>> can you comment on how u.s. sees this atlantic partnership with europe? >> okay. anymore questions? if not, can i add one? i'm sure you've all heard of the book speaking about the post-american world, you know? emerging, and now, what's your reaction to the thesis we may be entering a post-american world as we talk about the future of american power? again, -- >> i'll do trade policy. [laughter] unless anybody else would like to. >> just tell us when you'll be completed, that's all. >> right. i think you're absolutely right, there's been ten years of

negotiations, and they have not reached a successful conclusion, not because of lack of effort or political will, but because i think the world fundamentally changed over a decade, and the china, india, brazil and emerging economying that existed in 2001 are different today. it's no longer appropriate, and this goes to the point about china living up to international norms and obligations, and it's no longer appropriate for us to provide unfettered access or new access to the market without other economies opening their markets as well. we were not able to achieve that, and we are still committed, we, the u.s., and i think all the parties in geneva to see what round of the devos round agenda we can be committed to to get done in various ways. we're committed to the ftas and help of bipartisan support in

congress, have those ratified and implemented. we have the trans-atlantic partnership which is important with the goal of setting a new high standard of trade agreements among the first countries that started the negotiation, but eventually, other countries as well who want to join, and are committed to the international rules and norm, and we'll hopeful those standards will eventually make their way into the multilateral trading system as well. we're in deep dialogue with the european union, announced a high level panel to look at a range of ways of expanding trade, everything from regulatory cooperation to an fta or beyond an fta. we're in that process now looking at what can get done multilaterally and plural laterally. >> also, i've been very much involved in that because of my former position of chairman of the ag committee. obviously, there's three

segments and there's the manufacturing sector, the services sector, and the agricultural sector. the perception was there that ag was holding this up, but at the end of the day, it was the services sector that really caused the last negotiations to fall apart. i'm sure the negotiations under usdr, ambassador ron kirk, a terrific guy and very positively trade oriented will resume. we'll have a farm bill this year. we've talked within the ag community we have to make sure wto complies that answers the question that the round presented, and hopefully, we'll have a -- at the end, if not this year, certainly within the next couple years, we'll have an end to the rounds that's concluded possibly. >> the question about that too

-- >> yeah, i think i was the first elected official in the country of georgia after russia, you know, had a little skirmish recently, and my comments are about that the relationship has to be more robust than it is. there is no question with the pressures that many of the european countries have had fiscally and maybe for other reasons, nato has become something different than i think originally envisioned, and my point is that that rebalancing, and i think the senator just eluded to that too, has got to change for that to really be a real robust relationship. it's been a little bit, not every country, but generally speaking, it's two one sided or ending towards the united states of america. for what it's worth, i thought

the way that they handled libya, first of all, i never thought libya was in our national interest. i'm a great -- i may get ire from people in the room, but i didn't see that in our national interest, but if we were going to be there, i thought the way it was handled by the administration was far better than us taking the lead. >> ask the question about the post-american world? >> i'd be delighted to respond to that. i wish all the countries of the world strength, economic progress, progress in democracy, progress in human rights, and i think each of their people the opportunity to live a good complete life, and i would hope i have not read the book, but i apologize, but i would hope they can join us in being part of the international community working through difficulties at the u.n.

and i am not ready to say, no, they can want reach the level that we have achieved, but i wish all well, and i hope we can work together. >> do you want to add something to the either of the questions? >> i won't review the book, but i would simply say to go back to the purpose of the book, i think we're in an american century, i think we'll be in an american century, requires us to exercise our influence more intelligently, more creatively whether it's food security or global health or pandemics, we have to be able to show leadership in dealing with those issues as well as the traditional issues of american foreign policy, but i have no doubt that we have very good days ahead of us. >> well, ladies and gentlemen, we've had an interesting one hour. you must say that before the

panel discussion began, i was afraid the polarization of america was still over here, and i'm amazed about the agreement here. there's an agreement that america will always be number one. [laughter] there's agreement that they with care for the fiscal deficit, agreement on working with the rest of the world. it's amazing. we achieved a lot of agreement here in davos, and now we have to transfer this spirit back to washington, d.c., and once that's done, the world will be a better place, so thank you very much. [laughter] [applause] [inaudible conversations]

>> well, one of the trickiest things about writing the book, for me, was thinking through the way, particularly in the human international rights context, rights were both kind of strait -- straddled with aspirational ideals and a more practical, inform mall mandate. >> on "after words" from distributing food to the poor in india to sex trafficking in

japan, richard thompson ford describes rights and how well meaning policies can help. house historian looks at the african-americans who served in congress. he's joined in the discussion by former congressman, and a book party at 11 from the lip, the life of senator al simp vonn wrote by his former press secretary and chief of staff. booktv, every weekend on c-span2. at the 1968 olympic games, they raised their fist in the block power salute. >> this is black power. they intimidated so many people, white people in particular by using that phrase, "black power" because when they used that word or phrase, "black power," people thought they meant destruction, blowing up statue of liberty or

destroying america. it was not anything about destroying america, but rebuilding america and having an america to have a new paradigm in how we could truly be part of the pledge doing that in high school about the land of the free, the home of the brave. we all want to be americans, but as young athletes, we found that something was wrong, something was broke, and we wanted to take our time to evaluate and then take our initiative to fix it. >> discover more about african-american history during black history month on booktv on c-span2, and online at the c-span video library. search and share from over 25 years of c-span programming at c-span.org/videolibrary. an constitute of medicine report saying adults suffer from chronic pain, and doctors at a

recent senate hearing offered recommendations for better treatment and research into chronic pain. senator tom harkin of iowa chairs this two hour hearing that also examines medical costs for chronic pain, the common barriers to treatment, and educating doctors and patients on pain relief treatments. >> the senate committee on health education labor and pensions will come to order. chronic pain is a significant public health challenge that has yet to receive adequate attention. given the tremendous impact it has on people all across our nation. it's estimated that approximately 116 million adults, and more than the number of adults affected by heart disease, cancer, and diabetes combined suffer from a form of chronic pain. these often di bill at a timing conditions have a tremendous impact on many daily activities

making it difficult for many individuals with chronic pain to meet their own basic needs. chronic pain profoundly affects quality of life. it remains one of the most challenges conditions to assess and effectively treat. i'll repeat that. it remains one of the most challenging conditions to assess and effectively treat, even though it's one of the top reasons for doctor's visits. because of the pervasive impact of chronic pain, we convened this important hearing today to explore the current state of research, car, and education with respect to chronic pain. to examine barriers associated with treatment, and gain opportunities for further research and prevention strategies. as the chair, not only of this committee, but of the labor health human services appropriations subcommittee, i've long encouraged a more ambitious emphasis on pain research at the national institutes of health.

in 2003,nih took a huge step forward in this area by creating the nih pain consortium. they recognized that despite the fact every institute and center addresses some aspect of chronic pain, none had the sole responsibility for this critically important issue; nor were the institutes coordinated their pain research. this lack of coordination limited the attention given to pain research. despite advances made by the nih pain consortium, still needs to be done at nih and across the federal government to address the unanswered questions, the unanswered questions surrounding diagnosis, treatment, and prevention of chronic pain. today's hearing will largely focus, not exclusively, but largely focus on the recently released report by the institute of medicine titled "relieving

pain in america: a blueprint for transforming prevention, care, education, and research." this crucial report examines the issue of chronic pain in america, identifies some barriers to more effective pain research and treatment and suggests a plan for addressing these barriers. the report advocates for enlightening health care providers, patients, and the public on the substantial burdens of living with chronic pain, and it highlights areas for improvement in pain, research, care, and education. education, we need to do a better job of educating in medical schools and in our residencies about the different forms of pain and how they should be treated. the so-called physiological pain that everyone recognizes right away from a sprained ankle, burn, or broken arm, or cancer.

