specialist. i quote, we cannot successfully treat the complexity of pain without treating the whole patient. insurance companies will pay for useless, expensive procedures and surgeries, but won't pay for the simple cognitive behavioral therapy and physical rehab therapy. from the patient with chronic pain. i've a masters degree in clinical social work. i have a well documented illness that explains the cause of my pain. but when my pain flares up and i go to the e.r., i'll put on the hospital gown, i'll lose my social status and my identity. i'll become a blank slate for doctors to project their own biases and prestigiouses on to. this is just four of thousands of thousands of testimonials that led us to conclude that alleviating pain in america must result in a cultural transformation in how pain is perceived, how physicians and other providers care for pain, and how we develop our social contract with each other to

advance clinical care, education, and research. we concluded 16 recommendations. and in doing so, we focused on the public health issues, pain, care and management, education of patients, communities and providers and research. and to help our committees with this activity, we prioritized for the 16 recommendations as ones 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 like to share with you the highlights of those four recommendations. the first is that the secretary of hhs should create a comprehensive population level strategy for pain prfrevention, management, and research. including an agenda for developing research, improve

pain assessment and management programs, improve ongoing efforts to enhance public awareness of pain. and this should include the multiple federal and private agencies. secondly, we recommended that the secretary of hhs with other federal state and private sector entities should develop strategies for reducing the barriers of the care of pain, focusing on particular on populations disproportionately affected by and undertreated for pain. third, we 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 are about 4,000 pain specialists in the united states. not nearly enough to cover all those with pain. and therefore we look to enhanced education and training of primary care physicians to work collaboratively and new care models to better direct and delineate for those suffering from pain.

and finely, as an immediate recommendation, we recommended that the director of nih should designate a lead institute at the nih that is responsible for moving the pain research agenda forward, along with increased support for and scope for the pain consortium. this should involve pain advocacy and awareness and organizations, and should foster public and private partnerships. there were 12 other recommendations as well, and we felt that these recommendations serve the goal of creating a comprehensive population level strategy for pain prevention management and research. the scope of the problems in pain management are truly daunting, and the limitations and knowledge and education of pain health care professionals are glaring. medical community must actively engage in the necessary cultural transformation to reduce pain 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 did. thank you. >> thanks, dr. pizzo. dr. maixner, welcome. please proceed. >> thank you, mr. chairman. let me just start by thanking the chairman for indulging these testimonies. it's truly an honor for me. i'm born in southeast iowa. and so to be testifying before an iowa senator is truly an honor for me. but more so for representing the pain research community and the patients who suffer from a hidden epidemic. so let me start my formal statement. it's truly a tribute to our political system that the voices of many as well as a few can be heard and acted upon. today i would like to further detail several of the points made in the imo report relieving pain in america, which provides clear and unequivocal evidence that more than 100 million of our fellow citizens are

experiencing a silent, hidden, and poorly treated epidemic. an epidemic that is as real as a polio epidemic that visibly shackled hundreds of thousand of americans and caused individuals and families to suffer greatly. no less real is the suffering of millions of americans who frequently suffer silently without the outward signs of an iron lung. similar to the polio epidemic, a transformative national effort is needed to crush the epidemic of chronic pain worldwide. i submit that we now possess the tools, the knowledge to conquer this epidemic, and to bring relief to millions worldwide. the real question is whether the fortitude and will to mount a focused campaign that results in adequate treatments and cures for common conditions exists within the united states today. during the remainder of my time, i'd like to highlight some of the salient points from the iom report, and also address some of

the barriers that exist in the area of research, education, and patient care. we've already heard two testimonies related to the magnitude of this problem, impacting over 100 million americans as we sit here today. with horrendous costs to society, over $600 billion annually paid by our society for these conditions. new to this, i think, committee, and to the understanding of the public i think is that 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 biological principles that lead to this very devastating set of conditions. and i firmly believe that we now have adequate knowledge with the biology, the psychology, and the social fabric that underlies chronic pain conditions, as well as the genetic factors that we are at the verge of being able

to make substantial progress on this massive public health issue. there are, however, several fundamental barriers that preclude a national transformative effort that i would like to highlight and recommend as outlined in the iowa report, but also 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 nih funding for pain research. though one can quibble about that level, it ranges from 0.4% to 1.3%, yet we know that the consumption of health care dollars is enormous. so if we look at medicare costs alone, 14% of the medicare budget is used to treat chronic pain. yet again only about 0.8% of our nih resources are used for the

study of chronic pain. if we look beyond medicare, if we look at the consumption of direct and indirect 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 to nih, targeted towards chronic pain and pain initiatives, or a allocation of nih appropriations that are use to further address a pain-related conditions. there are other substantial issues that are outlined in the iom report related to research, but to me that is one of the primary fundamental research barriers that currently is impeding progress. in the area of education, it's already been alluded to that

