JICM

JOURNAL OF INTEGRATIVE AND COMPLEMENTARY MEDICINE

Volume 28, Number 8, 2022, pp. 683–688
ª Mary Ann Liebert, Inc.
DOI: 10.1089/jicm.2021.0429

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ORIGINAL ARTICLE

Battlefield Acupuncture Use for Perioperative

Anesthesia in Veterans Affairs Surgical Patients:
A Single-Center Randomized Controlled Trial
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Mohanad Baldawi, MD,1 George McKelvey, PhD,1,2 Vijval R. Patel, MS,2 Brinda Krish, DO,1
Aashish Jay Kumar, MD,1 and Padmavathi Patel, MD1,2

Abstract
Introduction: The risks from opioid use are well known in and mandate nonpharmacological modalities for
the management of postoperative pain. The aim of this study was to investigate the effectiveness of battlefield
acupuncture (BFA) as an adjunct therapy for postoperative pain in U.S. veteran patients undergoing major sur-
gery under general anesthesia.
Methods: Patients undergoing major surgery performed under general anesthesia from June 2017 to June
2018 were enrolled in the study. Patients were randomly assigned to receive either BFA or sham acupuncture.
Outcomes such as pain intensity measured by visual analog scale score, opioid consumption, and the incidence
of analgesia-related adverse effects were compared between the study groups.
Results: A total of 72 subjects were included in this study (36 subjects in each study group). The median 24-h
opioid postoperative consumption measured in morphine milligram equivalent (MME) was lower in the BFA
group compared to the sham acupuncture group (18.3 [–12.2] MME vs. 38.6 [–15.9] MME, p < 0.001). Pain
intensity reported by patients at 6, 12, 18, and 24 h postoperatively was lower in the BFA group compared to the
sham acupuncture group. The incidence of postsurgical nausea and vomiting was lower in patients receiving
BFA compared to patients receiving sham acupuncture. There were no intergroup differences in terms of post-
operative anxiety or hospital length of stay.
Conclusion: The results from this study reveal the potential clinical benefits of using BFA for reducing pain
intensity and opioid requirements in surgical patients.

Keywords: acupuncture, pain management, opioid, randomized clinical trial, veterans

Introduction ditions, including low-back pain, cancer, and postoperative

pain.1,2 Auricular acupuncture includes different treatment
modalities, one of which is battlefield acupuncture (BFA).3
A uricular acupuncture is a traditional pain therapy
originating in Eastern Asia and has been reported to
be an effective adjunct in pain management of several con-
Opioid abuse is an epidemic ravaging community and the
U.S. health resources. The Center for Disease Control and

1
Department of Anesthesiology and Pain Services, Detroit Medical Center, Detroit, Michigan, USA.
2
Department of Surgical Services, John D. Dingell VA Medical Center, Detroit, Michigan, USA.
Disclosure: This article was accepted for oral presentation in the 2022 International Congress on Integrative Medicine
and Health.

