Among the many patients served by methadone maintenance treatment programs (MMTPs) is a small population with severe, refractory pain that may be effectively managed using long-term opioid therapy. Pain specialists have begun to treat these patients, and in some cases, methadone has been selected as the opioid analgesic administered for pain management. The use of methadone for pain in patients treated by MMTPs may lead to complex management issues. We present four patients who illustrate different outcomes associated with one challenging scenario, specifically the expressed desire on the part of the patient to withdraw from the MMTP because the opioid has become available for pain. Research is needed to evaluate the phenomenology of pain and addiction in this population and the outcomes associated with varied therapeutic strategies.