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The limited evidence available does not support the effectiveness of salmon calcitonin in the
treatment of acute and persistent metastatic bone pain (Martinez‐Zapata et al, 2006 Level I).
Bisphosphonates
IV pamidronate (3 daily doses) reduced pain associated with acute osteoporotic vertebral
fractures for up to 30 days post‐treatment (Armingeat et al, 2006 Level II).
Bisphosphonates reduced sub‐acute bone pain associated with metastatic carcinoma of the
breast (Pavlakis et al, 2005 Level I) or prostate (Yuen et al, 2006 Level I) and in multiple myeloma
(Djulbegovic et al, 2002 Level I).
Key messages
1. Bisphosphonates reduce bone pain associated with metastatic cancer and multiple
myeloma (N) (Level I [Cochrane Review]).
2. Salmon calcitonin reduces pain and improves mobilisation after osteoporosis‐related
vertebral fractures (S) (Level I).
3. Salmon calcitonin reduces acute but not chronic phantom limb pain (N) (Level II).
4. Pamidronate reduces pain associated with acute osteoporotic vertebral fractures (N)
(Level II).
4.3.8 Cannabinoids
Cannabinoids are a diverse group of substances derived from natural (plant and animal) and CHAPTER 4
synthetic sources whose effects are mediated via cannabinoid receptors. Although over
60 cannabinoids have been identified in products of the cannabis plants, the most potent
psychoactive agent is delta9‐tetrahydrocannabinol (delta9‐THC) (Hosking & Zajicek, 2008).
Potentially useful actions of cannabis include mood elevation, appetite stimulation, an
antiemetic effect and antinociception. The clinical use of naturally occurring cannabis is
unfortunately limited due to a wide range of side effects, including dysphoria, sedation and
impaired psychomotor performance, memory and concentration. Cannabis withdrawal
symptoms resemble those of opioid and alcohol withdrawal (Hosking & Zajicek, 2008). There is
also concern that chronic exposure can predispose to the development of psychosis in
susceptible individuals (Luzi et al, 2008 Level IV).
A number of expert committees have examined the scientific evidence assessing the efficacy
and safety of cannabinoids in clinical practice (House of Lords, 1998; Joy et al, 1999; NSW Working
Party, 2000). Insufficient rigorous scientific evidence was found to support the use of
cannabinoids in clinical practice.
In 2001 a qualitative systematic review examined the evidence for cannabinoids as analgesics
(Campbell et al, 2001 Level I) and found no evidence for clinically relevant effectiveness, but
significant side effects.
In acute pain, a number of studies investigated different cannabinoid presentations for
postoperative analgesia. No benefit was found with a single dose of oral THC on the second
day following hysterectomy in 20 women (Buggy et al, 2003 Level II). Unexpectedly, high‐dose
(2 mg) nabilone in the presence of morphine was associated with increased pain scores in
patients who underwent major orthopaedic or gynaecologic surgery (Beaulieu, 2006 Level II).
A dose escalating study using an oral mixture of THC and cannabidiol (Cannador®) following
cessation of PCA after a range of surgical procedures found that the need for rescue analgesia
was reduced with increasing dose, but that side effects occurred at the higher dose (Holdcroft
Acute pain management: scientific evidence 93