we know the physiological source of that pain, but then how about the physiological pain for which we don't know the source? irritable bowel syndromes, spastic collins, back pain, and so many others where there does not seem to be underlying trauma, but we don't know the source. how do we educate our doctors to understand this, and to make, as i say, the right type of assessment and diagnosis, so i look forward to the testimony about our expert witnesses who approach the issue of chronic pain from a variety of perspectives, all with the ghoul of addressing this critical, but often neglected health issue, and this is a public health issue, and what it costs this country, both in terms of

dollars, but in terms of lost activity and loss of quality of life, so i thank you, all, for being here today, and i look forward, certainly, to your testimonies. we'll have two panels. on the first panel, we'll here from dr. lawrence tayback, national institute of health, number two person at nih, and he serving as the director of research and co-leads the nih pain consortium. dr. taybak, thank you for your service and your record will be made part of the record in its entirety, and if you can sum it up in a couple minutes, i'd appreciate it. i ask unanimous concept for the record to be left open for senators who may be coming here later. welcome, and please proceed. >> mr. chairman, thank you, and thank you for the opportunity to

testify about one of the most important and i'll highlight what nih is doing about pain research and treatment, and i hope to convey promising opportunities that science offers to overcome the challenges of preventing and treating chronic pain. pain provide useful information of warning of bodies of damage, but chronic pain is harmful in terms of diabetes, art arthritis, or cancer. this is a problem for the future. perhaps, the most important modern insight about pain is chronic pain, however it begins, can also become a disease in of itself. this recognition of chronic pain of the disease has important implications for how we study pain, treat it, and structure

our health care systems to provide care of suffering from the pain. congress took steps in advancing research, education, and caring for people with the pain with decisions made in the affordable care act that directed the secretary of the department of health and human services to establish the research coordinating committee, the itrcc. their responsibilities include summarizing advancing in pain care, identifying gaps and duplications of effort across the federal portfolio in recommending how to decimate information about pain care. they will hold their first meeting on february 27th. the secretary engaged secretary of medicine to have a conference on pain to recognize pain as a public health problem, survey the care, identify barriers to care, and recommend how to

reduce barriers. one report noted that progress requires a better understanding of the biology of pain, improvements in the therapy, develop process, and removal of barriers to optimal care and the health care system at large. nih activities drive improved scientific understanding, complement private sector development, and inform the societal and care delivery issues that ultimately fall within other agency's missions. the nih pain consortium coordinates pain activities across the nih, constitutes and centers with individual components of nih taking the lead on specific programs as agreed to their mission. for example, the nih blue print for neuroscience research is soliciting interdisciplinary research to learn how changes in neurosignalling signals chronic pain. they also addressed education of

pain and researchers and there's another key highlighted by the report. the investigator referred to pain, and nih undertook specific initiatives including one entitled "mechanisms, models, and management in pain research" which the iom commended for its soundness. they target specific conditions including recently ocular pain migraine, joint disorders, and nerve damage from cancer therapies to name but a few. the national cementer for complementary and alternative medicine funded two cementedders on cron -- centers on chronic back pain and speering an agency effort on the pain consortium to develop criteria for back pain. the national institute of diabetes, digestive, and kidney

diseases research network is another example that embraces the whole body approach. in conclusion, as a scientist, i'm encouraged by the opportunities for progress that research presents. as a clinician who experienced treating parties in pain, i embrace the important shift of treating chronic pain as a complex, multifaceted syndrome of its own, and we have to work together to enable delivery of more effective treatments and take full advantage of what medical science provides now and in the future, the report calls for transformation of how we as a nation understand an approach, pain management, and prevention. it's the first icc meeting, and the meet will begin its work towards developing a frame work to execute the transformation within the research community. thank you, and i'd be happy to answer any questions. >> dr. tabak, thank you very

much, and thank you for your leadership on this issue. we have a few questions. i want to delve into the department's strategy with respect to coordination of pain management. can you elaborate on when to expect the department to provide us with a full report on what steps the federal agencies take to implements iom report recommendations, and is the conceived strategy recommended by the iom being completed? >> first step is the establishment of the interagency coordinating committee, and they established this in july 2010 and selected the final roster of 19 members, including seven federal members, seven academic members, and six public members. this committee will hold its first meeting on march 27th on nih campus with doctor story landis, director of nhis, will

act as the interim chair. nih is working with other member agencies to gather and ally the agency's pain related scientific advances, their scientific portfolios to get an overview of the public-private partnerships and their efforts so their may be reviewed and discussed at the committee's first meeting in march. >> okay. second, i'm interested in initiatives to promote prevention wellness. you talked about the prevention to pain. as you know, we have a large segment of part of the american care act that is prevention and wellness. what about the role of prevention? i mean seems like we have chronic pain, but how do you prevent it? are there prevention strategies? >> obviously, this is a

multifaceted problem, and first solution, of course, is to delineate those people who are most at risk to develop chronic pain, and there a number of ongoing studies which seek to identify so-called risk factors that individuals may have which make them particularly susceptible. this can take the form of studies of their genetic backgrounds. for example, in the oral pain evaluation and risk assessment, termed opra, and you'll hear 3w0*u9 that in the second panel, individuals have been studied in a prospective form, and a number of genes of interest have been identified with nose that associate with pain and these give you clues as to who might be particularly susceptible. another change variant has been discovered with seems to be

predictive for people from chronic back pain after back surgery. this gives you insights as to who may be more or less does -- more or less susceptible to these painful conditions. another option or two begin to dissect the molecular pathways which underlie croppic pain, -- chronic pain, and in so doing, identify no and novel targets that allow you to intervene to either reduce or, indeed, eliminate the progression from an acute situation to a more chronic one, so, for example, scientists have identified several specific molecules from the omega-3 fatty acids, and what they are able to do is reduce pain associated with inflammation, which, as you

know, is now generally treated with cox up hib -- cox inhibitors. there's a series of studies ongoing using realtime brain imaging allowing us to understand how one is able to control one's reaction and sensation to painful stimuli, and in so doing this, once, again, we may be able to come up with biomarkers to allow us to identify a subset of people most at risk. >> very good. thank you very much. i'll leave the record open for any questions that senator enzi and others might have. . >> thank you. >> we'll call the second panel. dr. phillip -- i hope i correctly pronounce that, the

chair of the iom report just referenced here. he's joining us from stanford university, professor in the immunology department focusing on the report and reameses for future areas of research, and next we have dr. william maxner. please come up to the witness table, please, so dr. sarno there on the end. there you go. welcome, dr. william maxner, doctor at the university of north carolina at chapel hill. he comes to us today with significant experience in the area of pain management research. he has experience working at nih and developed an oral facial pain management program at chapel hill.

kristin, national director will share with us her personal story of chronic pain, and she was appointed to serve on the inner agency research coordinating committee at nih, and the committee was created to coordinate activities across the federal government. next, we have dr. john sarno, a doctor at the new york medical center and practitioner at the rehabilitation of medicine. he's the awe nor of four books and pain, sharing his work with respect to treating chronic pain. i thank you for coming here. your testimonies will be made a part of the record in the entirety, and i ask you to sum up in 5-7 minutes, probably a light down there, i don't get too nervous if it goes over unless it's a long time, but if you're summing up five, six,

seven, eight minutes, that's fine with me, and your statements will be made part of the record in their entirety. please proceed. >> [inaudible] >> punch the button. >> thank you very much, mr. chairman. it's an honor to be here with you today, and i appreciate very much your interest in this important topic. today, i'd like to show you the results of our institute of medicine committee that i co-chaired with norene clark from the university of minnesota. the port -- port of michigan rather, excuse me. the important findings from the committee elude to as follows, the number of americans suffering from chronic pain numbers 116 million which is an underestimate because it doesn't take into account children, custodials in facilities, people in the military and others, so this is a hijack problem in

terms of magnitude of numbers and shadowed by the financial impact of pape in the country as well. currently, we spend between $560 billion a year on pain. that's more than we spend as a nation on cancer, heart disease, and diabetes together. it's $100 billion from the state and federal budgets to cover the cost of pain care, and the reality is that those expendtures are not alleviating pain in america as we know it today. our committee was certainly mindful of the fact that there is much to be done in developing cost effective technologies as we go forward, but the magnitude is simply astounding. we recognize we had five charges, some from the affordable care act through hhs and to the nih and the work. the first was to di lineate the public health patterns of care,

