science research is learning how changes in brain patterns effect pain. and they address education of pain care. the compliment and encouraged investigator initiated research in nih, the oim commended articles for comprehensiveness. other opportunities target specific conditions including recent, ocular pain migrain, and nerve damage from cancer therapy to name a few. the national center for alternative medicine recently funded through centers on chronic low back pain and spear heading a transnih effort to

develop criteria for back pain. the national institute of digestive and diabetes research network is another example that embraces the systematic or whole body approach. in conclusion, as a scientist i'm encouraged by opportunities for progress that research conditions, i've experienced treating patients with pain, i support the shift to treating pain as a complex of itself own. to take full advantage of what medical science can provide now and in the future the report called for transformation of how we as a nation approach pain mth and prevention.

the committee will begin the work to skput the transformation within the community. thank you and i would be happy to answer any questions. >> thank you very much, very much and thank you again for your leadership on this issue. i just have a few questions, i want to go into the department's sfraj with respect to coordination on pain management, can you tell us what steps the federal agencies are taking to put in place the iom report and the timeframe for it being completed? >> first step in this process, of course, was the establishment of the inter agency pain coordinating committee. it was stab lished in 2010.

the members have been selectsed. the committee will hold the first meeting on march 27th on the nih campus with the director of ninds, who will act as the interim chair. the nih is currently working with other iprcc member agencies to gather and analyze the agency's pain related scientific advances and their portfolios to get an over view of their public/private partnerships and their individual efforts towards education and dissemination, to they may be reviewed and discussed at the committee's first meeting in march. >> okay. second i'm interested in prevention and wellness, we have a long segment of the affordable care act 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 strategies? >> so obviously, this is a multiple facetted problem and so the first portion of course, is to delineate those people that are most at risk to develop chronic pain and there are a number of on going studies which seek to identify so-called risk factors that individuals may have, which make them vulnerable to pain. this can take the form of studies of genetic backgrounds, for example, in the risk assessment, which is termed opra, and you perhaps will hear more about that in the second panel, individuals have been studied in a pro peck active manner and a number of genes of interest have been identified

with those that associate with pain, and they give you clues as to who might be particularly very well they arable -- vulnerable. and another gene has been discovered that seems to be protective of people from chronic back pain after back surgery. this gives you insights as to who may be more or less vulnerable to these painful conditions. another option is to disect the path ways and in doing so, identify new targets that would allow you to intervene, to reduce or 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, they are able to reduce pain associated with inflammation, which you know is now generally treated with opiods or inhibitors. finally, there are a series of studies that are ongoing, using real time brain imaging that allows us to understand how one is a able to control what one's reaction and sensation to painful stimulus is. and in so doing this, once again, we may be able to come up with a bio marker that will allow us to identify the subset of people who are most at-risk. >> very good. thank you again very much, i'll leave the record open that other senators may have. thank you very much. >> thank you. >> we will call the second

panel. dr. phillip pizzo, i hope i correctly pronounced that. who is the chair of the iom report that i just referenced here. dr. pizzo is joining us from stanford university why he is a professor at the department. dr. pizzo will focus on the iom report and future areas of research. next we have dr. william maxnor, would you come up to the witness table, please, and same with ms. beasley and dr. serno. there you go. we welcome dr. william maxnor. he is at the university of north carolina at chapel hill. dr. maxnor comes today with

significant experience in pain management research. christian beasley, the executive director of the national association will share with us her personal story with chronic pain, she was appointed to serve on the pain research coordinating committee at nih, the committee was formed to coordinator research. and next we have dr. john serno a professor at new york university medical center and practitioner at rusk rehabilitation medicine. the author of four books a pain will share his work with respect to treating chronic pain. i'll thank all of you for coming here, your statements will be made a part of the record in their entirety and i ask if you can sum up in five or seven

minutes, it's probably a little light down there, i do not get nervous if it goes over, unless it's a long time, if you are summing up five, six, seven, eight minutes that is fine with me. like i said, your statements will be all made a part of the record in their entirety. please proceed. >> thank you, very much. >> 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 the important topic. today, i would like to share with you the results of institute committee that i cochair. the important findings from our committee eluded to earlier as follows, the number of americans suffering from chronic pain numbers 116 million, which is an

under estimate because it does not include children or people in chronic facilities or people in the military and others. this is a huge problem in terms of magnitude of numbers, but it's equally shadowed by the financial impact of pain in this country as well. currently we spend between 560 to $635 billion a year. that is more than we spend as a nation on cancer, heart disease and diabetes together. it costs us $100 billion from our state and federal budgets to cover the costs of pain care and the reality is that those expenditures are not relieving pain in america as we know it today. our committee was mindful of the fact that there's much to be done in developing cost effective methodolgies as we go forward but the magnitude is simply astounding, we recognize