683
 684
Prevention (CDC) estimates there are more than 1000 emer-
gency room visits and 91 deaths related to opioid misuse
every day.4 Health care practices have been implicated as
causative factors in this epidemic with poorly defined post-
operative pain treatment resulting in many patients receiving
larger opioid prescriptions than needed. Resolving this issue
requires a collaborative effort, including curbing the exces-
sive prescription of opioids by surgical providers, while man-
aging postsurgical pain appropriately.
This study aimed to determine whether BFA is associated
with decreased opioid requirements, perioperative pain, and
perioperative analgesia-related adverse effects in U.S. vet-
erans undergoing major surgery under general anesthesia.
This study was approved by the Institutional Review
Board of the John D. Dingell VA Medical Center, Detroit,
Michigan.
Materials and Methods
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Study design
This double-blinded randomized clinical trial is regis-
tered on ClinicalTrials.gov (Clinical Trial Registration no.
NCT04615299). Patients undergoing a surgical procedure
under general anesthesia from June 2017 to June 2018 were
screened for enrollment in the study.
Patients (n = 72) were randomly allocated using a
blocked randomization list into two equal groups (n = 36
per group; block sizes 4 and 8) to either receive BFA or
sham acupuncture. Blocked random sequence generation
was obtained using an online randomizer (Sealed Envelope
Ltd. 2021. Create a blocked randomization list. Online
document at: https://www.sealedenvelope.com/simple-
randomiser/v1/lists). For treatment allocation, the physi-
cian placing the BFA or sham needles performed the ap-
propriate treatment regimen based on the random
generated treatment allocations assigned within individual
sealed opaque envelopes.
The physician placing the BFA or sham acupuncture
was not involved in assessing or treating the patients for
any study measure or outcome. Patients receiving treat-
ment were blinded to treatment allocation. All health care
practitioners providing study-related treatments and evalu-
ating study outcomes were blinded to treatment allocation.
All eligible subjects received an educational session on the
theory of BFA, and written informed consent was obtained
from participants before surgery.
Patients were deemed eligible to participate in the study
if they were: (1) 18–100 years old, (2) undergoing major sur-
gical procedure, (3) required to stay in hospital for at least
24 h postoperatively, and (4) able and willing to give infor-
med consent. Major surgery was defined as any extensive
procedure requiring general anesthesia and overnight or
extended hospital stay. These included bowel cavity oper-
ations, vascular surgeries, and joint reconstructive surgeries.
Patients were excluded from the trial if they have: (1) his-
tory of bleeding or coagulopathy disorder, (2) history of
psychiatric or neuropathic disorder, which might interfere
with pain assessment, and (3) continuous epidural anesthetic
treatment following surgery.
The anesthetic management was general anesthesia with
provision of intravenous opioids intraoperatively and during
BALDAWI ET AL.
recovery. Fentanyl was the only intraoperative opioid used. All
patients were admitted to the postanesthetic care unit follow-
ing surgery where they received BFA or sham acupuncture.
Acupuncture technique
After disinfection of the patient’s ear, a 2 mm stainless
steel needle (Aiguille d’acupuncture Semi-Permanente ASP
gold, France) was implanted in patient ear using the needle
plastic injector. The needle was implanted on the same side
as patient surgical field or in the patient’s right ear in case of
midline surgical field. The correct needling was confirmed
by a characteristic click at the time of insertion, and no other
needle stimulation was required. The needles spontaneously
fell out after 3–4 days postoperatively.
In the sham acupuncture group, a blunt needle was used
to superficially penetrate the patient’s ear and then removed
immediately. BFA and sham needles were placed in five
auricular acupuncture points, which are linked with pain
relief: Omega 2, Shen Men, Point Zero, Hypothalamus, and
Cingulate Gyrus5 (Fig. 1). The treated auricular points were
covered with skin nonsensitive tape to ensure successful
blinding.
Measured outcomes
The primary outcomes were pain visual analog scale
(VAS) score and opioid requirement in morphine milligram
equivalent (MME) in the first 24 h following surgery. VAS
score is used in epidemiologic and clinical research to mea-
sure the intensity of pain.6 MME is the unit of measurement
of opioid intake widely used in clinical practice when pre-
scribing different opioid medications.7
The secondary endpoints were postoperative length of stay,
postoperative nausea and vomiting, and any other adverse
effect reported within 24 h following surgery, including
acupuncture site infection, acupuncture site bleeding, aller-
gic reaction to acupuncture needles, and scar tissue forma-
tion at the site of acupuncture placement. Patient satisfaction
with postoperative analgesia was estimated using a 10-point
scale.
Statistical analysis
Power calculations for continuous outcome for a superi-
ority trial were based on a detection of 33% difference in
opioid consumption, a decrease in the primary outcome mea-
sure from 30 MME in the control group to 20 MME in the
experimental group with a standard deviation of 15 MME
between study groups (https://www.sealedenvelope.com/
power/continuous-superiority/). This analysis concluded that
a minimum of 36 participants in each group were necessary
to produce 80% statistical power. A 33% reduction in opioid
consumption with a standard deviation of 15 MME repre-
senting a moderate standard mean difference of 0.5 compa-
red to controls was based on a meta-analysis where auricular
therapy was observed to reduce analgesic use (standard
mean difference, 0.54 [95% confidence interval: 0.30, 0.77];
5 studies).8
Differences between groups were considered statically
significant when a p-value was <0.05 (2-sided). Normally
distributed continuous data were analyzed using two
 BATTLEFIELD ACUPUNCTURE IN VETERANS AFFAIRS SURGICAL PATIENTS
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independent samples t-test and presented in mean – standard
deviation, while nonparametric continuous data were analyzed
using Mann–Whitney U test and presented in median –
interquartile range. Chi-square test was used to analyze
categorical data. Statistical analysis was conducted using
STATA software.
Results
Patient characteristics
Seventy-two* patients met inclusion criteria and were
enrolled in the study. The majority of patients underwent
abdominal surgeries, including total and partial colectomy,
open and laparoscopic hernia repair, and laparoscopic cho-
lecystectomy (n = 26), and the others underwent urinary tract
surgeries, including open and laparoscopic prostatectomy
and nephrectomy (n = 21), orthopedic surgeries, including total
hip and total knee replacement surgeries (n = 19), thoracic
*Correction added on May 18, 2022 after first online publi-
cation of May 6, 2022: The total number of patients was
mistakenly listed as seventy-five. It has been corrected to se-
venty-two to reflect the total number of patients listed in the
subsequent breakdown by the authors.
685
FIG. 1. Niemtzow’s BFA points. BFA,
battlefield acupuncture.
surgeries, including video-assisted thoracoscopic surgery and
lung resection (n = 3), and vascular surgeries, including carotid
endarterectomy and lower extremity angioplasty (n = 3).
In the randomization process, 36 patients were assigned
to receive BFA, and same number of patients was assigned
to receive sham acupuncture. Figure 2 demonstrates the
patient enrollment process. Table 1 summarizes patient
characteristics in the study groups.
Primary outcomes
Subjects receiving BFA had lower average MME at
24 h postoperatively compared to subjects receiving sham
acupuncture (18.3 [–12.2] vs. 38.6 [–15.9], p < 0.001). In
comparison to sham acupuncture group, pain intensity was
significantly lower in BFA group at 6, 12, 18, and 24 h fol-
lowing surgery (Table 2). Study groups had similar VAS
score in the preoperative period.
Secondary outcomes
On a 10-point scale, patients receiving BFA reported higher
satisfaction compared to patients receiving sham acupuncture
(Table 3). Patients receiving BFA had lower incidence of
nausea and vomiting compared to patients receiving sham
acupuncture. There were no significant differences between
 686 BALDAWI ET AL.

