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 that? >> dr. maixner, sure. >> yes. i agree totally with what was just said. i think it's very important that we don't disassociate mind-body when we talk about chronic pain conditions and put chronic pain

conditions into strictly an in their head psychological component. it's very clear from current research that there is an underlying neurobiology that associated with affect and mood and emotion nalt. there is a neurochemistry there is a very well assessed neurobiology. and we know that many of the pain pathways that our patients have activated, activate these same pathways in the brain that are involved in affect and mood and emotional response. so chronic pain is really a mosaic. it's a mosaic of interactions between the active -- the effective domains of the brain and those areas of the brain involved in processing pain information. they are overlaid. so it is really impossible for us to disassociate mind-body. and in fact when we talk about the emotional, psychological aspects of pain, we're really talking about an underlying

neurobiology that leads to the overall gestalt that our patients complain about. >> dr. pizzo? >> thank you. well, i certainly agree and appreciate that there is a broad array of contributing factors as has been stated, i think it is also important for us to be very sensitive to the words we use and the way that they're 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 that when we don't know an answer, we often ascribe it to something else. and those assignments are often emotional and almost contributed back to the individual, as if that individual becomes the victim of their own suffering. and i think therefore our view, the view of our committee, 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 in very discrete and very 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 its manifestations and interactions. >> i guess -- ms. veasley? 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. but this is not the experience of the average pain patient in our country. and i would just put out there that there is many examples in medical history, for example, ulcers that were one attributable to stress and inability to emotionally cope that we now know answers to. their cause is a bacteria. and just because we do not understand yet due to the inadequate research effort that

we've had, the mechanisms and risks that result in chronic pain do not mean it is made up in your mind and is not real. thank you. >> if i might respond, i think what dr. sarno was saying, and i have looked at this a lot, 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. as he said, the unconscious can sometimes in order to hide up 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 underlyings of people's minds

sometimes create the pathways to real physical pain. am i correct in that? >> yes. as i said, emotional phenomenon can be responsible for physiologic pain. and that's the important thing to bear in mind. >> dr. pizzo, in looking over this relieving pain in all of america, and looking at some of the different approaches that were taken, i don't see that being researched that much. now maybe i just don't understand it all that well. but i don't see that kind of approach being researched. that so or not so? >> the approach meaning the emotional basis for pain? >> not emotions not being affected by pain. >> right. >> 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 broad and not defined by any boundary. and my comments really are not too pit one approach against the other, not to say that emotions are good or bad or physiologic pain more important tla than that manifest, but rather in our society today there is a degree of stereotyping that does take place inadvertently and that does have consequences. just as a matter of ocean, that one something isn't physiologically defined, it's often attributed to an emotional reaction. that is really what i was addressing and speaking to. i think it is important, and we heard very eloquently crisp tin that when manifests, there is often a rallying of our

community to that individual because it defines suffering. i know this from my own experience as a pediatric oncologist, someone who has cared for children with cancer and pain for many decades. but when someone comes in with a pain that is not fully define order delineated, as you described extremely eloquently, we make other assignments in terms of cause. and that is what creates the bias of both our providers, doctors, nurses, communities, our insurers, what they'll pay for, 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. you know, 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 science. i just 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 in what causes pain, how it's manifest, and how we can go about a treating it. the therapies that we have today, although they work and many people are quite limited, and we need brand-new insights to 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? >> thank you, chairman. and thank you again for holding this hearing. i think it's very important and helpful. i'm going back now a 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, the 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 were able to convince the doctor on duty at a particular time that you were in great agony, when they went off shift and 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, it was not part of the equation, and there was even some doubt about whether it was possible to do that, given there is some subjectivity involved. but clearly that's something that we were able to get around. so my cushion is how do we make sure that the hard records that

exist in nursing homes and hospitals, in various settings of patient care, particularly as we move into electronic health record environment have appropriate fields so that the patient's pain experience is 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 that certain steps be taken with respect to the day to day records, would that be a good idea? and is this something that we should be -- i've been very active, along with the chairman and others on electronic health records and meaningful use and all that. should we be focusing on this as a topic in that discussion as well? let me start with ms. veasley. she gets the rhode island jump. >> well, it's difficult, because we don't have the answers for patients.

