Year : 2015 | Volume
: 2 | Issue : 2 | Page : 115--117
Use of opium as antiepileptic in patient with frontal lobe epilepsy: A case report
Naresh Nebhinani, Vrinda Pareek
Department of Psychiatry, All India Institute of Medical Science, Jodhpur, Rajasthan, India
Department of Psychiatry, All India Institute of Medical Science, Jodhpur - 342 005, Rajasthan
Frontal lobe epilepsy (FLE) manifests with brief, nocturnal seizures arising in the frontal lobe along with unusual behavioral symptoms or postures, frequently misdiagnosed as a psychogenic nonepileptic seizure (PNES) or a sleep disorder. Ancient literature has rarely mentioned the antiepileptic effect of opium or different opioids. Here we are presenting a case with FLE, though initially diagnosed PNES, who had significant relief in his symptoms on using opium, and this led to opium dependence. Index case further emphasizes concern and caution as misdiagnosis of FLE may lead to substance dependenc.
|How to cite this article:|
Nebhinani N, Pareek V. Use of opium as antiepileptic in patient with frontal lobe epilepsy: A case report.J Geriatr Ment Health 2015;2:115-117
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Nebhinani N, Pareek V. Use of opium as antiepileptic in patient with frontal lobe epilepsy: A case report. J Geriatr Ment Health [serial online] 2015 [cited 2021 Dec 1 ];2:115-117
Available from: https://www.jgmh.org/text.asp?2015/2/2/115/174283
Despite subsequent advances in neuroscience, frontal lobe epilepsy (FLE) remains the most challenging of all the epilepsies for both diagnosis and management. FLE cases are particularly prone to misdiagnosis as psychogenic nonepileptic seizures (PNES) due to their sometimes atypical presentation and postures, and most of the time surface electroencephalogram (EEG) does not show characteristic interictal or ictal abnormalities. 
The management of epilepsy has changed dramatically over hundreds of years, ranging from herbal plants to modern antiepileptic drugs. Not much has been documented about the use of opium as an antiepileptic in modern literature, although there are certain references about its use before phenobarbital was discovered and the latest research interest involves testing its potential role in seizure control.  We present a case with FLE, who had significant relief in his symptoms on the use of opium and this led to opium dependence, which further emphasizes the misdiagnosis of FLE as PNES leading to substance dependence.
Mr. M, a 55-year-old illiterate farmer, presented to us with the complaint of sudden episodes of jerky movements lasting for about 30 s to 2 min. The patient had been having these episodes for the last 2 years. There was history of stroke 2 years ago, following which he was diagnosed with triple vessel disease atherosclerosis and was found to have bilateral renal artery stenosis. He was diagnosed with hypertensive retinopathy simultaneously. Thereafter, bilateral external iliac artery stenting was done as part of an interventional procedure.
After said event, the patient started experiencing episodic abnormal jerky movements without any loss of consciousness. These episodes would last for 30 s to 2 min involving all the four limbs or at times the unilateral upper and lower limbs (predominantly on the right side). These episodes were generally nocturnal in nature. There was no associated urinary or fecal incontinence or tongue bite. During these episodes, the patient did not respond to verbal commands, although he also did not lose consciousness. The frequency of such episodes was 1-2 every night and one episode in 2-3 days during daytime. Just before the onset of episodes, the patient would wake up from sleep experiencing numbness or a tingling sensation on the right side of the body. At times, he would get very anxious before the movements. After the episode, the patient would remember the episode, though he could not respond verbally during that time. He would not report headache, weakness, or generalized pains after such episodes. His interictal EEG recordings were reported normal.
He had consulted several physicians and the episodes were mostly labelled as "psychogenic seizures," except that he was once diagnosed with generalized tonic clonic seizures and received tablet carbamazepine 200 mg, 1 tablet thrice daily. Due to lack of improvement with said treatment for about 1 month in spite of being compliant, the patient stopped the medications. He continued to have symptoms for the next 18 months. Thereafter, due to the sociocultural milieu and the age-old rural belief of opium being the cure for every problem including clinical scenarios where medication fails, the patient started consuming opium. His daily intake was about 2-4 g in divided doses. The patient felt significant improvement in the frequency as well as duration of said movements. He gradually had to increase the opium dose to achieve the desired effect as there was decreased effect with the same dose. He reported tolerance and withdrawals signs, but denied the typical craving for opium. After about 5 months of opium consumption, due to nonavailability as well as financial constraints, he started reducing his daily opium intake. Hence, expectedly, the seizure frequency increased.