FIG. 2. Flow diagram

showing patient randomization
and allocation processes.
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study groups in the incidence of anxiety. All patients were Discussion

observed to have covering tape over acupuncture or sham Auricular acupuncture originated in Eastern Asia and has
acupuncture areas intact at the 24 h postoperative period. been used in the treatment of pain of different origins. In this
No acupuncture-related adverse effect was reported in the study, BFA was used as an adjunct anesthetic modality on
BFA or sham acupuncture groups. U.S. veteran patients undergoing major surgical procedures
under general anesthesia. The results revealed that patients
receiving BFA had reduced 0–24-h postoperative pain and
Table 1. Patient Characteristics and Type decreased opioid requirements compared to patients receiv-
of Surgery for Study Groups ing sham acupuncture. In addition, there were lower nausea
and vomiting rates and higher overall satisfaction for post-
BFA Sham
operative analgesia in patients receiving BFA.
Patient (n = 36); acupuncture
characteristics n (%) (n = 36); n (%) Opioid abuse has reached an epidemic level in U.S.
Mortality from drug overdose in the United States, mostly
Gender from opioid overdose, has more than tripled from 1999 to
Female 3 (8.3) 2 (5.5) 2015, and comprised 25% of drug overdose-related deaths
Male 33 (91.7) 34 (94.4) worldwide.9 In 2015, the CDC estimated that 91 individuals
Age, mean (–SD) 64 (–13.6) 64.2 (–9.4) died each day from opioid overdose in the United States.10
BMI, mean (–SD) 30.1 (–6.1) 28.8 (–5.9) This epidemic has placed an enormous burden on the U.S.
Race health care system as providers treat *1000 patients with
African American 13 (36.1) 18 (50) opioid overdose daily.4
White 18 (50) 12 (33.3) Recent evidence from the VA facilities scrutinized the new
Hispanic 1 (2.8) 0 prescribing guidelines for postoperative pain management,
Others 4 (11.1) 6 (16.7)
ASA class Table 2. Comparison Between Study Groups
Class I 1 (2.8) 0
for Pain Visual Analog Scale Score
Class II 2 (5.6) 2 (5.6)
Class III 32 (88.9) 33 (91.7) BFA; Sham
Class IV 1 (2.8) 1 (2.8) Postoperative mean acupuncture;
Type of surgery time (–SD) mean (–SD) p
Abdominal surgery 10 (27.8) 16 (44.4)
Urinary tract surgery 7 (19.4) 14 (38.9) Presurgery 4.8 (–2.6) 5.4 0.2
Orthopedic surgery 17 (47.2) 2 (5.6) 6h 4.3 (–1.9) 6.8 (–1.9) <0.001
Thoracic surgery 1 (3.3) 2 (5.6) 12 h 3.6 (–1.7) 6.4 (–1.6) <0.001
Vascular surgery 1 (3.3) 2 (5.6) 18 h 3.1 (–1.5) 5.6 (–1.6) <0.001
24 h 2.3 (–1.4) 5.3 (–2) <0.001
ASA, American Society of Anesthesiologists; BFA, battlefield
acupuncture; BMI, body mass index; SD, standard deviation. BFA, battlefield acupuncture; SD, standard deviation.
 BATTLEFIELD ACUPUNCTURE IN VETERANS AFFAIRS SURGICAL PATIENTS
Table 3. Comparison Between Study Groups
for Secondary Outcomes
BFA Sham
(n = 36); acupuncture
Outcome n (%) (n = 36); n (%) p individual procedures. This imbalance in specific surgical
Patient analgesia 7.1 (–1.2) 6.1 (–1.7) 0.003
satisfaction,
mean (–SD)
Total hospital stay 3.5 (–3.2) 4.8 (–8.7) 0.42
in day,
mean (–SD)
Nausea 1 (2.8%) 13 (36.1%) 0.0004
Vomiting 0 11 (30.6) 0.0003
Anxiety 4 (11.1%) 5 (13.9%) 0.72
BFA, battlefield acupuncture; SD, standard deviation.
which started in response to IV opioid shortage.11 It demon-
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strated a significant decrease in severe pain score, although
there was a similar decrease in IV opioid prescriptions fol-
lowing implementation of the new guidelines. Previous studies
reported increased risk of opioid dependency in patients re-
ceiving postoperative opioid prescriptions.
Multiple population-based studies of opioid-naive pa-
tients undergoing surgery found that patients receiving
opioid prescriptions were at high risk for chronic opioid use
following surgery.12,13 A review of 1.3 million opioid-naive
patients found that the rate of opioid use at 1 year postoper-