curriculum is a fundamental problem. i served at unc school of dentistry as dean of associate affairs for six years and had an opportunity to look at the curriculum content that we have devoted to pain management and pain mechanisms. i'm proud to say that at unc we have 20-some hours of didactic offers and practical aufrgs, which in my view is still very insufficient. 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 diagnosis, assess, and treat patients with chronic pain conditions. so i recommend major curriculum reform that is associated with discussions with accrediting agencies, and perhaps

discussions with the department of education that will help mandate further change in curriculum. i am not one to easily recommend mandates, but i can tell you this is a daunting task trying to work in more clock hours for a specific discipline. manpower issues, edge -- the lack of education has directed the sparse manpower that we have with respect to individuals that are competently trained to deliver management and diagnoses of chronic pain conditions. and i think expansion of our gme programs that will permit sponsored fellowships and residencies in health care related to chronic pain management would be extremely helpful. barriers to patient care. they are substantial. as we heard earlier, reimbursements for primary care physicians who are on the front line. reimbursement is very poor for

these conditions. and i think mechanisms need to be placed for primary care physicians for reimbursements, but also mechanisms to improve their continuing education opportunities, incentives given to our 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 a 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 represent the most important portals of entry to the health care system. portals of referral from primary care physicians, portals of entry for patients who suffer from debilitating chronic pain conditions. adds we all know, most chronic pain conditions in patients

require doctor shopping, going from one doctor to another for diagnosis and treatment. we desperately need coordinated pain centers that have both education, patient care, and research missions behind their walls. and this will be one of the most important, i think, aspects of action that will help break through barriers that both patients and commissions face. i have other aspects and recommendation to my written testimony, but would just like to conclude by saying that by addressing and breaking through these barriers will fuel new economic opportunities and job creation that will enter well into the 21st century. the tools and pathways needed to conquer the hidden epidemic of chronic pain are now before us. we americans have an established a proud history of curing debilitating public health epidemics and to improve the

human condition. a national initiative similar to what we addressed with the polio epidemic is needed. it is within our reach, and we will relieve suffering of millions of americans by so accomplishing this initiative. is to hear and to act upon the vceidic. thank you, chairman. >> thank you very much, dr. maixner. senator whitehouse? >> thank you, chairman. if you don't mind, i would also like to make a brief comment, first of all thanking you for holding a hearing on this important topic. the costs that come with chronic pain are enormous, and they're not just health care costs measured in dollars. they're also human costs measured in quality of life. as rhode island's attorney general, i brought together a group of health care stakeholders to look into

problems we were facing. in 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, if my memory serves it was memorial hospital the take that first stop, and other hospitals have since followed on. promoting an awareness and education about pain management particularly for patients nearing the end of life, both across providers and patients has to be a fundamental part of any strategy to improving pain care. we worked with joan tino of brown university who had done a study showing the majority of families who are with a dying loved one reported that their loved one had died in pain. of the families who reported that their loved one died in pain, a majority of the families

described that family member's pain as severe or excruciating. so it's a really important issue, and it gives me great pleasure to introduce christine veasley, who is a dedicated advocate and executive adviser of the national vulvodynia organization. she happens to be a resident of north kingstown, rhode island. krissin received her batch or of signs before coming to the association, she worked in the department of neurology at the john hopkins school of medicine, investigating the physiological mechanisms of pelvic pain and inflammation. i am pleased to announce that chris was recently pointed to the nih's new interagency pain research coordinating committee. her personal and professional experience will be a great asset to the committee whose mission is to identify gaps in basic and

clinical research on the symptoms, causes, and treatment of pain. so chris, congratulations on that achievement, and that important assignment. we look forward to hearing your testimony today. and i'll close again with gratitude to the chairman for allowing me to recognize a native rhode islander who we're very proud of. >> thank you, mr. whitehouse and for your opening statements too. ms. veasley, your entire statement will be made a part of the record. please pro veed. >> as director of the nvi and organization that serves a long neglected and stigmatized women with chronic vul have a pain, as a sufferer myself, it's truly a privilege that i do not take lightly to be before you today to share what some of americans are experiencing in their daily battle against chronic pain. we're very grateful for the committee's work, calling on the iom to study what the iom

concluded was a national crisis that we have a moral imperative to address. the iom report and today's hear having given us renewed hope, hope that our country is listening to us, cares about our plight, and is ready to enact long overdue change to help us regain some quality of life in our ability to contribute to society. i survived a near fatal accident when i was 15 years old and also found a resolution to the debilitating vulvar pain i experienced in my 20s, but i've had residual back and neck pain. and since 2008 i've developed jaw and facial pain as well as migraine headache. my story echoes the experiences of millions. i'm just 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 will be somewhat incapacitated. and many in our country really don't have this choice anymore. from the moment i open my eyes every morning, the first thing i

feel is pain, and it stays with me throughout the day. as the numbers of hours i devote to managing appointments, pain symptoms and medication side effects, which right now averages about 25 hours a week for me, my normal daily activities have become more and more difficult, and the most meaningful pieces of me and my wife feel like they slowly fade 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 left completely disillusioned, forced to navigate the health care system on our own, and implement a trial and error process that can easily take months to years to find a treatment to lessen the pain that we experience. in the last four years alone, i've been a to specialists in four different states. i've tried 15 different treatments, and i still live with moderate to severe daily pain that impacts every part of my life. i've easily spent $10,000 on