the magnitude of pain and challenges and problems as they stand today. the second was to review the impediments and barriers to accessing care to individuals with pain. to better dilineate individuals with pain. to access the tools at our disposal today to be used for research, education, care, and treatment and to discuss better ways of developing new approaches to research and pain through public and private partnerships. we were fortunate to have an outstanding committee of teen individuals remitting virtually all professional disciplines from science and medicine to law, ethics, nursing, and clinical practitioners and worked over a 7-month period to produce the report before you, and in doing so, we reviewed the literature, we held in number of

public workshops, meetings, reviewed testimony from over 2,000 individuals, commissioned an economy report to help us assess impact of pain, and we concluded that relieving acuting chronic pain is a significantly overlooked problem in the united states. we were guided by the series of overarching principles as we began the work. the first is pain management is a moral imperative. the second is that chronic pain can be a disease in its own right, that there's a need for a more comprehensive approach using interdisciplinary methods to treat, diagnose pain, and better utilize working strategies and we recognize the importance of patient and other providers in the education management and prevention of pain. we were not specifically charged to look at the importance of

issue of use in pain, and we'll recognize there's multiple sides to the important issue, and that this is a topic that should be further studied, but we mainly focused on pain from a public health perspective, and in doing so, we also recognize the individual impact of pain, and i'd like to read you four testimonials from over the 2,000 received. first from an advocate. treating a pain patient is like fixing a car with four flat tires. you cannot just inflate one tire and expect a good result. you must inflate all four. from a physician with chronic pain, pain management and physical rehabilitation was not in the school curriculum or in my family practice residency. my disability could have been avoided or lessened with treatment and i could still be the provider rather than the patient. from a clinical pharmacy specialist, i quote, "we can want successfully treat the pain

without treating the whole patient. insurance companies pay for useful, expensive procedures and surgeries, but won't pay for the cognitive behavioral therapy." from a patient with chronic pain, "i have a master's degree in social work, a well-documented illness that explains the cause of pain, but when the pain flairs up, i go to the er, put on the gown and lose my identity. i'm a blank slate for doctors to promote their own prejudices on to." these are four of thousands testimonials that led us to conclude that alleviating pain in america must result in a cultural transformation how pain is perceived, how physicians and providers care for pain, and how we develop the social contract with each other to advance clinical care, education, and

research. we had 16 recommendations, and in doing so, we focused on the public health issues, pain, care, and management, education of patients, communities, providers, and research, and to help, our committees with the activity, we prioritized for the 16 recommendations as what we felt should be completed and implemented by the end of 2012. we brought our report forth in june of 2011 with that hopeful expectation, and i'd like to sure with -- share with you the hopefuls of the recommendations. first, dhs should create a comprehensive population level strategy for pain treatment, management, and research, and this should be coordinated across public and private sectors, include an agenda for research, improve pain assessment and management

programs, improve ongoing efforts to create public awareness of pain, and this recommends that the secretary of hhs with other entities should develop strategies for reducing the barriers of the care of pain, focusing in particular on populations disportionally affected and under treated for pain. third, recommended that health care providers, insurance, and others should work collaboratively between pain specialists and primary care clinicians including referral to pain specialists when appropriate. there's about 4,000 pain specialists in the united states, not nearly enough to cover all of those with pain, and therefore, we look to enhanced education and training of primary care physicians to work collaboratively on new care models to better direct and lineate for those suffering from pain. finally, as an immediate

recommendation, we recommended that the director of nih should designate a lead institute at nih that is responsible for moving the pain research agenda forward along with increased support for the pain consortium. this should involve pain advocacy and awareness and organizations and should foster public and private parties. there were 12 other recommendations as well, and we felt these recommendations served the goal of creating a comprehensive population level strategy for pain prevention, manager, and research. the scope of the problems in pain management are truly daunting, and the limitations and knowledge in education, health care professionals are glaring. medical community must actively engage in the necessary cultural transformation to reduce pain and suffering of americans and work collaboratively to do so with public and private sectors. thank you very much for listening to me.

>> thank you, dr. pizzo. did i pronounce that right? >> yes, you do, thank you. >> welcome, please proceed. >> thank you, mr. chairman. let me just start by thanking the chairman for indulging these testimonies. it's an honor for me. i'm born in ottumwa, iowa, southeast iowa, and testifying before an iowa senator is an honor for me, but also representing the pain research committee and the parents who suffer there a hidden epidemic. let me start my formal statements. it's a tribute to the political system that the voices of a few can be heard and acted upon. today, i'd like to further detail several of the points made in the imo report, relieving pain in america, providing evidence that more than 100 million of the fellow citizens experience a silent, hidden, and poorly treated

epidemic. an epidemic is as real as a polio epidemic that visibly shackled hundredings of millions of americans causing family and friends to suffer greatly. they suffer silently without the outward signs of an iron lung. similar to this, a transformative natural effort is needed to crush the epidemic of chronic pain worldwide. i submit we have the tools and knowledge to conquer the epidemic bringing relief to millions worldwide. the question is whether the fortitude and will to mount a focus on pain that results in adequate treatments and cures for common conditions that exist within the united states today. during my time, i'd like to highlight some of the points from the iom report, and also address barriers that exist in

the area of research, education, and care. . we've already heard two testimonies related to the magnitude of the problem impacting over 100 million americans as we sit here today. with horrendous cost to society, over 600 billion annually paid by our society for these conditions. more than this, this committee and to the understanding of the public, i think is a chronic pain is truly a disease. it's more than a symptom. it is a disease in its own right. we understand the biology to a large extent, and many of the genetic and bilogical principles that lead to this very set of conditions. i believe we have adequate knowledge with the biology, psychology, and social fabric that underlies chronic pain conditions as well as factors that we're at the verge of being able to make substantial

progress on the massive public health issue. there are, however, several barriers that preclude a national transformative effort that i'd like to highlight and recommend as outlined in the iom report and offer some of my own, i think, perspectives on solutions as well. with respect to barriers to research, in my view, one of the major barriers represents the substantial mismatch between the allocation of pain research. though one qifls about that level, and it ranges from 0.4% to 1.3%, yet, we know that the consumption of health care dollars is enormous. if we look at medicare costs alone, 14% of the medicare budget is used for chronic pain alone, and nih resources are used for the study of chronic

pain. looking beyond medicare and the consumption of direct costs associated with treating common conditions including chronic pain, we find that almost 30% of direct and indirect costs are associated with the payment for the treatment of chronic pain conditions. in my view, there needs to be additional resources either provided by nih, targeted towards chronic pain, and pain initiatives or an allocation of nih appropriations that are used to further address further pain related conditions. there's other substantial issues outlined in the report of research, but, to me, that's one of the primary fundamental research barriers currently impeding progress. in the area of education, it's eluded to that curriculum is a

fundamental problem. i served at unc school of dentistry, and i had opportunity to look at the curriculum content devoted to pain management and pain mechanisms. i'm proud to say that at unc, we have 20-some hours of offerings and practical offerings which, in my view, is still sufficient, but compared to medical curriculum, where the average student receives nine sessions related to pain management and pain mechanisms, woefully inadequate in my view to provide competent individuals who are able to diagnose and treat patients with chronic pain conditions. i recommend major curriculum reform that is associated with discussions of crediting agencies and perhaps discussions with the department of education that will help mandate further

change in curriculum. i'm not one to easily recommend mandates, but i tell you it's a daunting task trying to work in more clock hours for a specific discipline. the lack of education has direct impact on the sparse manpower that we have with respect to those competently trained to deliver management and diagnosis of chronic pain conditions, and i think expansion of our gme programs that will percent sponsored -- permit sponsored fellowships in residencies with health care related to chronic pain management would be extremely helpful. barriers to party care, they are substantial. as we heard earlier, reimbursements for primary care physicians on the front line, reimbursement is very poor for these conditions, and i think mechanisms need to be placed for