but yet we have millions of patients flooding doctor's offices every day needing help. and until we have that basic research, until we teach compassionate care, until providers understand that while we may not know all the mechanisms, just like any other diseases of the central nervous system, there are things that you can do to help patients. and to continue to ignore the pain that someone reports -- i mean as you previously mentioned, end of life care. i recently lost my mother-in-law to pancreatic cancer, which is excruciating. never once is her pain questioned, but the ability to treat it was hampered by the fact that we don't have the answers yet. for providers. so they're 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. >> well, thank you very much for

asking that question, which is enormously important. we are moving as a nation much more toward refined electronic medical system in 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 already in hand, there is much more that we need. and it's one of the recommendations that we made to the secretary of hhs and the related agencies to really facilitate a better collection of information that could 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 be enormously important going forward. >> yes? >> yes, i agree. and i think we have very, very good methodology available to us

to rapidly assess both in-patient and out-patient levels of pain. and i think it can be easily implemented into electronic patient record. i think the larger problem is how is that information acted upon by the health care system. so when there is really a substantial pain, do we have well-trained individuals who can respond to that -- to that cry? do we have individuals who can impact what we assess? so the assessment tools are clearly there. but again, as i articulated in my testimony, we have very poor education with respect to pain and pain management, which greatly impacts the manpower that can respond to the epidemic that i discussed. >> i see that my time is expired. chairman, thank you very much. >> just as a follow-up, senator, dr. sarno, a new patient comes in to you. they've got pain.

what do you do? how do you assess that person's pain? what process? >> well, as i said, he's got to be thoroughly worked up, studied, and all of the known pathological processes that could be involved. so that's 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 is going on, and so on. because i think that -- i'm going to say the same thing i said before. emotional phenomenon can bring about physiologic change. and we've 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. >> thank you very much. senator hagan? >> thank you, mr. chairman, and thank you for holding this hearing. i think it's extremely important, because i do know that there is millions of people in our country today that are obviously suffering in chronic pain. and dr. maixner, all of you welcome. and i appreciate the expertise that we have here as well as the personal experts. dr. maixner, you seem very optimistic in your testimony about the future for pain research and treatment. in your testimony you state that pain scientists are having great success in unraveling the pathway of physiology and pathological basis of pain. you describe to me some of the way 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 that underlie common pain conditions. we've identified many of the risk factors that lead to conditions like tmd, fibromyalgia, and many of the cn 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, led to treatments and prevention. we are at that step now in the pain field where we've identified biology factors, genetic factors, psychological factors. not all, but many are now at our hand that we can begin to put them together into models to develop potential new treatment

strategies that relate to cognitive behavioral therapies, other types of behavioral therapies that can influence response and 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 are large-scale population-based studies that are housed out of these advanced pain centers of excellence that i've noted. these centers would have not only a patient care mission 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 effect of therapies that we can now conceptualize from these theories that we have now put forward, and to demonstrate the comparative effect 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 could lady to new interventions, both behavioral interventions and therapeutic interventions. >> thank you. dr. pizzo and dr. maixner, y'all have discussed doctor shopping. i know dr. maixner has. and sometimes this is a barrier to properly treating patients with chronic pain. can -- on average, how many doctors does a patient suffering from chronic pain see before getting a proper diagnosis? do you have any estimates on the

cost of this -- the numbers of different doctors that a patient might go to? what does that cost the health care system? and is it because the patient doesn't get the response or they're 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 just slightly broaden it if you would be willing? >> please. >> clearly, what we know today and what you have heard is that we're 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 as we would like them to be able to. and even though we have some wonderful centers and need more as great maxnor can be given as a nation, as a nation we need to