atively was 6% in patients receiving 1-day opioid prescrip-
tions following surgery, and 13.5% in patients receiving
prescriptions for more than 7 days postoperatively.14
The implications of acupuncture for the management of
postoperative pain, opioid requirement, and nausea and vom-
iting have been studied in previous publications. Acupunc-
ture analgesic mechanisms are not fully understood; however,
multiple scientific studies suggested different theories, includ-
ing release of endogenous opiate peptides, activation of the
pain-related neuromatrix, and modulation of the hypothalamic-
limbic system in human brain.15–17 Previous meta-analyses
and randomized clinical trials concluded that auricular ther-
apy is effective in reducing pain and opioid requirement,18–30
while other clinical trials found no significant difference
between auricular therapy and control groups.31–36
The difference in outcomes in studies that have shown
no benefit from acupuncture use may be attributed to dif-
ferences in smaller sample sizes.35 Other studies that ob-
served no difference in postoperative pain levels did not
compare the total amount of opioid analgesics given to
each study group,32 and others have compared different
modalities of anesthesia such as comparing outcomes from
using acupuncture alone versus the use of local anesthesia
techniques.34
Management of nausea and vomiting can be a challenge
in the postoperative period. The effect of auricular therapy
on postoperative nausea and vomiting has been a subject
of debate in previous publications.19,22,26,28,32 In this clinical
trial, we found an association between BFA and decreased
incidence of nausea and vomiting. We hypothesize that re-
duced postoperative opioid requirement in patients receiving
BFA might have contributed to reduced incidence of opioid-
related adverse effects, including nausea and vomiting.
687
Limitations
A major limitation to this study was the lack of homo-
geneity of patient surgery type between treatment groups,
which was due to the small number of subjects undergoing
populations between study groups may ‘‘muddy’’ the speci-
fic benefits of BFA observed in this study. To address this
limitation, further BFA studies using larger sized groups of
more homogenous surgical populations are required. Studies
such as these may determine if the analgesic effectiveness
of BFA observed in this study can be replicated across spe-
cific surgical populations.
Clinical staff providing treatment to the study patients
were blinded to the patients’ group allocation due to the
study blinding method of covering the study patients’ ears
with adhesive tape. However, an intrinsic limitation of this
study is the potential difference in the clinical staff assess-
ment (assessment of VAS score) and treatment (adminis-
tering rescue opioid medications) of study patients.
Conclusions
In conclusion, the diminished postoperative pain inten-
sity, reduced postoperative opioid requirement, and the lower
incidence of postoperative nausea and vomiting observed in
surgical patients receiving BFA demonstrate the potential
advantages of this low-cost and low-risk therapy in this
patient population. Further research is needed to test the
effectiveness of BFA in individual surgical procedures.
Authors’ Contributions
All authors certify that they have participated sufficiently
in this work, including participation in the concept, design,
analysis, or writing of the article, and take responsibility for
the content of the article.
Author Disclosure Statement
No competing financial interests exist.
Funding Information
No funding was received for this article.
Supplementary Material
Supplementary Table S1
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Address correspondence to:
Mohanad Baldawi, MD
Department of Anesthesiology and Pain Services
Detroit Medical Center
3990 John R, Box 162
Detroit, MI 48201
USA
E-mail: mohanad.baldawi90@gmail.com