Patterns of opioid use in patients with trigeminal neuralgia undergoing neurosurgery

View More View Less
  • Department of Neurosurgery, University of Pennsylvania, Philadelphia, Pennsylvania
Restricted access

Purchase Now

USD  $45.00

JNS + Pediatrics - 1 year subscription bundle (Individuals Only)

USD  $505.00

JNS + Pediatrics + Spine - 1 year subscription bundle (Individuals Only)

USD  $600.00
Print or Print + Online

OBJECTIVE

First-line treatment for trigeminal neuralgia (TN) is pharmacological management using antiepileptic drugs (AEDs), e.g., carbamazepine (CBZ) and oxcarbazepine (OCBZ). Surgical intervention has been shown to be an effective and durable treatment for TN that is refractory to medical therapy. Despite the lack of evidence for efficacy in patients with TN, the authors hypothesized that patients with neuropathic facial pain are prescribed opioids at high rates, and that neurosurgical intervention may lead to a reduction in opioid use.

METHODS

This is a retrospective study of patients with facial pain seen by a single neurosurgeon. All patients completed a survey on pain medications, medical comorbidities, prior interventions for facial pain, and a validated pain outcome tool (the Penn Facial Pain Scale). Patients subsequently undergoing neurosurgical intervention completed a survey at the 1-month follow-up in the office, in addition to telephone interviews using a standardized script between 1 and 6 years after intervention. Univariate and multivariate logistic regression were used to predict opioid use.

RESULTS

The study cohort consisted of 309 patients (70% Burchiel type 1 TN [TN1], 18% Burchiel type 2 [TN2], 6% atypical facial pain [AFP], and 6% TN secondary to multiple sclerosis [TN-MS]). At initial presentation, 20% of patients were taking opioids. Of these patients, 55% were receiving concurrent opioid therapy with CBZ/OCBZ, and 84% were receiving concurrent therapy with at least one type of AED. Facial pain diagnosis (for diagnoses other than TN1, odds ratio [OR] 2.5, p = 0.01) and facial pain intensity at its worst (for each unit increase, OR 1.4, p = 0.005) were predictors of opioid use at baseline. Neurosurgical intervention led to a reduction in opioid use to 8% at long-term follow-up (p < 0.01, Fisher’s exact test; n = 154). Diagnosis (for diagnoses other than TN1, OR 4.7, p = 0.002) and postintervention reduction in pain at its worst (for each unit reduction, OR 0.8, p < 10−3) were predictors of opioid use at long-term follow-up. On subgroup analysis, patients with TN1 demonstrated a decrease in opioid use to 5% at long-term follow-up (p < 0.05, Fisher’s exact test), whereas patients with non-TN1 facial pain did not. In the nonsurgical group, there was no statistically significant decrease in opioid use at long-term follow-up (n = 81).

CONCLUSIONS

In spite of its high potential for abuse, opioid use, mostly as an adjunct to AEDs, is prevalent in patients with facial pain. Opportunities to curb opioid use in TN1 include earlier neurosurgical intervention.

ABBREVIATIONS ADL = activities of daily living; AED = antiepileptic drug; AFP = atypical facial pain; CBZ = carbamazepine; fADL = face-specific ADL; gADL = general ADL; GKRS = Gamma Knife radiosurgery; MCID = minimum clinically important difference; MVD = microvascular decompression; OCBZ = oxcarbazepine; OR = odds ratio; PFPS = Penn Facial Pain Scale; TN = trigeminal neuralgia; TN1 = Burchiel type 1 TN; TN2 = Burchiel type 2 TN; TN-MS = TN secondary to multiple sclerosis.

JNS + Pediatrics - 1 year subscription bundle (Individuals Only)

USD  $505.00

JNS + Pediatrics + Spine - 1 year subscription bundle (Individuals Only)

USD  $600.00

Contributor Notes

Correspondence John Y. K. Lee: University of Pennsylvania, Philadelphia, PA. leejohn@uphs.upenn.edu.

