Opioids affect the central nervous system and are known to produce dizziness, sleepiness, mood changes, and other actions that in some people have a negative impact on psychomotor or mental performance. The negative effects can be exacerbated in persons who are taking other prescription medications or illegal substances. Opioid-abusing drivers clearly represent an unnecessary danger to the public; although the vast majority of patients taking prescription opioids for pain safely drive to work and other activities, a subset may be impaired, but not be aware of or recognize the problem. The majority of pain patients would likely be surprised to learn that the legal systems in most parts of the world, including most states in the United States, do not differentiate between a pain patient taking a prescribed opioid at the right dose and frequency, and an abuser taking an illegal drug. For example, in some parts of the United States, a driver may be initially stopped for a relatively minor offense and, if the officer notices that the driver is wearing a fentanyl patch, charged with driving under the influence of drugs (DUID). The present narrative review attempts to highlight the existing problem, the different legal thresholds for arrest and prosecution for DUID, and the challenge of trying to have zero-tolerance for driving under the influence of a drug used illegally, while at the same time not arresting legitimate patients who are taking pain medication as prescribed. There is a clear and present need for an integrated assessment and addressing of the current confounding situation.