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trial of ketamine (1 mg/kg daily) administered via a TD nitroglycerin (glyce-
ryl trinitrate) polymer patch (5 mg/day) found that this novel approach
significantly reduced the requirements for oral morphine. 31 Overall, the use
of ketamine for acute care management of CTP would seem limited by side
effects, but there may be a role for the NMDA receptor antagonist in refrac-
tory cases.
Cancer and tumor pain 157
Aggregate evidence from three trials comparing the CNS stimulant methyl-
phenidate (2.5–5 mg/day) with placebo showed no benefit of methylphenidate
for CTP. 4
For bone pain, bisphosphonates, in particular pamidronate (90–120 mg/
dose) and zoledronic acid (4 mg/dose), are shown in multiple trials to be
effective in reducing bony CTP from metastatic disease. 19 Cochrane review in
2002 concluded that there is an analgesic role for bisphosphonates in
relieving bony cancer pain, but that the role of this class lies outside the
realm of acute pain relief. 32 Rather, the bisphosphonates are found to be of
potential use when other analgesic regimens (including radiotherapy) fail. 32
Calcitonin (100 units/day SC) provides marginal, if any, relief in patients
with metastatic bone pain. 33 Although one dated trial found calcitonin (200
units/day SC) reduced bony pain, a 2006 Cochrane review concluded that
calcitonin neither relieves bony pain nor reduces need for opioids. 34,35
Gastrointestinal CTP is commonly encountered and inoperable bowel
obstruction is a significant source of patient discomfort. Some agents have
been found helpful. While corticosteroids are, at best, marginally effective as
an opioid-sparing adjunct for CTP in general, this class may have a role in
tumor-related bowel obstruction. 36 A 2000 Cochrane review showed a tendency
towards pain relief in malignant bowel obstruction with administration
of IV dexamethasone (6–16 mg/dose). 37 Other cancer-related uses of corticosteroids
(e.g. in steroid-responsive tumors) fall outside this review’s scope.
The antisecretory agents aim to relieve bowel obstruction CTP, and also
to eliminate the need for uncomfortable nasogastric tubes. The most useful
such agent is octreotide IV (600–800 μg/day), which significantly relieves
pain from inoperable malignant bowel obstruction. 23,38 Some efficacy is also
likely with the antisecretory drug butylscopolamine (hyoscine butylbromide;
60 mg/day). 23