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Michael E Schatman,1– 3 Hannah Shapiro3,4 1Division of Medical Ethics, NYU School of Medicine, New York, NY, USA; 2Department of Anesthesiology, Perioperative Care, and Pain Medicine, NYU School of Medicine, New York, NY, USA; 3School of Social Work, North Carolina State University, Raleigh, NC, USA; 4McLean Hospital, Division of Alcohol, Drugs, and Addiction, Harvard Medical School, Boston, MA, USACorrespondence: Michael E SchatmanDivision of Medical Ethics, Department of Population Health, NYU School of Medicine, 550 First Avenue, New York, NY, 10016, USATel +1 425-647-4880Email Michael.Schatman@NYULangone.org

Malini Ghoshal,1 Hannah Shapiro,2 Knox Todd,3 Michael E Schatman4,5 1Inspirra Healthcare, Plano, Texas, USA; 2Division of Alcohol, Drugs, and Addiction, McLean Hospital, Belmont, Massachusetts, USA; 3Department of Emergency Medicine, The University of Texas MD Anderson Cancer Center Houston, Texas, USA; 4Department of Diagnostic Sciences, Tufts University School of Dental Medicine, Boston, Massachusetts, USA; 5Department of Public Health and Community Medicine, Tufts University School of Medicine, Boston, Massachusetts, USACorrespondence: Michael E Schatman Tel +1(425)647-4880Email Michael.Schatman@tufts.edu Although it is widely recognized that the United States has a severe and broad systemic racism problem, recent events have dramatically elevated the issue. Widespread protests in the US and around the world have brought much-deserved attention to the plights of Blacks, Indigenous and People of Color (BIPOC) regarding injustices that they experience on a daily basis. For the sake not only of BIPOC, but communities and societies as a whole, racial injustice can no longer be ignored or minimalized.1

Michael E Schatman,1,2 Hannah Shapiro,3 Jeffrey Fudin4– 7 1Department of Diagnostic Sciences, Tufts University School of Dental Medicine, Boston, MA, USA; 2Department of Public Health and Community Medicine, Tufts University School of Medicine, Boston, MA, USA; 3McLean Hospital, Division of Alcohol, Drugs, and Addiction, Harvard Medical School, Boston, MA, USA; 4Remitigate Therapeutics, Delmar, NY, USA; 5Department of Pharmacy Practice, Albany College of Pharmacy, Albany, NY, USA; 6Department of Pharmacy Practice, Western New England University, Springfield, MA, USA; 7Stratton VA Medical Center, Albany, NY, USACorrespondence: Michael E Schatman Tel +1 (425) 647-4880Email Michael.Schatman@tufts.edu The Affordable Care Act (ACA) was signed into law in March of 2010 by President Barack Obama, and represented the most significant expansion of health care coverage and regulatory overhaul since the establishment of Medicare and Medicaid in 1965.1 The expansion of the number of individuals covered by health insurance under the ACA, most notably the clause prohibiting insurers from refusing to cover those with pre-existing conditions, has dramatically improved access to chronic pain management for approximately 50 million Americans living with chronic pain.2 For a number of years, we have been writing about the urgent need to improve the deteriorating quality of pain management in the United States.3–6 Many patients believe that the war on prescription opioids, patients who rely upon them, and physicians with the audacity to still prescribe them has resulted in the marginalization of the nation’s pain care system.7–11 However, the looming potential demise of the ACA based purely on political motivations and characterological flaws presents an existential threat of colossal proportions to chronic pain patients.

Hannah Shapiro, 1 Ronald J Kulich, 2, 3 Michael E Schatman 3, 4 1Department of Biopsychology, Tufts University, Medford, MA, USA; 2Department of Anesthesia, Critical Care and Pain Medicine, Harvard Medical School/Massachusetts General Hospital, Boston, MA, USA; 3Department of Diagnostic Sciences, Tufts University School of Dental Medicine, Boston, MA, USA; 4Department of Public Health and Community Medicine, Tufts University School of Medicine, Boston, MA, USACorrespondence: Michael E Schatman Tel +1 425 647-4880Email Michael.Schatman@tufts.eduTo the best of our knowledge, no one has ever suggested that it is “easy” to suffer from intractable chronic pain, with some subgroups impacted more than others. This burden has had a particularly strong impact in the United States, where the chronic pain treatment system has demonstrated failings with respect to access to care1–8 Because chronic pain is so poorly treated in the United States, patients have struggled not only with their pain and its sequelae but also with mounting frustration and downstream psychological consequences. Depression and suicidality have been linked to poorly controlled pain,9,10 and the authors of a recent study11 noted that these phenomena are a concern within the context of opioid tapering. Similarly, Lembke has recently acknowledged that even mention of tapering can trigger severe anxiety in chronic pain patients,12 with data supporting the relationship between undertreated chronic pain and anxiety.13,14 Although myriad investigations have supported the existence of a reciprocal relationship between chronic pain and depression15–17 as well as between chronic pain and anxiety,18–20 detailed discussion of causality is beyond the scope of this analysis.

