If a person has an existing substance use disorder, then it's definitely helpful to have a proactive discussion about plans for pain care in acute circumstances (like a hospital stay). I have had patients in hospital with complex and severe wounds where the only way to apply and remove dressings from the wound was to give opioid pain medicine. However some of those people had either past addiction history or were (at the moment) receiving buprenorphine (a kind of opioid) for the treatment of opioid use disorder. It's not forbidden to add new opioids into hospital care, but the conversation must be intentional in advance to learn if the patient and the clinician are that would be the right decision. Conversely - for long-term pain - there is immense dispute about whether prescription opioids are "effective" at all. No one would argue they are "best" (the evidence does not show that). However, we have a bit of a dilemma. Every single treatment approach put forth for chronic pain that has some credible evidence seems to only work modestly, for some, and then not for others. If our treatments are only "so-so" (and opioids, too, have produced that kind of "modest" outcome in large trials), then the question is whether it is morally and ethically justifiable to keep prescription of opioids "on the list" for those patients where other treatments have failed. Some clinicians and policymakers argue "no", and (in essence), if other treatments fail, then just don't offer opioids. Others would say "actually we have to consider this challenging treatment too". That's an ethical dispute. However, IF the patient already has a history of drug use (current or past) then the risk of harm from opioid treatment is MUCH higher, and the possible benefit is usually going to seem less convincing.