primary care physicians to improve continuing education opportunities, incentives given to the general physicians to promote continuing education as it relates to pain management. the need for, in my view, for both patient barriers and primary care barriers is the need for advanced pain management centers. there has been words made to the effect that we need such centers. i think it's now time that advanced pain management centers become a reality. these can remit the most -- represent the most important portals of endrink to the health care -- entry to the health care system, referrals from primary care physicians, portals of entry for patients who suffer from di dibilitating chronic physicians, this requires doctor shopping,

going one doctor to another for treatment. we need coordinated pain centers that have both education, research care, and missions behind their walls, and this is one of the most important, i think, aspects of care that breaks through carriers 245 all face. i have other aspects in the written testimony, but i'll conclude by saying that addressing and breaking through barriers not only improve the human condition, but will fuel new economic opportunities and job creation that will enter the 21st century. the tools and pathways needed to conquer the hidden epidemic of chronic pain are now before us. we, americans, have a pride in improving the human condition. a national initiative similar to what we addressed with the polio

epidemic is needed. it's within our reach, and we will relieve suffering of millions of americans by so accomplishing this initiative. all that's required is to act upon the voices that suffer from this epidemic. thank you, chairman. >> thank you much, dr. maixner. i'll yield to senator whitehouse for further elaboration on the next witness. >> thank you, i'd also like to make a brief comment. >> sure. >> first of all, thanking you for holding a hearing on this important topic, the costs that come with chronic pain are enormous, and not just cost measured in dollars, but they are human costs measured in quality of life. as rhode island's attorney general, i brought together a group of health care stake holders to look into problems we

were facing and making pain management a routine part of patient care. our work centered on simple things like making pain a fifth vital sign recorded by the medical establishment, and it was memorial hospital the first to take the step, and other rhode island hospitals since followed on. promoting awareness and education and nearing end of life, and both cross providers and parties have to be a fundamental strategy to improve care, and brown university had done a study showing that the majority of families with a dying loved one reported that their loved one died in pain. of the families reported their loved ones died in a pain, they described the family member's pain as severe or excruciating.

it's a really important issue, and it gives me great pleasure to introduce christine, a dedicated advocate, executive director of the association and plays a critical role in raising awareness of pain disorders that disproportionally affect women, and she's a resident of north kingston, rhode island. he received her bachelor's of science at the university of wisconsin, worked in the department of neurology at the johns hopkins university hospital of medicine. pleased to announce she was appointed the nih's new interagency pain research coordinating committee, and her professional experience is 5 great asset to the committee whose mission is to identify gaps in basic and clinical research on symptoms, cause, and

treem of pain, so, chris, congratulations on the achievement, and important assignment, and we look forward to hearing your testimony, and i'll close, again, with my gratitude to the chairman for allowing me to recognize this native rhode islander who we are proud of. >> thank you. your record will be made part of the record in entirety, and proceed as you desire. >> thank you, mr. chairman. as one who serves a long neglected and women who suffer from genital pain, and this is 5 privilege that i do not take lightly to be before you today to share some of what millions of americans experience in their daily battle against chronic pain. we're grateful to call on the study what the iom committee concluded is a national crisis that we have a moral imperative

to address. the oim report gave us renewed hope, hope that our cares about us and listens to the plight to help us regain some quality of life. i survived a near fatal accident at 15 years old and also found a resolution to the pain i experienced in my 20s, but i've had back pain for 20 years, and i developed pain as well as migraine headache. my story echoes the experiences of millions. i'm one of many. the reality is that my choice in being here today, while it is a privilege, means that for the rest of this week and maybe next, that i'll be somewhat income pass at a timed, and many in the country don't have this choice anymore. from the moment i oche my eyes every morning, first thing i feel is pape and it stays with

me throughout the day. as the number of hours i develop to managing aappointmentments, pain symptoms, and medication side effects, which now averages 25 hours a week for me, my normal daily activities are more and more difficult and the most meaningful pieces of me and my life slowly fades away. due to an inadequate research effort, doctors don't have the training or scientific information they need to effectively manage pain. as patients, we're less completely disillusioned, forced to navigate the health care system on our own and implement a trial and ere -- ere rough process that takes months to years to find a treatment to lessen the pain we experience. in the last four years alope, i've been specialist in four states, tried 15 treatments, and i still live with moderate to severe pain that impacts every day of my life. i spent $10,000 on out of pocket expenses alone in the last two years.

i'm privileged to have an understanding employer and good health insurance, which many in the country, do not. pain exhausts, depletes, duh humanizes, and drapes you in every capacity. it's only by god's grace and with the support of my family that i function as well as i do and because pain's very purpose is to warn you something is wrong with your body, it's completely impossible to know. your mind is cloudy, attention scattered, and if feels like you live with a vail over your face. work is undone, productivity and efficiency are things of the past. i only selectively engage in activities i once enjoyed because of the increased pain and disability to follow. life does not stop. in goes on in our absence. chronic pain is invisible. you can't tell i have problems.

you look fine, but feel like dies on the inside. when you suffer from pain in an area of the body not discussed by the country like women with vulvodynia like we do, it's compounded with embarrassment and isolation. this impacts women. further, mounting research shows once you develop one pain syndrome, there's pain in other areas of your body. this is the reason why the nva joined forces with the associations, the cfid association of america and the tmj association to form the chronic pain research alliance. the first collaborative advocacy effort to advance a smarter and more cost effective approach to research on the neglected pain conditions that co-occur and impact women. there's tmj, chronic fatigue, fie bro myalgia, and our 2010

report drew the same conclusion as the oim. women have longer lasting pain than men and treated less aggressively and the reports are dismissed as hysterical and not real leading to mental health diagnosis. our failure to deal with these conditions add the wasteful $80 billion a year to the growing health care bill, and despite this toll, the nih's research investment averages $1.36 per affected women in 2010. the end result, as we heard, is that the afflicted are retunely misdiagnosed and left untreated and without hope. it takes years and multiple consults to obtain diagnosis, and when it's given, evidence-based treatments are limited forcing the afflicted to experiment with multiple treatments with unknown benefit and risk. because of the disperty and neglect of the conditions, it's

essential for future pain nichetives to have an appropriate conclusion of conditions. we applaud the health committee, iom, and nih for your initial steps to address the national crisis, and we support the oim's main recommendation that by the end of 2012, hhs creates a population strategy for pain. all the recommendations stem back to one thing, and that's research. we need an increased, smarter, and more cost effective federal research approach by placing greater priority on collaborative research across the conditions as well as across nih institutes and federal agencies. it's only through research we better understand the mechanisms of the pain to delineate treatments and have recommendations. then, and only then, will the

pain as well as the costly and wasteful health care spending come to an end giving the millions of american sufferers and their families the one thing we want returned to us, and that's our lives. thank you. >> thank you, ms. veasley. now dr. john sarno, and as i said, he was the author of four books, being mind over back pain in 1984, the second healing back pain in 1991, the third is mind, body, prescription, 1998, and the fourth book is the divided mind, which i have right here in 2006. so, dr. sarno, welcome to the committee, and please proceed. >> thank you, dr. harkin, and thank you for inviting me. pain syndromes can be grouped into two categories, those results from injury -- this is the way i see it -- from injury,

surgery, or associated with severe infection. as seen in parents in acute hospital settings, and those with pain in the back, neck, shoulders, and limbs of a psychophysical origin. the higher incidence of the latter group evolved into a public health problem of great magnitude over the past 40 years. it's smimented that 80% of the population have a history of one of these painful conditions which is led to the performance of a great dealing of unnecessary surgery and the widespread use of pain medication. it is troubling to realize the pattern of pain and physical examination findings often do not correlate with the presumed reason for the pape. for example, pain might be attributed to changes at the

lower end of the spine, but the patient might have pain in places that have nothing to do with the bones in that area or someone might have a lumbar disk herniated to the left and have pain in the right leg. more importantly, was the observation that 88% of the people with these pains had histories of such things as tension or migraine headaches, heart burn, hernias, stomach ulcer, clit clie toc, hay fever, and asthma, and a variety of other disorders, all of which have been strongly suspected by physicians of being emotional. ..

