Veterans from 57 VA medical centers on the utilization of BFA for pain treatment indicated that up to 75% of the patient’s found relief from their pain immediately post treatment. ³ In addition, a randomized controlled trial was conducted among military personnel who were treated with BFA for pain. The researchers found at 48-h post treatment there was an over 3 point decrease in pain in the intervention group, compared to a 0.96 decrease in pain among the control group, indicating BFA contributed to a clinically meaningful decrease in pain that was sustained 48 h after the intervention. ⁶ All of these studies have indicated that BFA can be an effective treatment for chronic pain in military personnel and veterans. In addition, a qualitative study conducted among BFA practitioners within the VA which examined the implementation of BFA found that the providers considered the treatment to be an effective short-term treatment for chronic pain and was most useful when offered in conjunction with other pain management strategies. ⁷

BFA and Homelessness

Homelessness among veterans remains a major public health problem^8,9 and VA is dedicated to the health and well-being of homeless veterans. The focus of our study was treatment of chronic pain in veterans who had experienced homelessness. It is currently estimated that up to 50% of homeless veterans experience chronic pain. ¹⁰ A scoping review focused on connecting homelessness to chronic pain and psychiatric disorders noted that chronic pain can often be significant among homeless populations and that stigma and bias related to homelessness by the healthcare system can contribute to pain development. ¹¹ In a scoping review of homeless-experienced people, the authors noted that most described their pain as moderate to severe and had been experiencing chronic pain for 10 years. ¹² Chronic pain is a severe and persistent problem among Veterans experiencing homelessness and additional research is needed to treat pain in a holistic manner. A few studies have found that BFA may be effective in treating pain in homeless veterans.^13,14 To further examine this line of research, this qualitative study examined the use of BFA in treating chronic pain in veterans who had experienced homelessness.

Purpose

The aim of this pilot study was to understand homeless veterans’ perspectives on the utility and impact of BFA. We examined changes in pain and how their pain interfered with their activities of daily living, the accessibility and utility of BFA as a treatment for chronic pain, and recommendations for improvement.

Methods

Design and Setting

This was a qualitative component of a pilot study of homeless veterans who participated in weekly BFA sessions to treat chronic pain for up to 12 weeks at one VA medical center in the Northeast.

Participants

Participants for this qualitative study were recruited from a larger study which included 33 veterans who participated in a pilot study to examine the impact of BFA on homeless-experienced Veterans. ¹³ Eligibility for the pilot study included either current episode of homelessness or a history of homelessness within the past 5 years, and a self-reported history of chronic pain that has lasted for at least 3 months. Veterans were recruited to participate in the BFA pilot study through flyers, word-of-mouth, and clinician referrals. During the consent process, all participants were asked if they would be willing to participate in a post-treatment interview regarding their impressions about receiving treatment and offering any feedback regarding the BFA study.

For this qualitative study, all 33 participants in the pilot study were asked during the informed consent process (prior to any BFA sessions) if they were interested in participating in an interview at the conclusion of their sessions. In total, 12/33 (36%) of the eligible veterans consented to participate in the post-treatment qualitative interview, which occurred either after the completion of the 12 sessions (10 participants) or after the veterans indicated they would like to discontinue the BFA sessions (2 participants). The demographics of the 12 veterans who participated in the interviews were roughly similar to the full sample of 33 veterans who participated in the overall study, with the exception that the full sample was more racially/ethnically diverse (see Table 1).

Table 1.

Demographic Data of Participants Interviewed About Battlefield Acupuncture (BFA) (n = 12)

Variable	Mean (SD) or n (%)
Gender
Male	9 (75%)
Female	3 (25%)
Age
Race	60.5 (±8.2)
White	12 (100%)
Number of BFA visits	10.8 (range 3-12)

Note: This sample was drawn from a larger study of 33 veterans participating in BFA with a mean age of 57.2 (±13.5), 81.8% male, 84.9% non-Hispanic white, attending a mean of 8.2 BFA visits.

Data Collection

Semi-structured interviews were conducted with participants to understand the perceived effects or impacts of BFA on participant’s pain, sleep, physical activities, mental health, and social activities, usability and acceptability of BFA compared to other treatments for pain, barriers to BFA treatment, and recommendation for improvement. Example questions included “Why did you decide to try BFA?”, “How does BFA compare to other treatments you have tried to manage your chronic pain?” and “Can you tell me about any changes to your health or in your life since beginning the study?” with probe questions for changes in sleep, fatigue, mental health, activities, and interactions with family and friends. Interviews were conducted between September 2022 and March 2023 and interview length ranged from 18-54 min. This study was approved by the Institution Review Board at the VA Bedford Healthcare System and participating Veterans provided written consent.

