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Pain is a common symptom of mesothelioma. In most cases it can be controlled with medication. Typically pain is on one side of the chest, sometimes in the shoulder or back, and may be dragging or like toothache. Movement or deep breathing may make it worse. The usual practice is to use simple painkillers initially such as paracetamol and ibuprofen. If these are ineffective the next step is to use morphine. Patients are often concerned about taking morphine because of its associations with illegal drug abuse, addiction, and belief that it is very powerful. In practice these worries are unnecessary, morphine is a safe drug when used as prescribed, an effective painkiller that does not usually cause addiction when used for pain, and should always be started in a low dose and only increased if necessary.

Morphine is usually commenced in a quick acting oral (by mouth) form, this may be liquid (Oramorph) or tablet (Sevredol). Patients are advised to take a dose every 4 hours if they have pain; after a few days the usual daily dose can be converted into a once or twice a day longer acting preparation and taken on a regular basis (e.g. Zomorph, MST etc). In the event of pain occurring in between the regular doses, patients are usually advised to have some oral morphine liquid or short-acting tablets to use – this is referred to as the ‘breakthrough dose’ for ‘breakthrough pain’.

Although morphine is an excellent drug it is not effective for all types of pain, other opioids (morphine-like drugs), such as methadone, may be more effective. Sometimes it is helpful to take regular paracetamol or ibuprofen as well because these have different modes of action on pain. In cases where there is involvement of nerves the pain may not respond completely to opioids and it may be helpful to add different types of medication. Some drugs usually prescribed for either epilepsy or depression have unique pain-relieving properties and can alleviate ‘nerve pain’. Palliative medicine teams and pain specialists can advise when pain is not responding to medication and in some cases specialised pain control techniques are necessary. A TENS (transcutaneous electrical nerve stimulator) machine may be useful. Occasionally it may be necessary to use techniques that destroy nerves that are particularly troublesome. These can include nerve blocks, spinal or epidural infusions of painkillers,and destruction of spinal cord nervous tissue by a technique called percutaneous cordotomy(see below).

If patients are unable to take medications by mouth it is possible to administer them in a daily infusion through a needle just under the skin via a syringe driver. This is a small battery-operated pump that slowly expels the infusion of medication from a syringe. This is a safe and effective method of delivery and many patients use this at home. The drugs are renewed, usually daily, by nursing staff. Alternatively one opioid, fentanyl, can be administered as a patch stuck onto the skin, this has to be changed every 3 days.

A procedure called a Percutaneous Spinal Cordotomy may help relieve pain that has not responded to conventional pain medicines. The procedure involves heating some of the pain nerves in the spinal cord that transmit pain information to the brain. It involves placing an electrode (about the size of a blood test needle) into these pain carrying pathways, using special x-ray guidance. It is done under a local anesthetic; the patient is awake so that they can communicate any sensations felt during the procedure. Patients who have been treated with this procedure can gain long term pain relief (months to years). Sometimes the procedure can be unsuccessful because the pain nerves cannot be identified safely. Any risk should be discussed with the doctor. There are currently four centres offering a Percutaneous Cordotomy service to patients – these cover the South, North, North-West and Midlands. They have all agreed to have their details circulated.

Drs Mike Williams or Nick Campkin, The Pain Clinic, Level D, Queen Alexandra Hospital, Cosham, Portsmouth  PO6 3LY
Tel: 02392 283271 Fax: 02392 286888  Email:  michael.williams1@porthosp.nhs.uk  nick.campkin@porthosp.nhs.uk

Dr Paul Cook (Consultant in Palliative Care & Anaesthesia), Room 21, Central Offices, Pennine Square, Royal Oldham Hospital, Rochdale Road, Oldham, OL1 2JH
Tel: 0161 656 1912 Fax: 0161 656 1929 E-mail: paul.cook@pat.nhs.uk

Dr Mahohar Sharman (Consultant in Pain Management), The Walton Centre for Neurology and Neurosurgery NHS Trust, Lower Lane, Liverpool, L9 7LJ.
Tel. 0151 529 8294 (Pain Clinic) or 0151 529 2098 (Aintree Palliative Care Service)

Mesothelioma UK recommends that patients discuss the appropriateness of this procedure with the doctor or hospital team who is currently caring for them.

Information for Referral for Health Professionals

Referral criteria is attached (provided with permission by Dr Pounder) - this information is for health professionals. Each centre has its own patient information leaflets. At a minimum, full patient details are needed, including a patient contact phone number, their awareness of diagnosis and prognosis, current medication, disease spread & the other health professionals involved in their care. All centres are happy to phone patients, to answer any referral or cordotomy queries, instead of a formal pre-procedure outpatient appointment. If the patients are geographically too distant this avoids the need for repeated travel to the cordotomy centre.

Referral criteria for health care professionals