becomes a lifelong problem. there is no logic to the traditional physical treatment. instead experience has shown, my experience that the only successful and primitive way to treat the problem is by teaching patients to understand what they have.

they must make the diagnosis and this cannot be made by a psychologist or a psychiatrist. to rule out cancer, tumors, bone disease and many others. the presence of persistent pain anywhere requires a comprehensive examination and test. though this my own earl syndrome is the result of emotional phenomenon, it is a physical disorder and must be studied as such. it is not quote in the patient's head, unquote. there is a need to raise consciousness both inside and outside the field of medicine to help to change people's perception of the cause of common pain syndrome of which representative of a major health problem. science is validated by experience and replication is

essential that these ideas also be subjected to research study in the future. thank you, sir. >> thank you dr. sarno. now we will start a series of five-minute rounds of questions or i should say a dialogue with all of you. dr. sarno something i just said. i'm going to skip around here a little bit. where is it? ms. veasley said something that i wanted to, oh yes. ms. veasley in talking about a report, you said that medical professionals are more likely to dismiss women's pain reports as

emotional, psychogenic, hysterical or oversensitive quote and therefore not real, leading to more frequent mental health diagnoses. so i ask you, is the pain real or is it just in her head? >> the pain is always real but i think the problem is it's not recognize sufficiently that emotional phenomenon can actually bring on pain. if you would like a physiologic explanation, that is simple too. the simple reduction of blood flow which can easily be accomplished by the brain to vital spinal nerves or any spinal nerve for that matter but usually it's more in certain areas, the low back for example or the neck or shoulders, it's easily done and i think it's important to recognize that emotions can stimulate physiologic change.

>> mr. chairman may i also address that? >> yes, yes. i agree totally with what was just said. i think it's very important that we don't associate mind and body when we talk about chronic pain conditions and put chronic pain conditions into strictly and in their heads psychological component. it's very clear from current research that there is an underlying neurobiology that is associated with affect, mood. there is neurochemistry and there is a very well assessed narrow biology and we know that many of the pain pathways that our patients have activated activate the same pathways in the brain that are involved in affect of mood and emotional response. so chronic pain is really a mosaic. it's a mosaic of interactions between the effective domains of

the brain of those areas of the brain involved in processing pain information. so it is really impossible for us to dissociate mind/body and in fact when we talk about the emotional, psychological aspects of pain we are really talking about an underlying neurobiology that leads to the overall gestalt of the sensation that our patients complain about. >> dr. pizzo. >> i certainly agree and appreciate that there is a broad array of contributing factors as as been stated. i think it is also important for us to be very sensitive to the words we use and the way that they are received. there is today a significant amount of perception felt by those suffering from chronic pain and in fact those called to serve on behalf of patients,

that there is a significant amount of quote emotional contribution. and i think while there is no doubt that our emotions contribute to our physiology, i think that we have much work to do to look at our approach to pain just as we do other neurological and psychiatric illnesses from a physiological perspective as well. this is a very complex interrelated array of events and i think one of the things that our committee certainly heard and the data describes that one of the challenges that happens in medicine is when we don't know one answer we often describe it as something else and those assignments are often emotional and almost contributing back to the individuals if that individual becomes the victim of their own suffering. i think therefore, our view, the view of our committee is this really speaks to why there needs

to be a cultural and social transformation in how we look at pain and its vast manifestations that affect individuals and very discreet and individual ways and to ground it in a better understanding of biology and illness which is truly biopsychosocial but which has much to be learned about and it's very manifestations and actions. >> i guess, yes. >> thank you. i certainly don't deny that my emotional health or anyone else that suffers with pain affects my ability to effectively cope with both the physical suffering and the effects of pain on my life. but while i was hit by a car and nearly died, my pain has never been questioned by any medical provider. this is not the experience of the average pain patient in our country. and i would just put out there that there are many examples in

medical history. for example ulcers that were once attributable to stress and inability to emotionally cope that we now know answers to. their cause is bacteria and just because we do not understand yet due to the inadequate research effort that we have had, the mechanisms and the risks that result in chronic pain does not mean that it's made up in your mind and it is not real. thank you. >> if i might respond i think what dr. sarno was saying and i have looked at this a lot is, it's not in someone's head. it's that certain psychological things that are happening in a person's unconscious can actually create things that cause real physical pain. the unconscious can sometimes in order to hide some other thing in your mind, could stem the flow of oxygen to a muscle or to

a nerve. that tightens it up and you feel real pain. i don't think dr. sarno is in any way suggesting that this is anything in your head. it's just that certain emotional or certain unconscious -- underlined in some peoples minds sometime create pathways to real physical pain. am i correct in that? >> yeah and as i said emotional phenomenon can be responsible for physiologic pain, and that is the important thing to bear in mind. >> dr. veasley been looking over this pain and looking at some of the different approaches that we are taking, i don't see that being researched that much. may be i don't understand at all that well but i don't see that kind of an approach being researched. is that so or not so? >> approach meaning emotional basis for pain?

>> not emotions being affected by it but the emotions, and emotions is the word i don't like but the unconscious mind, something going on deep inside is causing certain physiological reactions in your body that are painful. >> i think our view of the research needs around pain are actually quite rotted not defined by any laundry and my comments earlier are not to pit one approach against the other, not to say that emotions are good or bad or physiologic pain and more important not manifest but rather than in our society today there is a degree of stereotyping that does take place. inadvertently ended pertinently and that has consequences. it's not infrequent. just as a matter of observation that when something isn't physiologically defined, it's often attributed to an emotional

reaction. that is what i was addressing and speaking to. i think it is important, and we heard from very eloquently from christin that when an organ manifestation like cancer there is often a rallying of our community to that individual because it defines suffering. i know this from my own life experiences as a pediatric oncologist, someone who has cared for children with cancer and pain for many decades. but when someone comes in with pain that is not fully defined or delay needed as you describe extremely eloquently, we make other assumptions in terms of cause and etiology. that is what creates the bias of both our providers, doctors, nurses, communities, our insureds and what they will pay for and not pay for and these are profoundly important. we are all too much a society today, a medical world today

that is focused on doing something. our insurance companies around pain really are more focused on doing a procedure or giving medication and less about for example cognitive or behavioral therapies or physical therapies, which will work probably as well or better. so i think we need a broad approach based on that and i also want to underscore your earlier question about research. we need a lot more research and the research is not simply about what we think we know but what we don't know. there is an extraordinary need for much more fundamental basic research and what causes pain, how it is manifested in how we can go about treating it. the therapies we have today although they work in many people are quite limited and we need her and new insights develop better approaches and innovations that will only come from very fundamental research as well.

