conditions. we know that there's physical injury. it's one such physical exposer that activates, genetic path ways. lower social economic classes are prone and experience more physical labor and are more prone to physical injury. we note also that distress, psychological distress is also a big driver of genetic path ways that can lead to the up regulation of pain processing and affect in mood that our pain patients experience. and again, lower social economic status i believer is a surrogate marker for the amount of distress, the environmental exposer one of the important environmental exposers in addition to injury that can drive the pain systems. >> you are talking environmental exposer is stress. struggling to feed your family, or take care of your child or go

to work, fix a car that breaks down. that contributes to illness and contributes to pain? >> correct. and produces the emotionalality that can influence the expression of genetic path ways. these are environmental exposers that are of higher density and higher magnitudes of those that fall in the lower social economic classes. >> i would like to suggest a more freudian or psychodynamic explanation, if people are poor and they are angry, they are furious as a matter of fact, what society has allowed to happen. and that fury are evoke physical symptoms as defense against the rage. they cannot enrage, so what

happens is that they get sick and i believe this is an extremely common phenomanom. >> rather than burning down the capitol, they hurt themselves? >> yes. >> i think this is an important discussion and i'm glad you raised the issue very much. one other facet is there's an inter relationship between a cute pain and chronic pain. if you are not able to access care, there's a probability that what may have been a self limited becomes a more chronic and persistent one. so from a preventive strategy and economic strategy, early intervention is better than delayed inter vengz. >> which is why we are trying build community health centers. are we going to hold a hearing

in a do you mecouple of weeks o care access. my understanding for absenteeism among children is dental problems and toothaches and we have a huge problem there as well. does anyone want to say anything about dental care and lack of dental access and tooths pain and so forth? >> well, i would just like to note that this continues to be an evolving problem, especially among the lower economic 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 in the general community, patients have great difficulty finding access for this type of

treatment. >> i think you have a whole lot of children and other people are walking around with teeth rotting in their mouths and very painful and causing infections. >> in fact, our institute of medicine report, that numbered 116 million americans that are suffering from pain, did not include children. children do suffer pain as you well recognize. >> okay. chairman, thank you. >> thank you. again, that is in the area of the kind of a cute pain that then leads to chronic pain. >> that is right. >> and that kind of acute pain is perhaps more easily sdiy lil diagnosised early on and the question is do they have access to that kind of treatment. dr. pizzo, you ever read any of dr. serno's books?

"mind over back pain,"" the divided mind"? >> no. i have not. >> dr. max, you ever read them? >> i have not, but i'm familiar with the topics. >> ms. beasley have you read? okay. have you read your books? here is why i ask that question. can't read everything. ms. beasley told her story, i'm going to tell you my story and why dr. serno is sitting there and why as chairman i have him sitting there. i have always been healthy. jet pilot in the navy, took pride in my physical health. 1988, i just checked with the doctor'ses of, did i not know it was that long ago. i had an episode with my back.

very painful. i was walking outside here in the hall way and my pain hit my back so hard, i fell on my butt, kind of embarrassing. i did not know what was happening to me. it got a little bit better but at one point and i was working and than the next year i was working to americans with disablities act of all things as the chairman of the sub committee of this committee and i could not walk back and forth, i had to put a cot over in the capitol for me to lay on. shortly that, i had an mri. they looked at the mri and said, well you have a bulging disk. caused you problems. you should take an anti-inflammatory. so i did, and pain went away. about three years after that,

mid 'nien90s. i got a hotel room and i had to go to the bathroom. hi to crawl -- i had to crawl to get to the bathroom. i came mri. well, still have a bulging disk, but there's a hole down there where all your nerves go through that, is my layman's term of putting it and that thing is not so, maybe you need that opened up or something like that, well, i thought about that for a while. and i dis missed it because 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 or move. painful. i even had a chiropractor come into my office, he had to work on my back so i could get on the plane. it worked. made me feel good enough to get on the plane. then in 2004, i had another

episode and it was really bad. and i remember i was at the national convention up in boston. i could barely move. i came back and that was my third mri. i sent them up to the hospital for special surgery in new york to have them look at it. i wanted another opinion. well, yeah, i probably needed a steroid shots and i needed that hole opened up, whatever that was. i had breakfast one morning with mr. ira, brind, the head of the thomas jefferson university hospital. he was a friend of mine. i said i was not looking forward to it and the doctor s said i hd back surgery. i was not looking forward to it. i told ira, i said i guess i

have to have this back surgery. it's been going on for all these years. he said don't do it. don't do this. i'm going sends you a cd, and a book and read those first before you take any action. i got them the next day. he sent them down the next day from philadelphia and it was a cd and a book by dr. serna, healing back pain. i read this through and i said, you know, that sounds like me, that really sounds like me and so, i began to follow his regimen. that was in t2002004, i have nod a back pain since. i've never had any surgery. i have never had steroid shots or anything like that. or have any back pain since. now that is not quite true, every once in a while, i get a tinge of back pain, i have the knowledge, i know what is