Analysis

A thematic analysis was conducted using the six steps described by Braun and Clarke. ¹⁵ First, interviews were recorded and transcribed verbatim and two authors (KF and CS) familiarized themselves with the data by reading each transcript to get an overall sense of the data. Second an initial set of codes were developed and applied to the data independently by the two authors. Next, the two authors searched the coded data and collated the codes to reach a consensus for the candidate themes. Fourth, the candidate themes were reviewed and refined. Fifth, the two authors met to discuss defining and naming the themes, which were reviewed by a third author. Lastly, the final report was developed with selected extracts to highlight the main themes.

Results

Sample

Twelve veterans experiencing homelessness with chronic pain were interviewed (Table 1). Their average age was 60.5 ± 8.2 (range 43-71) years and 100% were white and 75% were men. On average participants completed 10.8 visits (range 3-12).

Thematic Results

The thematic analysis revealed three overarching themes (1) Prior experiences with chronic pain, (2) Appeal of a non-pharmacologic treatment, and (3) BFA had a positive impact on their health and well-being.

Prior Experiences With Chronic Pain: “I Felt like the Tin man. He’s Rusted in Place”

Participants described their experiences living with chronic pain, often for many years, and the impact that living with chronic pain had on their lives. Most often they reported either musculoskeletal pain or neuropathic pain that had a significant impact on their quality of life, “I kind of equivocate [my pain] to the movie the Wizard of Oz and the Tin Man. He’s rusted in place.” (Veteran 019). Many participants reported they were either currently taking or had previously tried a variety of medications for pain management including gabapentin, acetaminophen, and cortisone shots. Often these pharmacological therapies provided some relief, but only to a certain extent, “I do gabapentin. That’s for my neuropathy. It helps when they’re—it helps with it but doesn’t take it all out of me.” (Veteran 017).

Appeal of Non-Pharmacologic Treatment: “It’s Convenient, Short, and Natural”

Participants reported they appreciated how BFA provided another non-pharmacologic option for them to use to manage their chronic pain. Many discussed how they were already on “too many” medications, and they wanted to find alternative, non-pharmacologic treatments to provide additional pain relief, “Well, one it’s a natural thing and it’s not some more medicine that I have to take which I don’t, I don’t like taking as much as I got” (Veteran 007). Participants also valued how short and easy to access the BFA appointments were, “One, it’s convenient. Two, it’s short. It’s a short treatment span. Three, it’s natural. It’s--it has to do with the chakras and the electrical system in your body and tapping into it” (Veteran 019). In addition, most participants reported there weren’t any major disadvantages to trying BFA, with the most commonly reported side effects being some discomfort with the insertion of the pins and occasional pain when they laid on their ear at night. However, most participants found these side effects to be minor inconveniences and were worth the positive results they had from BFA.

BFA had a Positive Impact on Their Health and Well-Being: “Just try It!”

Overall, participants indicated that BFA had a positive impact on their health and well-being. In particular, participants reported improvements in the ability to participate in physical activities and reduced stress and anxiety. One participant noted, “[I have] extremely improved mobility to--from going from a 1, I’m up to like I’d say 8-1/2” (Veteran 019). With their improved mobility, the participants mentioned how they began partaking in activities they once enjoyed but hadn’t been able to participate in due to their chronic pain, like golf and community outings offered at their VA Supportive Housing. Participants also described how they felt an overall improvement in their well-being and a sense of freedom once their pain improved. As one participant noted once they completed the BFA sessions, “Just a sense of freedom, a sense of being young. I don’t know--just a general--other parts of, you know, life--dealing with stuff that didn’t--you know, you didn’t think, you know, was a problem, but it is.” (Veteran 014).

When asked if they would recommend BFA to other Veterans with experiences of homelessness, all the participants said they would, with many using the phrase “Just try it!” They indicated it would be particularly useful for Veterans who had exhausted other treatment options, “You know, try it. I mean if you exhaust all other things, you might as well. I mean, you’re not putting any substance in your body or anything like that. You’re just getting nifty jewelry.” (Veteran 004). Many recommended that BFA be freely accessible and incorporated into existing programs and locations for Veterans in the community including Veterans of Foreign Wars (VFWs) and American Legions. Others recommended incorporating BFA into VA clinics, “I think it should be offered more freely, you know. Including pain management and primary care” (Veteran 028).

Discussion

Overall, participants in this qualitative study reported BFA to be a brief, convenient, and effective non-pharmacological treatment for their chronic pain. Many participants described how they felt they had exhausted most other traditional treatments for their chronic pain and saw BFA as an acceptable and effective alternative treatment that provided relief. Overall, they reported only minor side effects, such as pain at the insertion sites, and felt the benefits outweighed this brief discomfort. Participants recommended that BFA should be more widely available within locations that serve veterans experiencing homelessness.