>> very well stated. thank you very much dr. pizzo. senator whitehouse. >> thane chairman and thank you for holding this hearing. i think it's very important and help all. i am going back now i couple of years to when we started working on this in rhode island, but the thing that struck me was the extent to which in various health care settings, they pain that a patient was experiencing was either deprecated or overlooked entirely and that there was a systematic bias against recording it and reporting it so that even if you are were able to convince the doctor at a particular time that you were in great agony, when they banafsheh did somebody else came on and they looked at your paper record, there was nothing to clue them because at that point pain was not treated as a vital sign and not part of the

equation and there was even doubt about whether was possible to do that and there there is some subjectivity involved but clearly that is something we are able to get around. so my concern is how do we make sure that the hard records that exist in nursing homes and hospitals and various settings of patient care particularly as we move into the electronic health record environment, have appropriate fields so that the patients pain experiences being recorded and can be treated seriously? do you feel that we are there nationally at this point? i see a lot of heads nodding no. do you feel that a federal standard requiring certain steps be taken with respect to the day-to-day records? would that be a good idea and is this something -- i have been very active along with the

chairman and others on electronic health records in meaningful use and all that. should we be focusing on that is a topic as well? let me start with ms. veasley. >> it's difficult because we don't have the answers for patients, but yet we have no answer for patients flooding doctors offices every day needing help, and until we have that they seek research, and so we teach compassionate care, and tell providers understand that while we may not know all the mechanisms, just like many other diseases of the central nervous system, there are things that you can do to help patients. to continue to ignore the pain that someone reports, and as you issue previously mentioned end-of-life care, i recently lost my mother-in-law to pancreatic cancer which is excruciating. never once was her pain questioned, but the ability to

treated was hampered by the fact that we don't have the answers yet for providers. so they are left to kind of come to their own conclusions based upon their clinical experience, kind of treat pain as they see it. so we really have to advance research and quickly. >> thank you very much for asking that question which is enormously important. we are moving as an issue much more toward refined electronic medical assistance and the united states congress and the affordable care act is helping with that and we appreciate that. but our committee did delineate just as you suspected that even though we have a lot of data, a lot of demographic data that is our dn, there is much more that we need and it's one of the recommendations that we made to the secretary of the hhs and the related agencies to really facilitate a better collection of information that can help guide much more deeply the

impact of pain on individuals. the metrics that we have are important but relatively limited and i agree with you that this would the enormously important going forward. >> i agree and i think we have a very good methodology available to us to rapidly assess both inpatient and outpatient levels of pain. and i think it could be easily implemented into electronic patient record. i think a larger problem is how was that information acted upon by the health care system. when there is substantial pain, do we have well trained individuals who can respond for that cry? do we have individuals who can impact what we assess? of the assessment tools are clearly there but again as i articulated in my testimony, we

have very poor education with respect to pain management which greatly impacts the manpower that can respond to the epidemic that i discussed. >> i see my time has expired. chairman thank you very much. >> just as a a follow up senator whitehouse, doctors sarno a new patient comes into u.n. they have pain. what do you do? how do you assess it? what process? >> as i said, you have to be thoroughly worked up and studied and all of the known pathological processes that could be involved, so that is absolutely essential. and when all of the important things have been ruled out then i think it's possible to go into some detail with that individual about his life, what's going on and so on.

because i think that, and i want to say the same thing that i said before, a notional phenomenon can bring about physiologic change and we have got to keep that in mind. obviously we have to make sure that there is nothing else going on, so exhaustive studies are indicated before we would then begin to think about emotions and pain. >> senator hagan. >> thank you mr. chairman and thank you are holding this hearing. i think it's extremely important because they do know there are millions of people in our country today that are obviously suffering in chronic pain and dr. maixner and all of the welcome and i appreciate the expertise we have here as well as the personal experts. dr. maixner you seem very optimistic in your text the money about the future for pain research and treatment, and your testimony, you state that pain scientists are having great

success in unraveling the pathophysiology and biological basis of pain. can you describe to me some of the ways that we as policymakers can be helpful to ensure a successful path forward in this area of research and treatment? >> yes, thank you senator for the question. thank you senator for the question. we are making great headway in the fundamental understanding of the biology, psychology and genetics and molecular pathways of underlying common pain conditions. we have identified many of the risk factors that lead to conditions like tmd, fibromyalgia and many of the so-called common idea patzek being conditions. so this is if you will parallel to what has happened in the cardiovascular community where risk factors such as lipids, cholesterol, stress, those factors have led to interventions, lead to treatments and prevention.

we are at that step now and the pain field where we have identified biological factors, genetic factors, psychological factors, not all but many are now in our hand that we can begin to put them together into models to develop treatment strategies that relate to cognitive behavioral therapies, other types of behavioral therapies that can influence emotional response in distress. we have identified new targets for drug development, novel targets for drug development that i think could be very helpful in the future. we have the pieces, but we don't have initiatives that are large enough and well enough funded by both public and private entities that allow us to put these pieces together to study them prospectively, to evaluate the validity of our hypothetical constructs that we have with these risk factors, so what i think is truly needed our

large-scale population-based ideas that are house out of these advanced pain centers of excellence that i've noted. the senators would have not only inpatient care missions related to the portal by which physicians and patients come into treatment, but represent also research initiatives to actually document the validity of these risk factors, to document the effective therapies that we can now conceptualize for these theories that we have now put forward and to demonstrate the comparative effectiveness across many existing treatments and new treatments that we can advance. we are at that point where we can put forward large-scale proof of concept trials that would lead to new interventions and therapeutic interventions. >> thank you. dr. pizzo and dr. maixner you all disgust doctor shopping and

sometimes this is a barrier to properly treating patients with chronic pain. on average how many doctors does a person suffering from chronic pain sea before getting a proper diagnosis and you have estimations on the cost of, the numbers of different doctors that the patient might go to and what does that cost the health care system and is it because the patient does not get the response or they are still in pain that they feel they have to go to another doctor or are they also looking for more medication? >> senator i think that's an important question. i wonder if i could slightly broaden it if you would. clearly what we know today and as you have heard we are spending as a nation between 565 to $630 billion a year on pain and that over 116 million individuals are affected by it.

many of those individuals don't have access to health care is we would like them to be able to and even though we have some wonderful centers and need more as dr. maixner has described clear expert care can be given as a nation we really need to think about it much more distributed model so that care is available to underserved communities who disproportionately are affected by pain, african-american and hispanic communities have a higher proportional degree of pain than other communities. those suffering from some of the diseases that christin veasley and others have spoken about are disproportionately affected by their pain. that needs we need a different care model and a different distribution of providers, both primary care physicians working together with specialists, nurses, pharmacists and others on the frontlines, who might work in tandem with those

centers, creating new partnerships between them. and we need to pay for those services in a different way. right now there is a disincentive to -- that happens because of our current fee-for-service health care model which doesn't allow enough time for physicians or nurses or others to spend with patients to listen to their stories, gather the information and developing portfolio or planned that is really going to be meaningful for them. that is another area. we think about how the payment system is restructured so we we are notched just paying for expensive services but those that fit the patient. the reality is there are lots of therapies available today. not one particular one is best for all patients and not all are good for anyone patient. we need to look at the right match between them. i would say that we certainly have innovations and interventions available today but we have a great need for defining more.

there is a great need for defining new innovative therapies that we hardly know about today just because of learning more about the nervous system and how it works. i think there are great opportunities that lie ahead and i hope these, coupled with better educational portfolios for physicians nurses and providers, working in tandem with specialists can create a new public health approach to this very severe problem. >> how about the actual doctor shopping? >> there's a fair amount of doctor shopping that goes on larger because no individual is often satisfied with the results. on our committee and christine could speak to this, we have heard this many times. in fact we have heard from some of our committee members who have suffered from pain that if you don't get the result from one person you should seek another because there may be another approach that would be beneficial to you. don't give up. it's a really significant part

of the equation. on the other hand, many go from one doctor to another because dr. abc or provider abc never listened, never engaged in never helped. that is something we need to deal with as well. >> ms. veasley. >> if i could respond to both of your questions, thank you. we hear a lot about translational science, and in any area, all the pain research in the world are research on any given condition that takes place, if it doesn't trickle down to the patient for which it is supposed to serve, it is not helping. i see a great opportunity for federal initiatives to support ongoing educational and awareness initiatives aimed at both the medical community, the public and the patience to continually keep us all informed of the latest research coming out of unc and other great institutions around the country. right now we don't have that. so even though some of these

great advances are taking place, it's not getting down to your average physician are your average patient. and in regards to doctor shopping, guinness goes back to research. if we don't have a sick research to inform clinicians of what the cause and effective treatments or for any pain condition, they are left to their own clinical conjecture to make decisions on whether patients cause or treatment ap and this even happens in the pain community. we find physicians who just specialize in pharmacology. they just specialize in nerve locks or implanting devices in patients even though a mound of research has shown that both the disciplinary cares how to treat pain. and so you know you have many reasons why patients go from doctor to doctor. one is that they are told their problem is not real. your pain does not exist. you must be imagining this. i don't see any sign or inflammation or any problem you

may have. we don't understand the mechanisms. i can tell you from personal experience and also from talking with thousands of patients, that for as many doctors as you see, because we don't have this basic research, you are going to get that many diagnoses and treatment recommendations. as i mentioned in my testimony, that leaves it up to the patient to fend for themselves or try to decide out of all of these treatments, which is going to help me. ..

