Gary M. Reisfield

Use of Metaphor in the Discourse on Cancer

With this metaphoric deluge, the oncologist lost a prospective new patient. A few hours later, Lance Armstrong was on a plane to Indianapolis, where he would establish a successful therapeutic relationship with the oncology team from Indiana University. Armstrong would, of course, survive widely metastatic testicular cancer and go on to win six Tours de France. While this epigraph may represent a wellintentioned effort by an oncologist to prepare a young man with an advanced, lifethreatening malignancy for a long and immensely difficult course of treatment, the image of violence had a devastating and unintended effect. Armstrong himself, probably unconsciously mirroring the oncologist’s martial metaphor, described the reaction in the consultation room as “shell shock.” The comments of both the physician and the patient are emblematic of the fact that metaphors—and especially martial metaphors— play a ubiquitous, but largely unrecognized role in medical and lay discourse. Indeed, as a reader of the Journal of Clinical Oncology recently noted, the “target” in the title of this section of the Journal is itself a military metaphor. And as the above comments suggest, metaphors can be more than mere rhetorical flourishes; they can have a powerful influence on the practice of medicine and the experience of illness. “The essence of metaphor is understanding and experiencing one kind of thing in terms of another.” Lakoff and Johnson have demonstrated that our conceptual systems are wired to operate metaphorically; that is, most concepts, particularly those that are abstract or complex, are at least partially understood in terms of other, more familiar concepts. Metaphors, then, are vehicles for understanding, mediating what is known and what is unknown. Mabeck and Oleson go further, arguing that metaphors don’t merely describe similarities; they create them. When metaphors enter our conceptual system, they alter that system and the knowledge, attitudes, and behaviors to which the system gives rise. For the physician, metaphors can be time-efficient tools for helping patients understand complex biologic processes. For patients, metaphors can impose order on a suddenly disordered world, helping them to understand, communicate, and thus symbolically control their illness. And for the therapeutic relationship, the language of metaphor can serve as the basis for the shared understanding of clinical reality. We will examine the use of metaphor in oncology. We will focus on the predominant metaphor, that of war, in terms of its strengths and limitations, in the contexts of the patientphysician relationship and the patient’s illness experience. Finally, we will briefly survey alternate metaphoric concepts.

The Prevalence and Significance of Cannabis Use in Patients Prescribed Chronic Opioid Therapy: A Review of the Extant Literature

BACKGROUND Cannabis is the most widely consumed illicit drug in the United States. Its use, particularly in early initiates, is associated with subsequent development of other drug and alcohol use disorders. OBJECTIVE The authors examined the prevalence of cannabis use and the association between cannabis use and aberrant opioid-related behaviors in patients prescribed chronic opioid therapy for persistent pain. METHODS PubMed was queried for studies of chronic opioid therapy in which aberrant opioid-related behaviors were quantitatively examined and in which cannabis use data (as determined by cannabinoid-positive urine drug tests) were extricable from that of other substances of abuse. RESULTS The prevalence of cannabis use among patients prescribed chronic opioid therapy in these studies ranged from 6.2% to 39%, compared with 5.8% in the general United States population. Furthermore, cannabis use in chronic opioid patients shows statistically significant associations with present and future aberrant opioid-related behaviors. CONCLUSION Cannabis use is prevalent in patients prescribed chronic opioid therapy and is associated with opioid misuse. Further research is necessary to clarify the strength and the nature of the association between cannabis use and opioid misuse, and to address additional questions about the consequences of cannabis use in the context of chronic opioid therapy.

Morphine hyperalgesia: A case report

We report a case of a patient with metastatic testicular cancer and intractable pain refractory to massive doses of oral, intravenous, and intrathecal (IT) opioids supported by analgesic adjuvants. During our efforts to control his pain, the patient exhibited opioid-induced hyperalgesia, an uncommon but important phenomenon seen with high-dose opioid therapy. With appropriate opioid adjustment—in this case reduction of intrathecal morphine dosage by a factor of 100—the condition rapidly resolved and the patient became pain-free and remained so until his death six weeks later. The keys to identifying this uncommon, but treatable, opioid side effect are recognizing it as a possibility when aggressive efforts to control pain with high doses of opioids, especially when administered neuraxially, are met with increasing pain.