INCLUDE WHEN CITING Published online January 11, 2019; DOI: 10.3171/2018.8.JNS1893.

Disclosures The authors report no conflict of interest concerning the materials or methods used in this study or the findings specified in this paper.

  • 1

    Burchiel KJ: A new classification for facial pain. Neurosurgery 53:11641167, 2003

  • 2

    Campbell FG, Graham JG, Zilkha KJ: Clinical trial of carbazepine (tegretol) in trigeminal neuralgia. J Neurol Neurosurg Psychiatry 29:265267, 1966

    • Search Google Scholar
    • Export Citation
  • 3

    Cruccu G, Gronseth G, Alksne J, Argoff C, Brainin M, Burchiel K, : AAN-EFNS guidelines on trigeminal neuralgia management. Eur J Neurol 15:10131028, 2008

    • Search Google Scholar
    • Export Citation
  • 4

    Di Stefano G, La Cesa S, Truini A, Cruccu G: Natural history and outcome of 200 outpatients with classical trigeminal neuralgia treated with carbamazepine or oxcarbazepine in a tertiary centre for neuropathic pain. J Headache Pain 15:34, 2014

    • Search Google Scholar
    • Export Citation
  • 5

    Headache Classification Subcommittee of the International Headache Society: The International Classification of Headache Disorders: 2nd edition. Cephalalgia 24 (Suppl 1):9160, 2004

    • Search Google Scholar
    • Export Citation
  • 6

    Hedegaard H, Warner M, Minino A: Drug Overdose Deaths in the United States, 1999–2015. NCHS Data Brief No. 273. Hyattsville, MD: National Center for Health Statistics, 2017 (https://www.cdc.gov/nchs/products/databriefs/db273.htm) [Accessed September 12, 2018]

    • Search Google Scholar
    • Export Citation
  • 7

    Jiang X, Orton M, Feng R, Hossain E, Malhotra NR, Zager EL, : Chronic opioid usage in surgical patients in a large academic center. Ann Surg 265:722727, 2017

    • Search Google Scholar
    • Export Citation
  • 8

    Killian JM, Fromm GH: Carbamazepine in the treatment of neuralgia. Use of side effects. Arch Neurol 19:129136, 1968

  • 9

    Lee JYK, Chen HI, Urban C, Hojat A, Church E, Xie SX, : Development of and psychometric testing for the Brief Pain Inventory–Facial in patients with facial pain syndromes. J Neurosurg 113:516523, 2010

    • Search Google Scholar
    • Export Citation
  • 10

    Linskey ME, Ratanatharathorn V, Peñagaricano J: A prospective cohort study of microvascular decompression and Gamma Knife surgery in patients with trigeminal neuralgia. J Neurosurg 109 Suppl:160172, 2008

    • Search Google Scholar
    • Export Citation
  • 11

    Maesawa S, Salame C, Flickinger JC, Pirris S, Kondziolka D, Lunsford LD: Clinical outcomes after stereotactic radiosurgery for idiopathic trigeminal neuralgia. J Neurosurg 94:1420, 2001

    • Search Google Scholar
    • Export Citation
  • 12

    Manchikanti L, Singh A: Therapeutic opioids: a ten-year perspective on the complexities and complications of the escalating use, abuse, and nonmedical use of opioids. Pain Physician 11 (2 Suppl):S63S88, 2008

    • Search Google Scholar
    • Export Citation
  • 13

    McNicol ED, Midbari A, Eisenberg E: Opioids for neuropathic pain. Cochrane Database Syst Rev (8):CD006146, 2013

  • 14

    McQuay H, Carroll D, Jadad AR, Wiffen P, Moore A: Anticonvulsant drugs for management of pain: a systematic review. BMJ 311:10471052, 1995

    • Search Google Scholar
    • Export Citation
  • 15

    Nicol CF: A four year double-blind study of tegretol in facial pain. Headache 9:5457, 1969

