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.?. >> yes. thank you, senator, for the questio >> 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 so-called common ideopathic pain 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 biological 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 emotional 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 lead to new interventions, both behavioral interventions and therapeutic interventions. >> thank you. dr. pizzo and dr. maixner, y'all

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 more for 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 billion 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 dr. maixner has described, where really expert care can be given, as a nation we really need to think about a 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 christine veasley and others who have spoken about her disproportionately affected by their pain, and that means we need a different care model and a different distribution of providers, both primary care physicians working together with specialists, nurses, pharmacists and other on the front lines who

might work in tandem with those that, centers, creating new partnerships between them, and we need to pay for those services in a different way. right now there's a disincentive 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 develop a portfolio or plan that's going to really be meaningful for them. that's another area that we need to -- when we think about how the payment system is restructured so that we're not just paying for expensive services but paying for those that fit the patient. the realities there are lots of therapies available today, not one is best for all patients and not all really good for all patients. we need to look at the good match between them. i would say we certainly have innovations and interventions that are available today, but we

have a great need for defining more. there's a great need for defining new innovative therapies we hardly know about today. we're just at the cusp of learning more about the nervous system and how it works and i think there are great opportunities that lie ahead, and i hope that these coupled with better educational portfolio, for physicians, nurses and providers on a distributive level working in tandem with specialists can create a new public health approach to dealing with this very severe problem. >> how about the actual doctor shopping? >> well, there's a fair amount of doctor shopping that goes on largely because no one individual is often satisfied with the results that they're having, and on our committee, and christine could speak to this, we've heard this many times, in fact, we've 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 will be beneficial to you. don't give up.

empowerment of individuals is a really significant part of the equation. on the other hand, many go from one doctor to another, because dr. a, b, c, or provider a, b, c, never listened, never engaged and never helped. that's something we need to do aboutacy well. >> ms. veasley. >> i could respond to both of your questions. thank you. in regards we hear a lot about translational science, and in any area, all the pain research in the world or research on any given condition that takes place, if it doesn't trickle down to the patient for which it's supposed to serve, it's not helping. and i see a great opportunity for federal initiatives to support ongoing educational and awareness initiatives aimed at both the medical community, the public and patients to continually keep us all informed of the latest research that's coming out of unc and other

great institutions around the country. right now we don't have that. so even 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 right back to research. if we don't have basic research to inform clinicians of what the causes and effective treatments are for any pain condition, they are left to their own clinical conjecture to make decisions on what a patient's cause or treatment may be, and this even happens in the pain community. we find physicians who just specialize in pharmacology. they just specialize in nerve blocks. or implanting devices in patients, even though a mound of research has shown that multidisciplinary care is how to treat pain. and, you know, so you have many reasons why patients go from doctor to doctor. one is that they're told that their problem isn't real. your pain doesn't exist. you must be imagining this.

i don't see any sign of inflammation or any problem that you may have. we don't understand the mechanisms. i can tell you from personal experience and talking to thousands of patients, for as many doctors you see because we don't have the basic research you'll get that many diagnoses and that many different treatment recommendations. as i mentioned in my testimony that leaves it up to a patient to fend for themselves and try to decide out of all of these treatments, which is going to help me? and that's completely impossible for anybody to do. regardless of your level of education or socioeconomic status. >> thank you. my time sup. >> senator? >> thank you very much, mr. chairman, for holding this important hearing and thank you very much panelists for being here. what i'd 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, if that's okay. >> yes. sure. >> i was interested 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 presumably also lower income people are more prone to suffer pain. as chair of the subcommittee on primary health care we did some months ago a hearing on poverty as a death sentence and what we found, if you're in the bottom 20 pursetile you would die 60% earlier than if you were in the top 20%. so i would like to ask you, i guess what you're saying is tha uneducated you're more likely to become ill. to experience pain. could somebody speak to that?

>> hmm., i could speak to that. i think that -- one social economic status actually may be a surrogate marker of environmental exposures. the types of exposures that put one at risk for the development of a variety of chronic pain conditions. so we know that there's physical injury, is one such physical environmental exposure that can activate genetic pathways that lead to pain conditions. individuals in lower socioeconomic classes are prone and experience much greater physical labor and are more prone to physical injury. we also know that distress. psychological distress sass a big driver of genetic pathways that can lead to the up regulation of pain processes and affect to mood that our 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 injure they can drive these pain systems -- >> you're saying environmental exposure such as stress? >> stress. >> in terms of how to feed your family, take ce -- go to work, fix a car that broke down. >> right, exactly. >> which contributes to illness, which contributes to panchts and produces what you just heard about that in fact can influence the ip mun system, genetic pathways. these are what i call environmental exposures that are of higher density and higher magnitude in individuals who fall within social economic classes of the lower tiers. >> dr. ? >> i would like to suggest a more freudian, if you will, or psycho dynamic explanation, and that is, poor people are poor