Abuse liability measures for use in analgesic clinical trials in patients with pain: IMMPACT recommendations

Summary Assessing and mitigating the abuse liability (AL) of analgesics is an urgent clinical and societal problem. Recommendations for improved assessment include: (1) performing trials that include individuals with diverse risks of abuse; (2) improving the assessment of AL in clinical trials (eg, training study personnel in the principles of abuse and addiction behaviors, designing the trial to assess AL outcomes as primary or secondary outcome measures depending on the trial objectives); (3) performing standardized assessment of outcomes, including targeted observations by study personnel and using structured adverse events query forms that ask all subjects specifically for certain symptoms (such as euphoria and craving); and (4) collecting detailed information about events of potential concern (eg, unexpected urine drug testing results, loss of study medication, and dropping out the trial). Abstract Assessing and mitigating the abuse liability (AL) of analgesics is an urgent clinical and societal problem. Analgesics have traditionally been assessed in randomized clinical trials (RCTs) designed to demonstrate analgesic efficacy relative to placebo or an active comparator. In these trials, rigorous, prospectively designed assessment for AL is generally not performed. The Initiative on Methods, Measurement, and Pain Assessment in Clinical Trials (IMMPACT) convened a consensus meeting to review the available evidence and discuss methods for improving the assessment of the AL of analgesics in clinical trials in patients with pain. Recommendations for improved assessment include: (1) performing trials that include individuals with diverse risks of abuse; (2) improving the assessment of AL in clinical trials (eg, training study personnel in the principles of abuse and addiction behaviors, designing the trial to assess AL outcomes as primary or secondary outcome measures depending on the trial objectives); (3) performing standardized assessment of outcomes, including targeted observations by study personnel and using structured adverse events query forms that ask all subjects specifically for certain symptoms (such as euphoria and craving); and (4) collecting detailed information about events of potential concern (eg, unexpected urine drug testing results, loss of study medication, and dropping out of the trial). The authors also propose a research agenda for improving the assessment of AL in future trials.

The Mirage of Impairing Drug Concentration Thresholds: A Rationale for Zero Tolerance Per Se Driving under the Influence of Drugs Laws

Motor vehicle crashes are a leading cause of morbidity and mortality in the United States. Drivers with measurable quantities of potentially impairing illicit or prescription drugs in their body fluids are multiple times more likely to be involved in motor vehicle crashes than those without such drugs in their bodies. Drug-related impairment, however, cannot be inferred solely on the basis of the presence of drugs in biological fluids. Thus, for more than a quarter century, there has been a search for drug blood concentrations that are the equivalent of the 0.08 g/dL threshold for alcohol-impaired driving in the United States. We suggest that such equivalents are a mirage, and cannot be determined due to variable drug tolerance, lack of consistent relationships between drug blood concentrations and impairment, innumerable drug combinations and multiple other factors. Thus, while the idea of determining impairing drug concentrations is attractive, it is ultimately unattainable, and withholding drugged driving legislation pending the acquisition of such data is tantamount to a plan for inaction with regard to an important and growing public health and safety problem. We propose specific legislation to address alcohol- and drug-impaired driving in the United States.

Acute Pain Medicine in the United States: A Status Report

BACKGROUND Consensus indicates that a comprehensive,multimodal, holistic approach is foundational to the practice of acute pain medicine (APM),but lack of uniform, evidence-based clinical pathways leads to undesirable variability throughout U. S. healthcare systems. Acute pain studies are inconsistently synthesized to guide educational programs. Advanced practice techniques involving regional anesthesia assume the presence of a physician-led, multidisciplinary acute pain service,which is often unavailable or inconsistently applied.This heterogeneity of educational and organizational standards may result in unnecessary patient pain and escalation of healthcare costs. METHODS A multidisciplinary panel was nominated through the APM Shared Interest Group of the American Academy of Pain Medicine. The panel met in Chicago, IL, in July 2014, to identify gaps and set priorities in APM research and education. RESULTS The panel identified three areas of critical need: 1) an open-source acute pain data registry and clinical support tool to inform clinical decision making and resource allocation and to enhance research efforts; 2) a strong professional APM identity as an accredited subspecialty; and 3) educational goals targeted toward third-party payers,hospital administrators, and other key stake holders to convey the importance of APM. CONCLUSION This report is the first step in a 3-year initiative aimed at creating conditions and incentives for the optimal provision of APM services to facilitate and enhance the quality of patient recovery after surgery, illness, or trauma. The ultimate goal is to reduce the conversion of acute pain to the debilitating disease of chronic pain.

