This guideline provides recommendations for primary care clinicians who are prescribing opioids for chronic pain outside of active cancer treatment, palliative care, and end-of-life care. The guideline addresses 1) when to initiate or continue opioids for chronic pain; 2) opioid selection, dosage It is challenging to face a potentially terminal illness: hoping for the best, while planning for the worst. The importance of pain management at the end of life is a professional, moral, and ethical obligation. Although pain may not be the most prevalent symptom at the end of life, it is the most feared. Guidelines should be developed by a multidisciplinary panel to address the spectrum of physical symptoms common at the end of life, modifying and building on existing practice guidelines for symptom management. Prescribers and pharmacists in various clinical roles are often challenged when treating patients with comorbid chronic pain and end-stage renal disease (ESRD) or hemodialysis (HD). There is a dearth of clinical guidelines available for chronic pain management in this setting. Pain management is one of the primary goals of hospice care - keeping the patient comfortable and managing symptoms to ensure they have the highest quality of life for as long as they live. Not all patients experience pain at end of life, but recognizing it and treating it effectively is essential. The Management of Opioid Therapy for Chronic Pain Working Group . The decision to widen the scope of 200the 3 guideline to opioid therapy for chronic pain, as opposed to • Does not address the use of opioids for patients receiving end of life treatment Despite over 20 years of evidence-based pain management guidelines, the risk of poor pain management continues among end of life patients. Undertreatment of pain results from lack of knowledge and education of nurses and the myths and misconceptions surrounding opioid use. Pain Management in Palliative Care Pain in palliative care qual