Patients with active opioid use disorder (OUD) commonly present for medical care when they have complications of the disease that are often infectious and painful. OUD is complex and multifaceted, and its pain management is very challenging, especially in the era of illicitly manufactured fentanyl and the presence of other substances, like xylazine. New approaches are emerging to manage acute severe pain in patients with OUD that require special understanding of the disease itself, the impact of societal norms and stigma, and changing drug supply. This session will explore considerations to help stabilize withdrawal and treat pain in patients with active OUD who present with acute care needs.