Acupuncture and Whole Health in the Veterans Administration

Empowering and engaging patients is our goal. Our current healthcare system, however, is a disease-based model in which patients are the passive recipients of advice, prescriptions, and interventions for chronic disorders. Clinical teams often feel they have little choice in managing these chronic conditions, including pain and mental health conditions, and often turn to medications rather than engaging patients in the lifestyle and behavioral modifications that would improve long-term outcomes more significantly.

The current model of healthcare delivery is ineffective, costly, and not sustainable. Nowhere is this more apparent than in our management of chronic pain. We are now seeing the effects of overprescribing opiates and benzodiazepines in an environment where patients are not actively engaged in their own well-being. There is an understandable push to overcome this challenge using nonpharmacologic approaches—not only for improving patients' quality of life (QoL) but for prescribers' desire to help patients in a more meaningful way.

One of the most promising nonpharmacologic approaches to pain management is acupuncture. Although this approach has been used for centuries in many countries in the world, this modality has gained support in the United States more recently due to the increasing amount of published evidence in support of acupuncture use. The Centers for Disease Control and Prevention published revised guidelines for the management of chronic pain, calling for use of nonpharmacologic approaches for chronic pain and cautious use of opioids in acute pain.¹ A review of literature that the Veterans Health Administration (VHA) Health Services Research and Development conducted showed good-quality evidence supporting the use of acupuncture for treating low-back pain, migraines, and osteoarthritis.² The American College of Physicians published new guidelines in February of 2017 for treatment of low-back pain, including acupuncture as a first-line treatment for chronic and subacute low-back pain.³

There is also evidence to support the use of integrative health practices, including acupuncture and mindfulness, as not only effective for treating pain and other conditions, but as cost-effective interventions as well.^4–6 Partially in response to this mounting evidence, the Comprehensive Addiction and Recovery Act of 2016⁷ mandated the Veterans Administration (VA) to include more complementary and integrative health approaches for the management of patients with chronic pain, substance-abuse disorders, and mental illness. In May of 2017, the VA endorsed the addition of acupuncture, when clinically indicated, to the veterans' medical benefits package.⁸

In the last decade, the VHA has increased the delivery of acupuncture to offer patients safe alternatives for the management of chronic illnesses, including pain. According to Healthcare Analysis and Information Group surveys, in 2011 42% of VHA facilities were offering acupuncture.⁹ Currently, based on an internal VHA data review, 88% of facilities are offering acupuncture. In 2015, the VHA partnered with the Department of Defense to train practitioners in an auricular protocol known as Battlefield Acupuncture for the treatment of pain. Developed by Richard C. Niemtzow, MD, PhD, MPH, this protocol has enabled rapid training of providers and improved access to acupuncture. To date, the VHA has trained more than 1700 providers in this protocol; some of the early outcomes of this deployment are presented in this issue of Medical Acupuncture.

The VHA recognizes that acupuncture alone is not the answer to chronic pain management, but when acupuncture is part of comprehensive personal health plans for patients, it can be transformative for their QoL. For this reason, the VHA has committed to a whole-health approach to care that empowers and equips veterans to meet their health and well-being goals, and live their lives to the fullest. Providers across the United States are sharing their personal anecdotes of success in pain reduction. More importantly, these providers are sharing that, when their veterans are actively engaged in decision-making as part of their well-rounded treatment plans, these veterans report having improved QoL.

We must shift our approach in healthcare, from a reactionary and prescriptive culture, to one that is proactive, patient-centered, and patient-driven. This large-scale shift will take time. Because acupuncture can often provide some immediate decreases in pain and improvements in functionality, there is a tendency to replace medications or interventions with only acupuncture. Although it is exciting to offer a safer alternative for treatment of pain and other issues, the challenge is that this approach still requires patients to be dependent on the healthcare system for care. Often, the number of treatments supported by the literature still leaves the veterans wanting and asking for more; the optimal frequency and duration of treatment is still unclear based on studies to date. In addition, a patient is often sitting passively in a room or laying on a table, and the risk is that we are neglecting to empower that individual to focus on self-care.

For truly sustainable ameliorations in pain or chronic illnesses, patients must be active in the development and use of their personal health plans. Therefore, it is critical to focus on patient engagement and empowerment first—identifying what patients' meanings, aspirations, and purposes are—to motivate patients to make the behavioral and lifestyle changes that are often so critical to improved health. When individuals are activated in this way, we will see a major shift in healthcare delivery, from one that is passive and provider-driven, to one that is active and patient-driven.

Chronic pain can be influenced by biopsychosocial factors, including poor sleep and nutrition, increased stress, and environmental exposures,¹⁰ and we also know that the neuroplasticity of our brains can allow us to change the way we sense pain.¹¹ Reducing chronic pain and improving QoL successfully, therefore, must also include active approaches in which patients modify factors that exacerbate pain. Examples of such approaches include physical exercise, cognitive–behavioral therapy, biofeedback, yoga, t'ai chi, and mindfulness-based stress reduction.^12–14 Educating patients and providers on the evidence for the use of acupuncture as part of personal health plans focused on self-care is essential if we want to be truly transformative in how we deliver healthcare and manage chronic pain.