At this point of time the patient consulted at a consultation-liaison clinic. He was admitted for differential diagnosis and further management. After thorough exploration and analyzing serial video clips of his abnormal jerky movement and due to the typical brief, predominant nocturnal seizures, abnormal body posture, and lack of any psychosocial stressor and psychiatric disturbances, we have kept the possibility of FLE along with opium dependence. As the patient gradually reduced the daily dose of opium, he did not report significant withdrawal symptoms. For the first few days, he continued to consume opium in a significantly lower amount, but eventually stopped after reassurance. Hence he was not put on a routine detoxification regimen [oral clonidine, nonsteroidal antiinflammatory drugs (NSAIDs), sedatives]. His magnetic resonance imaging (MRI) brain report showed a patchy area of chronic infarction in the superior left frontal lobe with parenchymal loss and peripheral flair intensity. Electrocardiogram (ECG) was suggestive of old healed anterior wall myocardial infarction. Along with antihypertensives and other symptomatic management, the patient was started on tablet oxcarbazepine 450 mg twice daily and tablet clobazam 5 mg twice daily. Following this treatment, the patient as well as his family members reported significant reduction in his seizure frequency and duration. He was further advised regular drug compliance, follow-up, and serum electrolyte monitoring.
The semiology of FLE is extremely diverse. In one study, the patients' age at onset of seizures ranged 1-65 years with the mean frequency of 15-20 seizures per month.  Seizures are usually nocturnal, brief, with sudden onset and termination, and without significant postictal confusion. They may occur in clusters, with at times secondary generalization. Clonic activity and asymmetric tonic posturing are typically reported in frontal seizures.  Partial seizures are more commonly reported during non-rapid eye movement (NREM) sleep than rapid eye movement (REM) sleep. 
Ictal EEG and sleep EEG usually detect epileptiform abnormalities in about 50% of patients. Nearly two-third of patients have significant improvement in seizure frequency and complexity with carbamazepine.  Similarly, the index case had normal interictal EEG recording on several occasions and also had very good response to oxcarbamazepine.
A recent study by Sabbaghzadeh and Asadbegi  has reported antiepileptic effects of poppy seed extract in mouse model in delaying the onset of seizures and reducing the severity of seizures. The authors further recommended the study of the antiepileptic property of different components of Papaver somniferum and to consider traditional medicines to achieve a safe drug with minimal side effects. The index case has also shown good seizure control with opium.
This case is noteworthy for two reasons. First, not much has been documented about the ancient use of opium as an anticonvulsant. Even today due to the sociocultural milieu, opium (raw form) is widely used to treat common ailments such as cough and somewhat less common ailments such as epilepsy. Even our patient had reported significant improvement after consuming opium, but later on, due to tolerance as well as difficulty in procurement, symptoms relapsed.
Second, as mentioned earlier, frontal seizures can present in a way that can often be misdiagnosed as a psychiatric disorder (generally, conversion reaction or even psychosis). This patient was suspected to suffer from PNES. However, the movements being nocturnal, the presence of aura, and the absence of any psychosocial gain and stressor favored the diagnosis toward epilepsy. We would also like to emphasize that due to misdiagnosis of FLE as PNES, the index patient started taking opium and developed opium dependence.
In cases similar to the index case, differentiating PNES from FLE can be challenging. Thorough history, physical signs, and neuropsychological testing are helpful adjuncts to the video EEG to confirm the diagnosis. A multidisciplinary approach is preferred for timely diagnosis and effective treatment.  The index case has reported better satisfaction with effective seizure control on oxcarbamazepine and being off opium.
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Conflicts of interest
There are no conflicts of interest.
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