and they are angry. they are furious, as a matter of fact, at what society has allowed to happen, and that fury will evoke physical sim sympt symptomology, and what happens she get sick and i believe this is san extremely common phenomenon. >> rather than burning down the capitol, they are turning that anger against themselves? >> exactly. >> let me ask -- one comment, because i think this is a very important subject and i'm glasses you raised the issue. one other facet, an interrelationship between acute pain and chronic pain, and if you are not able to access care because of socioeconomic limitations, there's a probability that what might have

ban self-limited problem become as more chronic and persistent one, and so from the preventative strategy and an economic strategy, early intervention is certainly better than delayed intervention. >> which is why some of us among other things have tried to built community health centers all over the country. >> yes. >> i want to ask one other question. i apologize for being late. are we going to hold hearings in a couple weeks on dental care access. my understanding is that one of the major reasons for absenteeism among children is dental problems and toothaches. and we have a huge problem there as well. does anybody want to say anything about dental care and lack of dental access and tooth pain and so forth? >> well, i would just like to note that this continues to be an evolving problem, especially amongst the lowers so yore economic socioeconomic problem

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 finding access for this type of treatment. >> i think you've got a whole lot of children and other people are walking around with teeth that are rotting in their mouths, causing infections and just very painful. >> rile. >> in fact, our institute of medicine report that numbered 116 million americans suffering from pain did not include children. in that number. so missing from that number is children and children do suffer pain, as you well recognize. >> okay. chairman, thank you. >> thank you. again, that's an area of the, kind of acute pain that then leads later on to chronic pain.

>> that's right. >> and that kind of acute pain is perhaps more easily diagnosed early on, and the question is, do they have access to that kind of diagnosis and that kind of thing? >> that's right. exactly. >> dr. pizzo, have you ever read any of dr. sarno's books? >> "mind over back pain," "healing back pain," "the divided mine 2006." >> no. i have not. >> that's okay. doctor? haou not but am very familiar with james lang and cannon's theories elaborated q books. >> ms. veasley? >> have you read your books, dr. sarno? here's why i ask thatt read ev. ms. veasley told her her story

and i'll tell my story and why dr. sarno is sitting here and as chairman i've had him here. i've always been healthy. jet pimt in the navy. physically active all my life. took pride if my physical health. 1988, i just checked with the doctor's office. i didn't know it was that like ago. 1988, i had an episode with my back. ex-extremely painful. walking down outside in the dirksen building and my pain hit my back so hard i femme right on my butt. ghrassg. i didn't know what was happening to me. it got a little bit better, and at one point, and then the next year i was working on the americans with disabilities act, of all things, 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 capitol over for me to lay on. shortly after that i had an mri.

they looked at the mri and said, well, you've got a bulging disc. causing you some problems. you should take an anti-inflammatory. so i did. pain went away. about three years after that, this is 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 couldn't even get -- i had to crawl to get to the bathroom. i came back here. had another mri. well, you still have a bulging disc, but there's this little hole down there where all your nerves go through. that's my layman's term of putting it, and that thing's not so -- maybe you need to have that thing opened up or something like ta. well, i thought about that for a while, and i dismissed it, because my back pain went away. after a while, it went away. but every time it would come, i

could barely sit, barely stand, barely move. painful. i eve hadn't a chiropractor come into my office. once i had to take a plane trip, they had to work on my back so i could even get on the airplane. actually, it chiropractic work for me to get on the airplane. then in 2004 i had another episode. it was really bad. i was at the national convention up in boston. i could barely move. in fact, i couldn't. i curtailed my activities there. 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 looked at. i wanted to get another opinion. well, yeah, i probably needed a steroid shot, shots, and i needed to have that hole opened up. whatever that was. i had breakfast one morning with

dr. -- not doctor. mr. brind, former chair of the university, thomas jefferson university hospital in philadelphia, just a friend of mine. i told him i wasn't looking forward to it and the doctors said i had 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 2004, i have not had 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. outcome. were as follows. 37 patients reported they had little or no pain and 22 patients said that they were 100 to 80% improved and 13 patients

reported no change to 40% improvement. 46 patients reported that they were now unrestricted physically. these figures are extraordinary when one considers 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 diagnosed with fibromyalgia, so with my connections i found the best doctors to talk to her

-- 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 isn't 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 methodologies, 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

find. >> 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 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 rubric 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 psychologists are not reimbursed well for their therapies. that is why, i advocated bundled reimbursements in 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