While the role of opioid analgesics has been established in the treatment of cancer pain, reservations persist about appropriate use in patients with chronic noncancer pain. Recent evidence from controlled clinical trials supports the effectiveness of opioids for treating noncancer pain of varying etiologies. The safety of opioids in noncancer patients has been an area of controversy because of confusion between physical dependence, which develops in all patients receiving opioids chronically, and addiction, which is a behavioural diagnosis that is rarely made in patients appropriately treated with opioids for pain. Abuse by secondary recipients of opioids is well documented and arises as a result of diversion by primary recipients, double-doctoring, forgery and theft. The frequency of forgery and theft of different opioids appears to be largely related to the corresponding number of legitimate prescriptions. While it is legitimate medical practice to prescribe opioid analgesics to patients with chronic noncancer pain, there is clear evidence that prescribing is affected by concerns of regulatory sanctions. Recent guidelines, including most recently comprehensive guidelines issued by the Canadian Pain Society, should help to reduce inappropriate undertreatment because of such concerns.