Treatment of osteoporotic vertebral compression fracture (OVCF) is multifaceted, but most techniques (e.g. kyphoplasty, nerve blocks, jacket splints) require orthopedic consultation. For the acute care provider, OVCF pharmacotherapy begins with acetaminophen. The ability of opioids to alleviate OVCF pain is not doubted, although there is little high-level evidence addressing the subject. Meta-analysis of five RCTs evaluating calcitonin versus placebo for acute OVCF concluded that the drug significantly reduces pain, with an effect consistently identified within seven days of treatment. The reduction in pain score over that associated with placebo is both long-lasting and substantial. Like calcitonin, the bisphosphonates have been studied for bony tumor and cancer-related pain. There is less evidence addressing their use for OVCF. Given the relative strengths of evidence for calcitonin and the bisphosphonates, and the drugs' safety and side effect profiles, the authors recommend reserving pamidronate for situations where other approaches fail or are contraindicated.