Acupuncture for the Treatment of Chronic Pain in the Military Population Factors Associated With Treatment Outcomes Anthony Plunkett, MD,* Thomas Beltran, BS,* Chelsey Haley, MSCR,w Connie Kurihara, RN,z Amy McCoart, RN, BSN,y Louis Chen, MD,*8 Indy Wilkinson, MD,* and Steven P. Cohen, MD8z Objectives: Acupuncture is characterized as an alternative or complementary medicine with a low complication rate and minimal side effects. There is a lack of robust evidence that shows acu- puncture is an effective treatment for chronic pain. The purpose of this study was to determine which (if any) characteristics can pre- dict successful response to acupuncture in chronic pain patients treated at military treatment facilities. Methods: Data from 222 patients who received treatment for a chronic pain condition were collected from 2 medical centers. The patients underwent at least 4 acupuncture treatments and had an average pain score of 4 or higher on a 0- to 10-point numerical rating scale or visual analog scale in the week before treatment initiation. A successful outcome was defined to be a 2-point or greater reduction on the numerical rating scale or visual analog scale 12 weeks postinitial treatment. Results: The overall treatment success rate was 42.3%. Multivariate logistic regression found a higher baseline pain rating and the use of stimulation needles to be associated with a positive outcome (odds ratio [OR] = 1.26; 95% confidence interval [CI], 1.03-1.55; P = 0.02 and OR = 2.73; 95% CI, 1.39-5.32; P = 0.03, respectively). Only the presence of one or more psychological comorbidities was found to be associated with treatment failure (OR = 0.67; 95% CI, 0.49-0.92; P = 0.01). Discussion: The use of electrical stimulation and higher baseline pain score were associated with a positive treatment outcome, while the presence of a psychological comorbidity diminished the like- lihood of treatment success. Practitioners should consider using electrical stimulation more frequently, and addressing psychopa- thology before or concurrent to treatment, when initiating acupuncture. Key Words: acupuncture, complementary and alternative medicine, military medicine (Clin J Pain 2017;33:939–943) A cupuncture is characterized as an alternative or com- plementary medicine with a low complication rate and little to no side effects. 1 Acupuncture has been practiced in China for more than 2500 years and has become popular in many European and western countries. 2 In 1997 and 2002, the National Institutes of Health Consensus Development Panel reviewed data on acupuncture and found strong evidence for efficacy in emesis control and dental pain; however, they determined there was a lack of significant evidence for chronic pain. 1,3 The epidemiology and treatment of pain are con- stantly being evaluated to determine which therapeutic modalities have the best success rate. Complementary and Alternative medicine (CAM) research has been slowly increasing in the past decade; however, due to regulatory issues, funding and support, much is still unknown about many CAM treatments. 4 Acupuncture is one of the most commonly used CAM treatments for pain. More than 10 million acupuncture procedures are performed yearly in the United States. 5 In 2010, the Pain Management Task Force was created to provide recommendations and guidelines for military pain treatment and research. One of the main aims was to increase research in CAM treatments, with a strong focus on acupuncture. 6 Since then, studies have been increasing in size and complexity to satisfy the need for acupuncture and alternative medicine research. Many studies have been conducted that attempt to identify factors that determine acupuncture success. Three previous studies have examined whether patient beliefs about the helpfulness of acupuncture affected treatment outcomes in patients with chronic back pain; however, the results were inconsistent. 7–9 In 2010, a study of 422 patients examined the pretreatment preferences and expectations of patients and patient outcomes. The results showed that patients with higher pretreatment expectations for the success of acupuncture expressed a preference for acupuncture over other back pain treatments and had a positive impression of acupuncture. However, none of the variables predicted short to long-term improvement of back-related symptoms. 10 Prady and colleagues conducted a systematic review of 31 acupuncture trials, including randomized controlled trials and quasi-randomized controlled trials. This study found little evidence that preferences in treatment or randomization affected outcomes. Furthermore, their analysis of demo- graphic factors was inconsistent and provided no statistical evidence for variations in outcomes. Limitations included no representation of non-English trials and low quality reporting of outcome measures in individual trials. 11 Received for publication August 15, 2016; revised December 15, 2016; accepted May 20, 2017. From the *Womack Army Medical Center; yHenry M Jackson Foun- dation, Defense and Veterans Pain Management Center, Fort Bragg, NC; wDepartment of Math and Science, Lincoln Memorial University, Harrogate, TN; zWalter Reed National Military Med- ical Center; 8Uniformed Services University of the Health Sciences, Bethesda; and zJohns Hopkins School of Medicine, Baltimore, MD. The views expressed herein are those of the author(s) and do not reflect the official policy of the Department of the Army, Department of Defense, or the US Government. The authors declare no conflict of interest. Reprints: Chelsey Haley, MSCR, 6965 Cumberland Gap Pkwy, Har- rogate, TN 37752 (e-mail: chelsey.haley@lmunet.edu). Copyright r 2017 Wolters Kluwer Health, Inc. All rights reserved. DOI: 10.1097/AJP.0000000000000518 ORIGINAL ARTICLE Clin J Pain  Volume 33, Number 10, October 2017 www.clinicalpain.com | 939 Copyright r 2017 Wolters Kluwer Health, Inc. All rights reserved.