Giuliano Lo Bianco, 1–3 Simon Thomson, 3 Simone Vigneri, 4 Hannah Shapiro, 5 Michael E Schatman 6, 7 1Università di Catania, Dipartimento di Scienze Biomediche e Biotecnologiche (BIOMETEC), Catania, Italy; 2I.R.C.C.S. CROB Centro di Riferimento Oncologico Basilicata, Rionero in Vulture, Potenza, Italy; 3Basildon and Thurrock University Hospitals NHSFT, Orsett Hospital, Pain Management and Neuromodulation, London, Essex, UK; 4Pain Medicine Department, Santa Maria Maddalena Hospital, Occhiobello, Rovigo, Italy; 5Department of Biopsychology, Tufts University, Medford, MA, USA; 6Department of Diagnostic Sciences, Tufts University School of Dental Medicine, Boston, MA, USA; 7Department of Public Health and Community Medicine, Tufts University School of Medicine, Boston, MA, USACorrespondence: Michael E Schatman Tel +1425647-4880Email Michael.Schatman@tufts.edu Abdominal pain is a nonspecific symptom which can be caused by myriad pathologies, resulting in frequent misdiagnosis. 1 Some pathological conditions can cause paroxysmal gastrointestinal symptoms, such as porphyria, cyclical vomiting, intestinal malrotation, peritoneal bands, and abdominal migraine. 2 Furthermore, emotional and psychological factors may also play an important role in the presentation of certain patients with gastrointestinal disorders, and accurate diagnosis can be confounded by these. An accurate diagnosis may be delayed or even abandoned due to the attribution of “functional” or “psychogenic” causality. 3 Physicians in numerous fields of practice too often respond in such a fashion when the more common causes of pain conditions are ruled out, 4 which potentially puts patients with rare pain disorders that are challenging to diagnose at considerable risk for needless, prolonged suffering. Further, the stigma associated with being diagnosed with a Somatoform Disorder or a Medically Unexplained Symptom (MUS) should not be understated. 5

Jonathan Greenberg,1,2 Ann Lin,1 Emily L Zale,1 Ronald J Kulich,2,3 Peter James,2,4 Rachel A Millstein,1,2 Hannah Shapiro,5 Michael E Schatman,6,7 Robert R Edwards,2,8 Ana-Maria Vranceanu1,2 1Integrated Brain Health Clinical and Research Program, Massachusetts General Hospital, Boston, MA, USA; 2Harvard Medical School, Boston, MA, USA; 3Center For Pain Medicine, Massachusetts General Hospital, Boston, MA, USA; 4Department of Population Medicine, Harvard T. H. Chan School of Public Health, Boston, MA, USA; 5Department of Biology, Tufts University, Medford, MA, USA; 6Research and Network Development, Boston Pain Care, Waltham, MA, USA; 7Department of Public Health and Community Medicine, Tufts University School of Medicine, Boston, MA, USA; 8Pain Management Center, Brigham and Women’s Hospital, Boston, MA, USACorrespondence: Ana-Maria VranceanuIntegrated Brain Health Clinical and Research Program, Department of Psychiatry, Massachusetts General Hospital/Harvard Medical School, One Bowdoin Square, 1 st Floor, Suite 100, Boston, MA, USATel +1 6177244977Fax +1 617-643-8777Email avranceanu@mgh.harvard.eduBackground: Increasing physical function is a challenging, yet imperative goal of pain management programs. Physical activity can improve physical function, but uptake is low due to chronic pain misconceptions, poor pain management skills, and doing too much too soon.Purpose: To increase physical function by 1) adapting an evidence-based, group, mind-body program to address the needs of patients with heterogeneous chronic pain and to facilitate individually tailored quota-based pacing with a Fitbit (GetActive with Fitbit) or without it (GetActive) (phase 1), and 2) assessing preliminary feasibility benchmarks (phase 2).Methods: We followed evidence based frameworks for developing interventions and for early feasibility testing. In phase 1 we conducted 4 focus groups with 22 patients with heterogeneous chronic pain and adapted the mind-body program. In phase 2 we conducted a nonrandomized pilot trial of the 2 programs (N=7 and 6) with qualitative exit interviews.Results: Focus groups showed high interest in increasing activity, a preference for walking linked to pleasurable activities, using a Fitbit to track number of steps, and learning skills to manage pain and aid with increased activity. Both programs had good to excellent feasibility markers. Participation in both programs was associated with signal of improvements in physical and emotional function, as well as intervention targets. Exit interviews confirmed high satisfaction and suggested modification.Conclusion: Results informed subsequent adaptations of the 2 programs and methodology for an ongoing pilot randomized controlled trial (RCT) of the 2 programs, necessary before an efficacy RCT of the 2 programs against an education control.Keywords: mind-body, chronic pain, fitbit, physical activity, focus groups, feasibility, physical function

