Even the most severe acute pain (lasting hours to days) can usually be controlled—with significant but tolerable adverse effects—using currently available analgesics, especially the opioids. However, chronic pain (lasting months to years) and especially pain arising from neuropathic causes are not very satisfactorily managed with opioids. It is now known that in chronic pain, receptors on sensory nerve terminals in the periph-ery contribute to increased excitability of these sensory endings (peripheral sensitization). The hyperexcitable sensory neuron bombards the spinal cord, leading to increased excitability and synaptic alterations in the dorsal horn (central sensitization). Such changes are likely important contributors to chronic inflam-matory and neuropathic pain states. In the effort to discover better analgesic drugs for chronic pain, renewed attention is being paid to the molecular basis of peripheral sensory transduction. Potentially important ion chan-nels associated with the primary afferent nociceptor include members of the transient receptor potential family, notably the capsaicin receptor, TRPV1 (which is activated by multiple nox-ious stimuli such as heat, protons, and products of inflammation) as well as TRPA1, activated by inflammatory mediators, and P2X receptors (which are responsive to purines released from tissue damage). Special subtypes of voltage-gated sodium channels (Nav 1.7, 1.8, 1.9) are uniquely associated with nociceptive neurons in dorsal root ganglia. Lidocaine and mexiletine, which are useful in some chronic pain states, may act by blocking this class of channels. Certain centipede toxins appear to selectively inhibit Nav 1.7 channels and may also be useful in the treatment of chronic pain. Genetic polymorphisms of Nav 1.7 are associated with either absence or predisposition to pain, and there may be a direct link between expressed levels of Nav 1.7 and enkephalin in sensory ganglia. Because of the importance of their peripheral sites of action, therapeutic strategies that deliver agents that block peripheral pain transduction or transmission have been introduced in the form of transdermal patches and balms. In addition, products that systemically target peripheral TRPV1, TRPA1, and sodium channel function are in development. Ziconotide, a blocker of voltage-gated N-type calcium channels, is approved for intrathecal analgesia in patients with refractory chronic pain. Ziconotide is a synthetic peptide related to the marine snail toxin Ω-conotoxin, which selec-tively blocks N-type calcium channels. Gabapentin/pregabalin, anticonvulsant analogs of GABA (see Chapter 24) that are effective treatments for neuropathic (nerve injury) pain act at the α2δ1 subunit of voltage-gated calcium channels. N-methyl-D-aspartate (NMDA) receptors appear to play a very important role in central sensitization at both spinal and supraspinal levels. Although certain NMDA antagonists have demonstrated analgesic activity (eg, ketamine), it has been difficult to find agents with an acceptably low profile of adverse effects or neurotoxicity. However, ketamine infused at very small doses improves analgesia and can reduce opioid requirements under conditions of opioid tolerance, eg, after major abdominal and spinal surgery. GABA and acetylcholine (through nicotinic receptors) appear to control the central synaptic release of several transmitters involved in nociception. Nicotine itself and certain nicotine analogs cause analgesia, and their use for postoperative analgesia is under investigation. Use of antibod-ies that bind nerve growth factor (NGF) has been shown to block inflammatory and back pain and is awaiting US Food and Drug Administration (FDA) approval. Finally, work on cannabinoids and vanilloids and their receptors suggest that Δ9-tetrahydrocannabinol, which acts primarily on CB1 canna-binoid receptors, can synergize with μ-receptor analgesics and interact with the TRPV1 capsaicin receptor to produce analgesia under certain circumstances. As our understanding of peripheral and central pain transduction improves, additional therapeutic targets and strategies will become available. Combined with our present knowledge of opioid analgesics, a “multimodal” approach to pain therapy is emerging. Multimodal analgesia involves the administration of multiple agents (eg, nonsteroidal anti-inflammatory drugs [NSAIDs], gabapentinoids, selective nor-epinephrine receptor inhibitors, etc) with complementary mechanisms of action to provide analgesia that is superior to that provided by an individual compound. Another benefit of multimodal analgesia is reduced opioid requirements with fewer adverse effects.