causing it. now, i'm going expose myself to this audience and whoever else is watching. sometimes when i tell people this, they think i'm nuts. they say, well what do you do and i say, it's easy, i talk to my back. and what i say is basically i do not have cancer, i don't have anything wrong with my spine. i don't have any injuries. so, therefore, it's coming from stress. somehow i'm being stressed out and my spinal nerves and stuff are being deprived of oxygen, and that is what is causing it, i need to ignore it and go about my daily activities just as though i'm completely well. when i do that, it goes away. i don't know that the iom is looking at this. now, you might say well that is

just you. this is a survey that was put in the book. in 1999, and again, this is small, they had 104 patients on whom data was collected and the following year, they reached 85 of the group, there were 39 males and 52 females in the group. and they were interested in the outcome. the categories for level of pain were as follows. 37 patients reported they had little or no pain and 22 patients said that they were 100 to 80% kbroimproved and 13 pati reported no change to 40% improvement. 46 patients reported that they were now unrestricted physically. these figures are extraordinary when one doctconsiders that the treatment is educational. augmented by psycho therapy.

75% were restored to normal or near normal physical function. so, i wonder why we are not looking at things like this. now, i have one more story. i have a near relative, a close relative of mine, she was diagnosised with identify rfibr so with my connections i found the best doctors s ts to talk about it and they d and i would -- she lives up in pennsylvania, so i would talk to her every so often, ask her how she is getting along and nothing was getting better. she had withdrawn from everything. i don't want to go into too much depth. last year, i checked up on her.

i wanted to checkup on her and she said you know, i think i've cured my fibromyalgia and i said really? was it that last doctor i set you up with? no a friend of mine gave me a dvd and a book by this doctor in new york. hi never mentioned -- i had never mentioned his name to her and she now is, i would not say totally pain free, but over her fibromyalgia, when i see two things like this, one personal with me, my own self and another with a close relative. i wonder why, why isn't this being looked at? doctor, why sichbt this being -- dr. maxnor. what ms. beasley said here is very important. she said it's logical to ask why not see a different doctor or

get better treatment. the answer was recently summarized by a leading pain official, quote, 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 improved substantially during the last decade." not to pick on you or anything, but you said here, on this page here, you said," i submit that we now possess the tools and knowledge to conquer this epidemic and bring relief to millions worldwide." well i read this, what was in the lancet, and saying that it has not improved during the last decade and there are other things not being looked at. so i don't know that we have the

tools and knowledge right now unless we start looking at all these other methodolgies, again, i'm talking about chronic pain that is not the result of cancer, or putting my hand in a fire or -- tooth problems or things like that. >> right. >> talking about chronic pain that seems during diagnosis to have no basis that they can finds. >> i agree. >> and that is where you go from doctor to doctor to doctor. >> exactly. >> that is why i wonder, do we possess the knowledge and tools or not. i know that dr. pizzo wanted to respond. >> let me comment on a few of your comments, senator. as you, think, articulated the back problems, brought me back

to my own at the age of 18, bailing hay, i ruptured a disk and as you recanted your story, my lower back began to ache, the emotional response, the tension that was just spoken to. i do want to note though that there may be a misunderstanding about the nature of the iom report and its perspective on the importance of behavioral int interventions, the primary tenant, chronic pain conditions where there's a major mismatch where we see and what the patient experiences is best explained by the biopsycho social model. there are good demonstrations of what we call educational therapy, awareness therapy, self

therapies, which are part of the overall ruberic that multi-discipline airy pain programs use, there's reasonably good so-called meta analysis, using therapies some of which you have just described in your own case, that are effective in some patients. and so one of the challenges that we have is really trying identify those sub populations that will respond to people like you and i, that when we engage our methods to alleviate this pain. so, i, you know, i think the oim record has tried to capture that. the issue is, it's not common practice across the united states in part because of reimbursement issues. these -- the psychologyists are not reimbursed well for their

therapies. that is why, i advocated bundled reimbursements in multi-discipli multi-discipline pain management so i think the oim report has noted this very important therapy. >> i just noted it, but -- >> it is minuscule. i agree with that. and one other comment too, from our own research, we are finding one of the primary domains of risk, it's the ability of the individual patient to sense the internal and outside environment. this rests excitement of the central nervous system. it augmented, it's allowing us to think about our lower back pain and those path ways in the

brain involved in back pain can rekindle and show expression again. we believe that is one of the targets. one of the targets for intervention, trying decrease sematic awareness. >> i don't know if that was inherent with you or me, can people be taught that? >> yes. but not all individuals can respond though. that is the trick. dr. pizzo, i'm sorry. >> thank you for sharing your story, i'm glad you are doing well. just a couple of other things if i may. first the oim report that i chaired along with others was not a call to a specific intervention or therapy, but a call to action. it identified problems broadly and did not identify what root specifically should be taken for an individual, and did recognize