think of a more distributed model, so that care is available to under served communities who are effected by pain, african american and hispanic communities have a higher pro portion of pain than other communities. those suffering from some of the diseases that christine beasley and others have spoken about are dis pro portionately effected by their pain. we need a different way to distribute. we need primary care physicians working together with on the front lines health care providers that can work together, to create new partnerships between them and we need to pay for those services in a different way. right now, disincentive, who does not allow enough time for nurses and

doctors to spend with the patients to develop a plan that will be meaningful for them. that is another area that we need to think about. we need to think about how the payment system is restructured so we are not just paying for expensive services but paying for those that fit the patient. the realty is that there's therapies that are available today, and not one particular one is best for all patients and not all are good for any one patient. need to look at the right match. between them. i would say that we certainly have innovations and interventions that have available today, but we have a need for defining more. there's a great need tore defining new -- for defining new innovative therapies that we hardly know about, we are just at the edge of learning about the nervous system and how it works. there are great opportunities that lie ahead skpirks hope these coupled with a better portfolio for doctors and

nurses, working in tandem with other health care providers can help. >> what about doctor shopping? >> there's a lot of that going on because no individual is happy with the treatment they are getting. we heard this many times and in fact, we have heard from some of our committee members who suffered from pain, that if you don't get the results from one person, you should seek another. because there may be another approach that could be a benefit to you. don't give up. empowerment of individuals is a significant part of the equation. on the other hand, many go from one doctor to another, because doctor a, b, c, or provider a, b, c, never engaged and never helped. that is something that we need to do about as well. >> ms. beasley? >> if i could respond to each of

your questions. we hear a lot about translational science and in any area, all the research on any given condition that takes place if it does not come down to the patient for which it's supposed to serve, it's not helping. i see a great opportunity for federal initiatives to supported on going educational and awareness initiatives aimed at the medical community, the public and patients, to continually keep us all informed of the latest research that is coming out of unc and other great institutions around the country. right now, we don't have that. so, everyone though some of these really great advances are taking place, it's not getting down to your average physician and your average patient. in regards to doctor shopping, again, this goes back to research. if we don't have basic research to inform doctors of what the causes and effective treatments are for any pain condition, they

are left to their own clinical conjecture to what a patient's cause or treatment may be, this happens in the pain community. we find physicians that specialize in pharmacology or nerve blocks or implanting devices in patients even though we have found that multi-disciplined care is how to treat pain. you have many reasons why a patient goes from doctor to doctor, and one they are told their problem is not real. your pain is not existing. you have to be imagining this. i do not see a sign of inflammation or any problem that you may have. we do not understand the mechanisms. and i can tell you from personal experience and from talking with thousands of patients, for as many doctors as you see, because we don't have this basic research, you'll get that many diagnosis and that many treatment recommendations. and as i mentioned in my

testimony, that leaves it up to a patient to fend for themselves and try to decide, out of all the treatments, which is going to help me. that is impossible for anyone to do. regardless of your education. >> thank you. my time is up. >> thank you all for being here. what i would like to begin with mr. chairman is ask unanimous consent to have testimony from dr. robert shapiro who is an expert on headache put into the record. i was interested s by a couple of issues, that spring out to me. number one, the institute of medicine report found that a person with lower educational

level, and i presume lower income people are more apt to suffer pain. we did a hearing some months ago as poverty as a death sentence and what we found is if you are in the bottom 20%, you'll die 6.5 years earlier than if you are in the top 20%. so i would like to ask you, i guess what you are saying is that if you are poor, did you are uneducated you are more likely to become ill, and more likely to experience pain. could someone speak to that? >> yes, senator, i could sbepea to that. i think that, one social economic status actually may be a surrogate marker of environmental exposers, the type of exposers that put one at risk for a v