  • 16

    Office of National Drug Control Policy: Epidemic: Responding to America’s Prescription Drug Abuse Crisis. Washington, DC: Office of National Drug Control Policy, 2011 (https://www.ncjrs.gov/App/Publications/abstract.aspx?ID=256103) [Accessed September 12, 2018]

    • Search Google Scholar
    • Export Citation
  • 17

    Parsells Kelly J, Cook SF, Kaufman DW, Anderson T, Rosenberg L, Mitchell AA: Prevalence and characteristics of opioid use in the US adult population. Pain 138:507513, 2008

    • Search Google Scholar
    • Export Citation
  • 18

    Pollock BE, Schoeberl KA: Prospective comparison of posterior fossa exploration and stereotactic radiosurgery dorsal root entry zone target as primary surgery for patients with idiopathic trigeminal neuralgia. Neurosurgery 67:633639, 2010

    • Search Google Scholar
    • Export Citation
  • 19

    Sandhu SK, Halpern CH, Vakhshori V, Mirsaeedi-Farahani K, Farrar JT, Lee JYK: Brief pain inventory—facial minimum clinically important difference. J Neurosurg 122:180190, 2015

    • Search Google Scholar
    • Export Citation
  • 20

    Substance Abuse and Mental Health Services Administration, Center for Behavioral Health Statistics and Quality: Treatment Episode Data Set (TEDS): 2002–2012. National Admissions to Substance Abuse Treatment Services. BHSIS Series S-71, HHS Publication No (SMA) 14-4850. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2014 (https://www.samhsa.gov/data/sites/default/files/2002_2012_TEDS_National/2002_2012_Treatment_Episode_Data_Set_National_Body.htm) [Accessed September 12, 2018]

    • Search Google Scholar
    • Export Citation
  • 21

    Taylor JC, Brauer S, Espir ML: Long-term treatment of trigeminal neuralgia with carbamazepine. Postgrad Med J 57:1618, 1981

  • 22

    Torrance N, Smith BH, Watson MC, Bennett MI: Medication and treatment use in primary care patients with chronic pain of predominantly neuropathic origin. Fam Pract 24:481485, 2007

    • Search Google Scholar
    • Export Citation
  • 23

    Tyler-Kabara EC, Kassam AB, Horowitz MH, Urgo L, Hadjipanayis C, Levy EI, : Predictors of outcome in surgically managed patients with typical and atypical trigeminal neuralgia: comparison of results following microvascular decompression. J Neurosurg 96:527531, 2002

    • Search Google Scholar
    • Export Citation
  • 24

    United States Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Center for Behavioral Health Statistics and Quality: Drug Abuse Warning Network (DAWN), 2011. Ann Arbor, MI: Interuniversity Consortium for Political and Social Research, 2015 (https://www.icpsr.umich.edu/icpsrweb/ICPSR/studies/34565) [Accessed September 12, 2018]

    • Search Google Scholar
    • Export Citation
  • 25

    Wiffen PJ, Derry S, Moore RA, Kalso EA: Carbamazepine for chronic neuropathic pain and fibromyalgia in adults. Cochrane Database Syst Rev (4):CD005451, 2014

    • Search Google Scholar
    • Export Citation
  • 26

    Zakrzewska JM, Lopez BC, Kim SE, Coakham HB: Patient reports of satisfaction after microvascular decompression and partial sensory rhizotomy for trigeminal neuralgia. Neurosurgery 56:13041312, 2005

    • Search Google Scholar
    • Export Citation
  • 27

    Zakrzewska JM, Patsalos PN: Long-term cohort study comparing medical (oxcarbazepine) and surgical management of intractable trigeminal neuralgia. Pain 95:259266, 2002

    • Search Google Scholar
    • Export Citation

Metrics

All Time Past Year Past 30 Days
Abstract Views 1084 1084 82
Full Text Views 84 83 2
PDF Downloads 104 104 0
EPUB Downloads 0 0 0