that there will be different approaches for difference individuals. i would say that like you, all of our lives are shaped by our personal experiences, mine comes from being a pediatric oncologist, i lived through pain and it comes from being the spouse of someone who suffers from fibramyalgia and has had decades of chronic pain. i've witnessed on a personal level, that approach to intervention, very different from psychological to pharmacology and behavioral and physical can have varying degrees of impact. the point being, there's not unch unfortunately a single solution. that under scores the message. if there was a single solution of the problem effecting 100

million or more in this country, we would celebrate it and embrace it. what we recognize is that there are therapies that can impact some, others benefit from other interventions and we need to work on that as well. and not lose sight of those that have tried and not benefitted yet from the medical therapies that are available today. >> i just want to respond. you are absolutely right, and is that is why during all of my tenure in the senate, and being on this committee, i have always wanted to open the doors and windows to everything, i want a lot of stuff looked at. i don't want anything dismissed out of hand. after all, testify my legislation that started -- it was my legislation that started alternative and integrateive medicine. >> i was there when you did that and i was proud when you did it. >> i'm not saying it's the answer, but we ought to be looking at these things and examining. just like what happened with me,

i'm not saying it will work with everybody, but it should be looked at and researched and tried. i mean -- >> that is right. >> -- not some foot note someplace. but delve into it. ms. beasley? >> you sharing your story points out that we don't understand pain. there's multiple paths ways that people can develop train and effectively treat pain and you know, similar to what you have discussed, i have done all kinds of mind body techniques, stress reduction, exercise yoga, bio feedback, all of these things, and i too, in a little different way, am a person of faith, i also speak to my pain, but i'm still left with severe pain and it's only on the left side of my body. i was hit by a car on my right

side, i only have pain on the left side of my body. while your experience is very real, as is mine and all the others. we cannot expect to understand pain when we are not researching it and you spend 96 -- when they spend 96% less than it does on the other diseases how can he expect to understand the mechanisms. there's genetic evidence that people are predisposed to develop heightened pain, there are people that are born without the ability to sense pain at all. which is not to their advantage bought they end up injurying themselves, but there's a genetic component. pain can be a dysfunction of the pain sensing network of the body itself. it can be a dysfunction or disease of the nervous central.

so, what you said brings us to the point, we cannot tease it all apart until we have a research effort that looking at it all. >> i could not agree more. senator white house, i have been dominating the question and answer. >> thank you very much. i preshlt very much the witness's work in this challenging area and i invite anybody who wishes to respond in the form of a response to a question for the record with thoughts about the ways in which the paper and electronic reported keeping of the health care system can be improved to improve awareness about people's pain conditions, forcing the issue of fifth vital signs and making sure the electronic health records address it. i would like to get your

comments in writing. i appreciate it. >> dr. serno, do you have any else to add at all to our -- do what we have been saying at all. you are been doing this for for 40? >> 45. >> 45 years. you've seen a lot of patients. do you have anything else to add? >> not really. it's just the idea that in medicine in general, there's a habit to look at things from the anatomic point of view and not recognize the impact of emotions on the physiology and that is all i would say, keep an open mind about that. i believe -- >> i hope we will do more research in that area. that is what i hope. that this group will now start

to take a closer look at that. well, to try to sum up, dr. pizzo, thank you, you talked about how much we were spending a year and how much coming from a state and federal budget, this was a great impact. you said that it's a moral importance and it is a disease in it's own right and that you need collaboration. we need a lot of collaboration among a lot of disciplines to look at this. dr. maxner, we talk about the barriers and mismatch of money, and we will look at that. i could not agree more with that. we will take a look at that. you talk about education, only nine sessions in medical school on this, something so prevalent,

how do we get our residencies and stuff, more intune with diagnosising people and focusing on pain. you mentioned the doctor shopping and what is happen t . tlg -- what is happening there, we need to educate our doctors and primary care people better than what we have been doing in the past. ms. beasley you bring a very personal story to this. they are just a lot of people like you around this country. maybe not with the same disease, but with others, back pain, and other things, all kinds of things that we just need to know more about. and how we -- how we do more research, get more research into these areas, no doubt about it. so, you bring a very strong

personal story. dr. pizzo said we need new innovative therapies that we may not know about. i think is that pretty pro found. we need new innovative therapies that we may not know about. so how many people do not know about 45 years of practice and treating people and honining th to a fine dregree on how you treat people with chronic pain -- i should not practice medicine without a license, but without a physical basis. and i think that doctor serno mentioned, the first thing to do is look at that, do you that first. and then, if there's nothing there then you have to move to a

different modeality, this is my own statement. i think there's too many people in our societies, some of us are equipped somehow, different people think different ways. different people can cope with things differently and assess things differently and this is my own judgment, i think there's just too many people in our country that think there's a pill, a drug or a surgery that will cure whatever you have. and i think maybe we have been brought up to think that. that there's something out there, of, i just get the right drug or pill or surgery it will cure me. i don't know that we put enough into the up front prevention and i'll close on this. when i think about prevention in the area of pain. it's educating not just the doctors and residencies, but people. when they come through