that we had five charges from the affordable care act through hhs and nih in our work. the first was to delineate the health care, the magnitude of the challenges in problems as they stand today. the second was to review the barriers to accessing care for individuals with pain. to better delineate the demographic groups and special populations who are impacted by pain, to identify the scientific tools and technologies that are at our disposal today and that might be used for both research, care, education, 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 out standing committee of 15 individuals representing all professional disciplines from

science, medicine, to law and nurses and clinical practitioners, in doing so, we reviewed the literature, we held a number of public work shops and meetings we reviewed testimony from other 2,000 individuals, we commissioned a report to help us assess the impact of pain and we concluded that relieving acute and chronic pain is a significantly overlooked problem at the united states, we were guided by a series of over arching principals as we began our work, the first is pain management is a moral importance. and second, chronic pain can be a disease in its own right. there's a need for a more kpomp hence i have approach using enter -- using preventive strategies. we recognize the importance of

collaboration between physicians and patients and other providers in the education management and prevention of pain. we were not charged to look at the important issue of drugs and their use in pain. we recognize there are multiple sides in the issue and it a topic that should be further studied but we focus odd pain from a -- we focus oed on pain from a public health perspective. i would like to read you four testimonials. treating a pain patient can be like fixing a car with four flat tires, you cannot 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 never addressed in my medical school curriculum, disability

could be -- from a clinical pharmacy specialist, i quote, we cannot successfully treat the complexity of pain without treating the whole patient. insurance companies will pay for useless procedures and surgeries but will not pay for the physical rehab therapy and cognative therapy. from a patient in chronic degree, i have the documents showing the cause of my pain, but when i go to the er i put on the hospital gown and lose my social status and identity, i become a blank slate for prejudices and biases to be projected on to. that led us to conclude that relieving pain in america must result in a cultural change in

how it is perceived and cared for 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 made a priority for the 16 recommendations ones that we felt should be completed and put in place by the end of 2012. we brought the report forth in june of 2011 with that hopeful exception. i would 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 prevention

treatment management and research and this should be coordinated across public and private sectors, include an agenda for developing research and improved pain assessment and management programs and improve on going 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 and state and private sector entities should develop strategies for reducing the barriers of the care of pain rngs focusing in particular on populations dispro portionately and under treated for pain. we recommended that health care providers and insurance and others should work together between pain specialists and prior care clinicians, including referrals to pain specialists when appropriate. there are 4,000 pain specialists in the united states, not nearly enough to cover all those with bain and therefore we look to

enhanced training to work collaboratively in new care models to better direct and delineate for those suffering from pain. and finally 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 -- this should include organizations and 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 prevent management and research. the scope of the problems are truly daunting and the limitations in knowledge and education of pain professionals are glaring. the medical community must

actively engage in the necessary cultural transformation to reduce the pain suffering of americans and work collaboratively to do so with public and private sectors. thank you for listening to me. >> thank you, dr. pizz o did i pronounce that right? >> yes. >> thank you, proceed. >> let me start by thanking the chairman for indulging these testimonies. it's truly an honor for me, i'm born in iowa, southeast iowa, and so, to be -- testifying before an iowa senator is an honor for me, more for representing the pain research community and patients that suffer from hidden epidemic. it's important that the voices of many as well as a few can be heard and acted upon. today, i would like to further

detail several points made in the imo report that provides clear evidence that more than 100 million of our fellow citizens are experiencing a silent and poorly treated epidemic. an epidemic that is as real as a polio epidemic that visibly effected many people and caused families to suffer. millions americans suffer silently without the outward signs of an iron lung. similar to the polio epidemic, a transformed effort is needed to crush did epidemic of chronic pain worldwide. i submit that we now possess the tools and knowledge to conquer the epidemic and bring relief to millions worldwide. the real question is whether the fo fortitude and will to haved a kwetd treatments and concerns for common conditions exists

within the united states today. during the remainder of my time, i want to highlight some of the 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 proportionate allocation of nih appropriations that are used to further address 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 offerings, 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 issue, education -- the lack of education has direct impact on 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. as 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 recommendations to my written testimony, but would just like to conclude by saying that by addressing and breaking through these barriers will not only break through but 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 and 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. all that is required is to hear and to act upon the voices of those who suffer from this epidemic. thank you, chairman. >> thank you very much, dr. maixner. i briefly introduced -- but yield to senator whitehouse for further elaboration of our next witness. >> 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 that was the first to take that first step and other hospitals have since fopped on. 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. with worked with dr. joan tino of brown university who had done a study showing that a majority of families who were 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 director of the national vuvvodynia organization. she happens to be a resident of north kingstown, rhode island. christin received her bachelor of science. before coming to the association, she worked in the department of neurology at the john hopkins school of medicine, investigation of neurological pain and inflammati