you will die six and a half years earlier than if you're in the top 20%. i would imagine -- i would like to ask you -- i guess which you are saying is if you are poor, uneducated, more likely to become adult, margaret lee to experience pain. can someone speak to that? >> yes, senator, i can speak to

that. i think one social economic status may be a surrogate marker of environmental exposures. the types of exposures have but one of risk for the development of a variety of chronic pain conditions. so we know that there is physical injury is one such physical environmental exposure that can activate genetic pathways that lead to pain conditions. individuals with lower socioeconomic classes are a proud and experience much greater physical labor and are more prone to physical injury. we also know that distress, psychological distress is also a big driver at genetic pathways that can lead to the up regulation of pain processing and affected ms. back pain patients experience. and again, lower socioeconomic status i believe is a surrogate

marker for the amount of distress, the environmental exposure, one of the important environmental exposures in addition to industry that can drive these pain systems -- the >> environmental exposure as stress. >> in terms of how to feature family. >> exactly. >> to contribute to illness, which contributes to pain. >> and emotionality that lowers your immune system, genetics that the expression of genetic pathways. these are what i call environmental exposures that are of higher density and higher magnitude and individuals to fall within social economic classes of the lower tiers. >> i would like to suggest a more freudian if you will, as come as psychodynamic explanation and that is that poor people are poor and they are angry. they are furious, as a matter of fact i was society has allowed

to happen. and that fury will either physical symptom believe it or not as a defense against the rage. they can't reach, so what happens is they get sick and i believe that this is an extremely common phenomenon. >> turning down the cab and on turning angry against themselves. >> exactly. >> one comments because i think this is an important discussion and i'm glad you raised the issue very much. one facet that extends from what.your maixner said. this acute pain and chronic pain. if you're not able to access care because of the socio- comic limitations, there is a probability that what might've been a self-limited problem becomes a more chronic persistent one. so from a preventive strategy

and economic strategy, early intervention is certainly better than delayed intervention. >> which is why some of us among other things try to build community health centers all over the country. >> i want to ask another question. i apologize for being late. we will hold hearings in a couple weeks on dental care access. my understanding is one of the major reasons for absenteeism among children is dental problems and she takes. and we have a huge problem there as well. does anyone want to say anything about doesn't care and lack of dental access into the pain and so forth? >> well, i would just like to note that this continues to be an evolving problem, especially amongst the lower socioeconomic population that many of us in the academic community serve. access to care for children still remains a problem, especially as it relates to good

pain services and pain management. it is really a neglected area of pain management and we find it in the general community patients have great difficulty assigning access for this type of treatment. >> you've got a lot of children and other people walking around causing infections that are just very painful. >> infector institute of medicine report that 160 million americans suffering from pain did not include children and that number. so missing from that number is children to suffer pain as you recognize. >> chairman, thank you. >> that is in the area of the kind of acute pain that then leads on to chronic pain. and that acute pain is perhaps more easily diagnosed early on in the question is coming to

their access access to that client of diagnosis. >> have you ever read any dr. sarno spokes? mind over back pain 1984, healing back pain 1991, nine by prescription 1998 or the divided line 2006? >> no i haven't. >> dr. maixner, have you read any of his books? >> i'm not, but i am very familiar with the theories that are elaborated quite well in the books. >> ms. veasley, have you? here's why asked the question. you can't read everything. ms. veasley told her story. a minute to you my story and moisture and i had him here. i've always been healthy. jet pilot in the navy,

physically act all my life. took her to my physical health. 1988 i checked the doctor's office over here. i did know was that long ago. 1988 had an episode with my back, extremely painful. i was working on the holy ratio in the dirksen building and my pain had my back so hard i fell right on my, kind of embarrassing. i didn't know what was happening to me. it got a little bit better, but at one point and i was working them in the is working on the americans with disabilities act as the chairman of the subcommittee of this committee and i couldn't even walk back and forth i had to put a cot in the capital for me to lay on. shortly after that i had an mri. they look at the mri and said you've got a bulging disc. causing you some problems. you should take an

anti-inflammatory. so i did. the pain went away. about three years after that, in the mid-90s again i got back pain so bad i was in los angeles. i was in a hotel room. i had to go to the bathroom. i had to crawl to get to the bathroom. i came back here, had another mri. wow, still have a bulging disc, but there is this hole down there whirl your nerves go through. that's by laymen terms i am putting it. they said maybe you need to have that thing opened up or something like that. well, i thought about that for a while. and my back pain went away after a while it went away. but every time it would come, i could barely sit, i could barely stand, daily news. i even had a chiropractor, and to my office so i could even get

on the airplane. actually it worked. higher per week worked. maybe feel better anyway long enough to get on the airplane. and then in 2004 had another episode and it was really bad and i remember is that a national convention up in boston. i could barely move. in fact i curtailed my duties there. i came back and that was made third mri. i sent them up to the hospital for special surgery to have been like that. i wanted to get another opinion. well yeah, i probably needed steroid shots and needed to have the whole looked back, whatever that was. i had breakfast one morning with mr. iver brand, former chair of the university, thomas jefferson university hospital, just a

friend of mine. i told him i wasn't looking forward to this but i checked with the doctors here in a i said i probably needed back surgery. one of the doctors told me they had back surgery and they were fine. i really wasn't looking forward to that. so i told iraq, i guess i'm going to have to have his back surgery. it's been going on all these years. he said don't do it. don't do this. i'm going to send you something. when they send you a cd in the book and read those first before you take any action. i got them the next day. there is a cd in about by dr. sarno. i read this very night that, that sounds like me. that really sounds like me. and so, i began to follow this regimen and that was in 2004. i haven't had a back pain sense. i've never had any surgery. i've never had steroid shots or

anything like that. i haven't had any back pain sense. now that's not quite true. everyone started to get a little tinge of back pain, but i know what is causing it. i have the knowledge and i know what is causing it. now, i'm going to expose myself here to this audience and whoever else is watching. sometimes i tell people this they can ims. they say what you do? is that it's very easy. i talked to my back. and when i save basically i don't have cancer, i don't have anything wrong with my spine, i don't have any injuries, so therefore it is coming from stress he is somehow i am been stressed out and my spinal nerves are being deprived of oxygen and that is what is causing it. so you need to ignore that. i may need to go about my daily activities just as though i was completely well. and when i do that, it goes

away. i don't know that the iom is lucky not this. now you might say well, that is just you. this is a survey put in the book in 1999. again, this is a small cohort. they had 100 for patients on whom data is collect good. the following year they reached 85 of the group to determine the outcome. 39 males and 52 females in the group and they are interested in the outcome, 37 patients report they now have little or no pain. 22 patients were not 80 to 100% improved. 13 patients reported 40% to 80% improved to 13 reported no change to 40% improvement.

