Current ACR treatment guidelines for chronic pain consist of a multistage treatment algorithm based on increasing analgesic potency. Tramadol is currently recommended as an alternative for patients unresponsive to or intolerant of nonselective NSAIDs and COX-2 inhibitors for the relief of moderate to severe chronic pain (ACR 2000 ). Tramadol ER has benefits that may merit its use earlier in the treatment decision process for moderate to moderately severe chronic pain. Tramadol ER, either as monotherapy or in combination with antiinflammatory agents, as first prescription therapy (following initial use of acetaminophen), for patients who require 24-hour relief from their moderate chronic pain may spare the use of nonselective NSAIDs and COX-2 inhibitors, as well as reduce side effects and improve patient compliance. Tramadol ER may also postpone the need for scheduled opioids and the risks inherent in their use.