Michael E Schatman,1–3 Hannah Shapiro4 1Boston PainCare, Waltham, MA, USA; 2Department of Diagnostic Sciences, Tufts University School of Dental Medicine, Boston, MA, USA; 3Department of Public Health and Community Medicine, Tufts University School of Medicine, Boston, MA, USA; 4Department of Biopsychology, Tufts University, Medford, MA, USACorrespondence: Michael E SchatmanBoston PainCare, 85 First Avenue, Waltham, MA 02451, USATel +1 339 425-647-4880Email Michael.Schatman@tufts.eduOn January 22, 2019, a Massachusetts State Representative introduced House Bill 3656, “An Act requiring practitioners to be held responsible for patient opioid addiction”.1 Section 50 of this proposed legislation reads, “A practitioner, who issues a prescription for a controlled substance placed in Schedule II, which contains an opiate, shall be liable to the patient for whom the written prescription was written, for the payment of the first 90 days of in-patient hospitalization costs if the patient becomes addicted and is subsequently hospitalized”.

David J DiBenedetto1,2, Kelly M Wawrzyniak1,2, Michael E Schatman1,3, Hannah Shapiro1,4, Ronald J Kulich2,51Research and Network Development, Boston PainCare, Waltham, MA, USA; 2Department of Diagnostic Sciences, Tufts School of Dental Medicine, Boston, MA, USA; 3Deparment of Public Health and Community Medicine, Tufts School of Medicine, Boston, MA, USA; 4Department of Biopsychology, Tufts University, Medford, MA, USA; 5Department of Anesthesia Critical Care and Pain Medicine, Harvard Medical School, Massachusetts General Hospital, Boston, MA, USAObjective: To determine the average amount of time required to detect opioid aberrancy based upon varying frequencies of urine drug testing (UDT) in a community-based, tertiary care pain management center.Subjects: This study was a retrospective analysis of 513 consecutive patients enrolled in a medication management program, receiving chronic opioid therapy between January 1, 2018 and December 31, 2018.Methods: Data were extracted from medical records including age at start of the study period, sex, ethnicity, marital status, and smoking status. UDT was performed at each prescribing visit via semi-quantitative immunoassay, and at the discretion of the clinician, a sample was sent for external confirmation using gas chromatography or mass spectrometry testing to clarify questions of inconsistency with patients’ reports or prescribed medications. For purposes of the study, “opioid aberrancy” was defined through inconsistent UDT.Results: One hundred and fifteen patients (22.4%) had at least one inconsistent UDT during the study period, and 160 (2.8%) of all UDTs were inconsistent. At this rate of inconsistency, it was determined that with monthly screening, it would require up to 36 months to detect a single aberrancy, and semi-annual testing would require as long as 216 months to detect an aberrancy.Conclusions: More frequent UDT can be helpful in terms of earlier detection of opioid aberrancy. This has significant implications for helping avoid misuse, overdose, and potential diversion. Furthermore, early detection will ideally result in earlier implementation of treatment of the emotional and behavioral factors causing aberrancy. Such early intervention is more likely to be successful in terms of reducing substance misuse in a chronic pain population, providing a higher degree of patient adherence and safety, as well as producing superior overall patient outcomes. Finally, economic benefits may include substantial savings through avoidance of the necessity for drug rehabilitation and the empirically established higher costs of treating opioid misuse comorbidities.Keywords: urine drug testing, frequency, opioid safety, economic benefits

Mycorrhizal symbioses the union of roots and soil fungi are universal in terrestrial ecosystems and may have been fundamental to land colonization by plants 1, 2. Boreal, temperate and montane forests all depend on ectomycorrhizae1. Identification of the primary factors that regulate symbiotic development and metabolic activity will therefore open the door to understanding the role of ectomycorrhizae in plant development and physiology, allowing the full ecological significance of this symbiosis to be explored. Here we report the genome sequence of the ectomycorrhizal basidiomycete Laccaria bicolor (Fig. 1) and highlight gene sets involved in rhizosphere colonization and symbiosis. This 65-megabase genome assembly contains 20,000 predicted protein-encoding genes and a very large number of transposons and repeated sequences. We detected unexpected genomic features, most notably a battery of effector-type small secreted proteins (SSPs) with unknown function, several of which are only expressed in symbiotic tissues. The most highly expressed SSP accumulates in the proliferating hyphae colonizing the host root. The ectomycorrhizae-specific SSPs probably have a decisive role in the establishment of the symbiosis. The unexpected observation that the genome of L. bicolor lacks carbohydrate-active enzymes involved in degradation of plant cell walls, but maintains the ability to degrade non-plant cell wall polysaccharides, reveals the dual saprotrophic and biotrophic lifestyle of the mycorrhizal fungus that enables it to grow within both soil and living plant roots. The predicted gene inventory of the L. bicolor genome, therefore, points to previously unknown mechanisms of symbiosis operating in biotrophic mycorrhizal fungi. The availability of this genome provides an unparalleled opportunity to develop a deeper understanding of the processes by which symbionts interact with plants within their ecosystem to perform vital functions in the carbon and nitrogen cycles that are fundamental to sustainable plant productivity.