out-of-pocket expenses alone in the past two years. i'm privileged to have an understanding employer and good health insurance, which many in our country do not have. pain exhausts, depletes, dehumanizes and drains you in every single capacity -- physically, emotionally, spiritually, and financially. 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 that something is wrong with your body, it's completely impossible to ignore. your mind is cloudy, your attention is scattered, and it feels like you live with a veil over your face, blurred, unfocused. work goes undone, production and efficiency things of the past. things i once enjoyed with my family because of the increased pain and disability that follow. life doesn't stop, it just simply goes on in our absence. chronic pain is an invisible disability. you wouldn't be able to tell by looking at me today that i have any kind of problem.

you look fine on the outside, but many feel like dying on the inside. and when you suffer from pain in an area of your body that is still not candidly discussed by our country, like women with vulvodynia do, the suffering is further compounded with embarrassment, stigma, and isolation. as the iom report highlights, all of what i describe disparately impacts women. further, mounting research shows that once you develop one pain syndrome, you are more likely to develop pain in other areas of your body. this is the reason why the nva joined forces with the endometriosis association, 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 the research on neglected pain conditions that frequently cooccur and disproportionately impact whim. in addition to vulvodynia, there

are fibromyalgia, irritable bowel and headache. our report drew the same conclusion as the ioms. women have more frequent, more severe and longer lasting pain then than men, but are treated less effectively. they're treated as hysterical and not real, frequently leading to mental health diagnoses. our failure to deal with these conditions adds a wasteful $80 billion a year to our health care bill. despite this impressive toll, the nih's research investment averaged just $1.36 per affected women in 2010. the end result, as we have already heard that the afflict ready routinely misdiagnosed, shuffled from office to office, inappropriately treat ed and left without help. it takes years to obtain an accurate diagnosis, and when one is gift, treatment is limited forcing the afflicted to experiment treatments with unknown benefit and risk.

because of the disparity and the historical neglect of these conditions, it's essential for future pain initiatives to include a long overdue and appropriate inclusion of these conditions. we applaud the health committee, the iom and the nih for your initial steps to address this national crisis, and we strongly support the iom's main recommendation that by the end of 2012, hhs create a comprehensive population level strategy for pain. additionally, all of 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 that we will better understand the mechanisms of pain, delineate effective treepts, and that the medical community will have the is effectcally proven information they need to make appropriate diagnostic and treatment recommendations.

then and only then will the half hazard treatment of pain as well as the costly and wasteful treatment come to an end giving millions of american pain sufferers and their families the one thing we desperately want returned to us, and that's our lives. thank you. >> thank you, ms. veasley. now with dr. john sarno, as i said, dr. sarno is the author of four book, the first 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 our committee. please proceed. >> thank you, senator harkin. 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 patients in an acute hospital setting. and those with pain in the back, neck, shoulders, and limbs of a psychophysical origin. the high incidence of the latter group has evolved into a public health problem of great magnitude over the past 40 years. it has been estimated that 80% of the population have a history of one of these painful conditions, which has led to the performance of a great deal of unnecessary surgery and the widespread use of pain medication. it is troubling to realize that the pattern of pain and physical examination findings often do not correlate with the presumed reason for the pain. for example, pain might be

attributed to degenerative arthritis 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 somebody might have a lumbar dis:00 that was 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 headache, heartburn, hiatus hernia, stomach ulcer, colitis, spastic colon, irritable bowel syndrome, hay fever, and as map. that's quite a listing, and eczema, all of which have been strongly suspected by physicians of being emotionally based. the pain syndromes here referred to as neural system we believe

to be fundamentally emotionally-based. simple awareness of the diagnosis itself we have found can be therapeutic and eliminate the pain. for some patients who accept the concept of what is going on, it is necessary to work with a psychologist to get at the root of the problem. although back pain may disappear spontaneously, in many patients it becomes a life-long problem. there is no logic to the traditional physical treatment. instead, experience has shown, my experience, that the only successful and permanent way to treat the problem is by teaching patients to understand what they have. a physician because he recognizes both the physical and psychological dimensions of the condition must make the diagnosis. this cannot be made by a psychologist or a psychiatrist.

it goes without saying that pain syndrome must always be properly studied to rule out serious conditions such as cancer, tumors, bone disease, and many others. the presence of persistent pain anywhere requires a comprehensive examination and tests. although this disorder to the attention neural syndrome is an 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 patient -- change people's perceptions of the cause of common pain syndrome, which represent a major public health problem. science requires of course that all new ideas be validated by experience and replication. it is essential that these ideas also be subjected to research study in the future.

thank you, sir. >> thank you, dr. sarno. now we'll start a series of rounds of questions, or i should say a dialogue with all of you. dr. sarno, something you just said. i'm going to skip around here a little bit. where is it that -- oh, yes. ms. veasley in talking about a report said that medical professionals are more likely to dismiss women's pain reports as emotional, psychogenic, or

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