Emerging biochemical targets in chronic pain: bridging molecular mechanisms and public health policy in the Indian context

INTRODUCTION: India confronts a chronic-pain paradox widespread under-treatment of pain coexisting with intense restriction of opioid prescribing. India's prevailing opioid-constrained pain-management model, constrained by narcotic legislation, institutional caution, and cultural stigma, is biochemically and clinically inadequate for the maladaptive pathophysiology of chronic pain. AREAS COVERED: This narrative review synthesizes emerging evidence on non-opioid biochemical targets relevant to chronic pain management in the Indian context, including glial modulators, cytokine inhibitors, NMDA and NK-1 receptor antagonists, selective sodium-channel blockers, TRPV1 antagonists, histone deacetylase inhibitors, and microbiome-based interventions. We discuss the molecular pathophysiology of chronic pain neuroinflammation, central sensitization, and glial activation and integrate preclinical and emerging clinical data. The literature was identified through PubMed, Scopus, and Google Scholar searches up to April 2026, focusing on chronic pain mechanism-based therapeutics relevant to the Indian clinical context. EXPERT OPINION: Translating mechanism-based pain therapeutics into Indian practice requires concurrent reform across medical education, pediatric pain prevention, and national drug policy. Embedding biochemical literacy in training, expanding equitable access to non-opioid agents, supporting indigenous translational research, and integrating validated Ayurvedic phytochemicals into mechanism-informed care offer a culturally grounded path forward.