The growing number of patients admitted to acute care settings with the dual problem of pain and chemical dependency is bringing this major dilemma to the forefront of clinical nursing practice. Orthopaedics is one of the clinical areas likely to encounter an increased proportion of such patients. The care of chemically dependent patients with pain is not only often enormously challenging but also potentially frustrating. Planning care for these patients is best accomplished with a team approach that includes the expertise of several specialties, particularly pain and addiction. Although considerably more research is needed to identify the most effective approaches to the care of chemically dependent patients with pain, sufficient information now exists to support suggestions for guidelines. This article addresses definitions of pain and chemical dependency, methods of identifying the chemically dependent patient, the prevalence of pain and addiction, clinical conflicts and dilemmas related to relieving pain in addicted patients, a framework for planning care, and specific guidelines for individualizing the plan of care. Orthopaedic nurses are challenged to accept a leadership role in improving the care of chemically dependent patients with pain by evaluating these guidelines and developing additional approaches.