46 patients reported now unrestricted physically. these figures are extraordinary when one considers the treatment of this physical disorder is educational. augmented in some cases by analytically oriented psychotherapy. 70% of the could relief from pain and 75% restored to normal or near normal physical function. so i wonder why we are not looking at things like this. one more story. i have a near relative of mine, a close relative of mine diagnosed with fibromyalgia. terrible pain. and so because of my connections in things with nih and stuff i found some of the best that there is to talk to her about her fibromyalgia and they did and i would talk to her every so

often, ask her how she is getting allowed and nothing was getting better. she was withdrawn her family. i don't want to go into this into much depth. last year i checked up on her. i want to check up and see how she was doing. she said i think i've cured my fibromyalgia. i said really? was at the last after he sets you up with? she said no, a friend of mine gave me this dvd in a book by this dr. sarno in new york. i had never mentioned his name to her. i hadn't thought about him in that context. and she now is i wouldn't say totally pain-free, but over her fibromyalgia. so when i see two things like this one personal to mount so that one at the close relative, i wonder why isn't this being looked at? why isn't this -- dr. maixner,

but ms. veasley center is very important. why not see a different doctor or get better treatment? is recently summarized by leading pain physician. overall, currently available treatments provide modest improvements in pain and minimum improvements in physical and emotional functioning. the quality of evidence is mediocre and has not increased substantially during the last decade. not to pick on you or anything, but you said here on this page here, i submit that we now possess the tools and knowledge to conquer this epidemic and bring relief to many millions worldwide.

well, the repo is in the lancet, saying that the quality of evidence is not increased substantially during the last decade. their other things not being looked at. so i do not know that we do have the tools and knowledge right now unless we start looking about these other methodologies. now again, i am talking about chronic pain that is not the result of cancer or putting my hand in a fire or tooth problems are things like that. i am talking about chronic pain that seems during diagnosis to have no physiological basis that they can find. and that is where you go from.dirty doctor to doctor to doctor. so, that is why wonder, do we really possess the knowledge and tools are not?

i am going to ask dr. maixner. >> well, let me just comment on a few of your comments, senator. as you i think articulated, the problem brought me back to my own veiling back today and sunday night and ruptured disc and as she recanted her story, my lower back began to ache. again, the emotional response and the tension that was just spoken to you. i do want to note though that i -- there may be a misunderstanding about the nature of the report and its dead on the import behavioral interventions. again, the primary tenant of the report is that chronic pain conditions where there is a major mismatch between what we see pathologically at what the patient experience says it is best explained by the biopsychosocial model.

within that is the psycho component of that, where there are very good demonstrations of what we call cognitive behavioral therapies can educational therapy, awareness. he, self therapies, which are part of the overall rubric that multi-paint programs use. there's actually reasonably good so-called meta-analyses using both operands behavioral therapies, some of which you have just described in your case. that are effective in some patients. and so one of the challenges that we have is really trying to a database subpopulations that will respond like you and like i when we engage our own intrinsic cognitive behavioral methods to alleviate this pain. so you know, i do think the report from my reading of it has

tried to capture that. the issue if it is not common practice across the united states in part because of reimbursement issues. the psychologists are not reimbursed well for their therapies. that is why advocated bundled services, bundled reimbursements and multi-paint programs, which allowed this type is educational this to occur. so i do think the report has noted this very important therapeutic intervention. >> i just noted -- >> is miniscule. i would agree with that. >> one, and from our own research that we are finding one of the primary domains of risk is what is called schematically awareness. that is the ability of the individual patient descends as he entered the as well as the extra environment.

it is i believe this represents augmentation or excitement of the system that actually augmented in the processing that this allows us to think about her lower back pain and pathways for the pain can rekindle an show expression again. and we believe that is one of the targets, one of the targets for intervention, trying to decrease grammatic awareness which can be influenced by emotionality of memory we generate. >> at about that is inherent with me or you, the can people be taught this? >> yes, not in all individuals can respond. >> first of all, thank you so much for sharing your personal story, which is deeply meaningful and moving and i'm glad you're doing well. i would say just a couple of other things that by may 1st. the iom report was not called to

a specific intervention or therapy, but a call to action to really identify the problem spradley. it didn't identify what specifically should be taken for any one individual and did recognize as he heard there will be different approaches for different individuals. now i would say that like you, all of our lives are shaped by our personal experiences. mine comes from being a pediatric oncologist, someone who lived in the. hav and impact of that illness on pain and comes from being the spouse of someone who suffers from fibromyalgia, who has had decades worth of chronic pain. i have witnessed on a personal level that the approach to intervention, very different sorts from psychological and psychiatric to pharmacological behavioral and physiological and physical can have varying degrees of impact.

the point being that there is not unfortunately a single solution. and i think that really underscores part of that. we would celebrate and embrace it. but we recognize is while there are therapies that can impact some, many need and would benefit from others and interventions and we need to work on that as well. and not lose sight through have not yet understood from those it today. >> i decide to respond. your absolutely right and that is why during all my tenure in the senate as chair of this committee and the appropriations committee and nih, i've always wanted to open the doors to everything. i want a lot of stuff with that. i do want anything dismissed out of hand. after all it was a legislation that started integrated in the

same. >> is a dna journey related the senate very credited. >> not that i say this is the answer, but we've got to be looking at these things in examining, just like would have been with me. i'm not saying it's going to work for everybody. but at least it ought to be looked at and researched. and tried. you've got to be a part of it, not just some little footnote someplace. but really delved into. >> i think you sharing your story, mind and the millions of others really points out that we don't understand pain. there's multiple pathways by which people can develop pain and affect of the tree pane is similar to what you discuss, i have done all kinds of mind-body techniques, relaxation, stress reduction exercise, yoga, biofeedback, all of these things

and i too am a little different way, the person of faith i also speak to my pain, but i can tell you i'm still left with severe pain and it's only on the left side of my body. i was had by a car of my right side. i only have paint on the left side of my body. so by your experience is very real, mine is very real as is all of these others. we really can't expect to understand pain we are not researching that and spend 96 -- the nih says 96% less than it does on diabetes, heart disease and cancer. had we understand how these mechanisms? is genetic evidence that people are predisposed to develop either heightened or less pain. there are studies and documentation of people who are born without the ability to sense pain at all. which is not to their advantage because the end up injuring

themselves. but this is evidence that there's a genetic component there. also evidence that pain is actually a dysfunction of the pan something network in our body itself. it can be a dysfunction or disease of the central and peripheral nervous system. so what you said brings us right back to the same point. we're never going to be able to tease all this apart until we have an adequate research effort. that looks at all of this. >> couldn't agree more. i'm sorry, senator white house has sort of been dominating the question answered. >> that's fine. i'm set, thank you very much. i appreciate very much the witnesses work in this challenging area and i invite anyone who wishes to respond in the form of a response to the question for the record with thoughts about the ways in which the paper and electronic record-keeping of the health care system can be improved to improve awareness about people's

pain conditions, forcing the issue with vital signs can and making sure the health records address the site be delighted to get your more thorough answers in writing so we can evaluate. i appreciate it and again chairman, thank you. >> dr. signout, i've been picking on you lately here. did you have anything else to add it all to what we've been saying about? you been doing this for 45 years. you've seen a lot of patience. she is anything? >> not really. just the idea that in medicine in general, there is a tendency

to look at things from the anatomical and physiological point of view and perhaps not recognize the impact of emotions on the physiology and that is the only thing i was a period keep an open mind about that because i believe -- >> i hope will do my research in that area. that is what i hope, that the group will now start to take a closer look at that. >> well, to try to sum up, dr. pizzo, thank you. he tacked. he tacked at how much we're spending a year and how much coming from our federal and state budgets, this is a huge impact on our financial wherewithal. he said that it is a moral imperative. i believe that. and if it is a disease in its own right and i think he also said in a collaboration. we need a lot of collaboration should really look at this. dr. maixner commode attacked about the barriers and mismatch of money and nih. i couldn't agree more.

the appropriations committee will look at that. he talked about education. only nine sessions in medical school on this. something so prevalent. i said that in the beginning. how to get our presidencies more in tune with diagnosing people and focusing on pain? but you also mentioned the.shopping and what is happening there. again i think we need to educate her.to send practitioners in primary care paid people better than what we've been doing in the past. you bring a very poignant personal story to this. there's just a lot of thought around this country, maybe not with vulvodynia, that fibromyalgia, it are the boss and her, that pain, all kinds of

things that we just need to know more about and how we do our research into these areas, no doubt about it. see you bring a very strong personal story. dr. piso said we need new, innovative therapies that we may not know about. i think that is pretty profound. when he got innovative therapies that may not know about. so how many people out on this committee don't know about 45 years apart is a pony in this to a fine degree on how you treat people with chronic pain that has no -- this is where i should practice medicine without a license, but without a