Benzodiazepines in Long-Term Opioid Therapy

The prescribing of long-term opioid therapy (LtOT) for chronic noncancer pain (CNCP) gained wide clinical acceptance over the past quarter century. The practice has become increasingly controversial in recent years, however, due both to questions about long-term efficacy and the potential for opioid-related morbidity and mortality [1–3]. Recently, several pain medicine thought leaders have retreated from long-held positions about the wisdom of prescribing LtOT for patients with CNCP [4]. The prescribing of long-term benzodiazepine therapy for anxiety and mood disorders, insomnia, and other indications is also both prevalent and controversial. Advocates for their use point to their rapidity of onset, efficacy, and tolerability, while opponents highlight concerns about sedation, cognitive and psychomotor impairment, abuse and addiction, physical dependence, and the sometimes enormous difficulties in tapering and discontinuing these medications [5–7]. It has been argued that the availability of psychological therapies and selective serotonin reuptake inhibitors (SSRIs) and serotonin-norepinephrine uptake inhibitors (SNRIs) for anxiety disorders, and sleep hygiene and melatonin for insomnia have made the long-term administration of benzodiazepines largely avoidable [7–9]. Although a detailed discussion of the safety and efficacy of benzodiazepine therapy is beyond the scope of this commentary, a recent critical appraisal of these agents offered the following conclusions [10]:

Radiopharmaceuticals for the palliation of painful bone metastases

Metastatic bone pain is prevalent in advanced cancer, and, despite a plethora of available therapies, effective palliation remains a clinical challenge. Bone-seeking radiopharmaceuticals are an often-overlooked but valuable analgesic option for select patients. These agents work by binding to hydroxyapatite at the tumor-bone interface of osteoblastic lesions, delivering therapeutic doses of radiation to closely circumscribed tissue regions. They have been shown to reduce pain and improve quality of life. Their safety, simplicity, convenience of administration, and cost-effectiveness make them suitable for hospice and palliative care settings.

Unexpected Urine Drug Testing Results in a Hospice Patient on High-Dose Morphine Therapy

A 41-year-old African-American woman was admitted to an inpatient hospice facility with advanced, inoperable cervical cancer. The patient was experiencing severe pain secondary to extensive local tumor invasion, osseous pelvic metastases, and sacral decubitus ulcers. Her pain was treated with an escalating-dose schedule of morphine sulfate until satisfactory analgesia was achieved with stable doses of a combination of controlled-release morphine sulfate (MSContin®, Purdue Pharma LP) 400 mg orally every 8 h, and immediate-release morphine sulfate (MSIR®, Purdue Pharma LP), 180 mg orally every 4 h, as needed for breakthrough pain (average 2 to 3 doses per day). The patient experienced several episodes of life-threatening vaginal bleeding for which she was hospitalized for red blood cell transfusions and bilateral hypogastric artery embolizations. She spent the final 12 weeks of her life exclusively on the inpatient hospice unit. Approximately 3 weeks before her death, the patient underwent urine specimen collection and analysis of morphine and metabolites. GC-MS analysis revealed the presence of morphine as well as small quantities of hydromorphone. During the past 2 decades, chronic opioid analgesic therapy (COAT) for chronic nonmalignant pain has gained increasing clinical acceptance. An unintended consequence of more liberal opioid prescription practices has been a dramatic increase in the abuse and diversion of these drugs. According the most recent National Survey on Drug Abuse and Health (1), the number of new, past-year abusers of prescription opioids was 2 147 000—more than the number of new abusers of any other single class …

Medical Cannabis and Chronic Opioid Therapy

ABSTRACT Fourteen states and the District of Columbia have legalized the use of cannabis for medical purposes. A small, high-quality literature supports the efficacy of medical cannabis for the treatment of neuropathic pain. The smoked botanical product, however, is associated with a number of adverse medical and psychiatric consequences. Furthermore, experimental data indicate that acute use of cannabis results in impairment of every important metric related to the safe operation of a motor vehicle. Epidemiological data show associations between recent cannabis use and both psychomotor impairment and motor vehicle crashes, associations that are strengthened by the concomitant use of alcohol and other central nervous system depressants. Finally, data from pain clinics reveals an unusually high prevalence of cannabis use in nearly all age groups and an association between cannabis use and opioid and other substance misuse. Based on available data and expert opinion, concomitant use of cannabis and opioids is an absolute contraindication to the operation of a motor vehicle. In patients who use cannabis and are prescribed opioids, heightened vigilance for opioid- and other substance-related problems is warranted. It is appropriate to refrain from prescribing opioids to individuals using medical cannabis if there is reasonable suspicion that the combination will pose a risk to the patient or others.