Previous quantitative studies of BFA treatment have reported clinical improvements in pain,^3-5,13,14 and this study complements those findings with qualitative data garnered from the perspectives of Veterans with lived experience of homelessness on the impacts that BFA treatment has had on their health and well-being. In addition, two qualitative studies conducted among BFA providers within the VA have provided insight on provider perspectives where they found BFA to be an effective alternative treatment for pain that was simple to administer with short appointment times.^7,16 However, both studies noted several barriers in implementing BFA including constraints on providers time, support from leadership, and lack of research demonstrating the effectiveness of BFA.^7,16 Taylor and colleagues ⁷ discussed several strategies to deliver BFA to Veterans from the perspective of providers, including integrating BFA within existing VA clinics, establishing separate BFA clinics with walk-in hours, and having dedicated BFA personnel.

Our research provides additional value to these studies because it includes the perspective of BFA participants, which to our knowledge has not been previously explored in the qualitative literature. Veterans who participated in this study echoed some of the BFA provider sentiments by suggesting BFA be more widely available to homeless-experienced veterans in locations where they frequent, including locations outside the VA medical centers. Prior research has found that while all homeless-experienced Veterans utilized some health or social care, only 25% of homeless Veterans used VA homelessness services. ¹⁷ This indicates it may be particularly important to provide BFA services in easy to access community locations to maximize outreach to homeless-experienced Veterans.

The VA, along with other healthcare systems, is undergoing a transformation to a Whole Health System of Care ¹⁸ which is a patient-centered approach to care that empowers and equips Veterans with tools and skills to be proactive about their overall health and well-being. ¹⁹ Complementary and Integrative Health (CIH) modalities are an integral part of the Whole Health transformation, where the VA benefits package covers 9 approaches, including acupuncture, biofeedback, massage therapy, meditation, guided imagery, chiropractic care, clinical hypnosis, tai chi, and yoga. ²⁰

Inclusion of CIH modality benefits within the VA was mandated by US congress in the 2016 Comprehensive Addiction Recovery Act (CARA), ²¹ as a method of improving treatment for chronic pain among Veterans and reducing the need for prescription opioids. The results of this study gave additional insight into the perceived benefits of BFA among a high priority population of Veterans with the lived experience of homelessness, many of whom had a history of substance use disorders. Veteran participants expressed one of the greatest benefits of BFA was that they were able to find relief from their chronic pain without the use of additional medications, which is particularly important among this high risk population where substance use disorders are prevalent. ²² Future research should continue to explore how best to introduce and educate veterans about BFA, and how to offer BFA in conjunction with other healthcare services that veterans are receiving. The theoretical mechanisms of action that BFA has on Veterans’ health also needs to be further elucidated as well as any direct or indirect effects on various domains of health including mental illness, addiction, and social dysfunction. Overall, research on the impact of BFA for Veterans experiencing homelessness is limited,^13,14 but has shown promise in this population and should continue to be explored in future studies.

This study has several limitations. First, a convenience sample of Veterans were recruited and so there are potential responses biases that Veterans who participated in the study had different experiences than Veterans who did not participate in the study. In particular, our qualitative research sample was limited to white Veterans so further research is needed on how generalizable to veterans of other races/ethnicity. Second, a small sample of 12 Veterans from a single site were included in this study so replication of these findings in other samples is needed. Third, Veterans who did not complete the 12 BFA sessions were included so whether a full course of BFA is needed to produce the reported benefits is unknown. Finally, this was a qualitative study designed to understand the experiences of Veterans who received BFA and there was no comparison group or careful control of other supportive services participants also received during the study.

Conclusion

Research into the utility and efficacy of BFA in the VA is growing and has demonstrated promise as a CIH modality to treat chronic pain in conjunction with conventional health care services. Prior quantitative research has found reported improvements in pain among Veterans immediately after the BFA appointment.^2,3,5 In addition, prior qualitative research demonstrated that BFA providers believe it to be an effective, short-term complementary approach to treating chronic pain,^7,16 despite reported barriers in implementing BFA delivery. ⁷ Our qualitative results added a new perspective to these previous studies by including the experiences of homeless Veterans, who indicated they appreciated BFA as an alternative approach toward the treatment of their chronic pain beyond what is typically offered in conventional health care, and the convenience of short appointment times and accessible services. Our findings support the VA continuing to offer BFA as a CIH modality, with particular attention toward reaching high acuity populations like Veterans experiencing homelessness who have a range of mental health and substance use disorders, along with chronic medical conditions.