While opiate medications provide short term pain relief, their use in chronic pain has remained controversial due to questions of long term efficacy, addiction potential, and proper prescribing guidelines. This study examined differential outcomes between two opiate treatment strategies: 1) a Tolerable Pain (TP) strategy in which patients were maintained on steady dosages of opiate medications, and 2) an Adequate Relief (AR) strategy in which dosages were increased in response to reports of inadequate pain relief. 135 patients (mean age=52.52, SD=7.47) from a VA pain clinic, eligible for long-term opiate treatment, received medications monthly over a 1 year prospective trial according to their randomly assigned treatment. Outcomes included self-reported pain and relief and substance abuse (clinician rated behaviors and discharge due to substance misuse). Linear mixed-effects modeling was the primary analysis method. The AR group had significantly higher dose increases over the year (19.52 mg morphine equivalents difference at month 12). Ratings of worst pain and ‘amount of relief after taking medications' showed a significant treatment group x month interaction (p<0.05) resulting from the AR group having greater declines in worst pain and greater relief compared to the TP group over the study period. No treatment group differences were found in clinician ratings of medication misuse or discharge (overall 29.20% discharged due to misuse). Chi-square revealed that history of substance abuse predicted discharge in AR (p<0.01) but not in the TP group. History of alcohol abuse was not predictive of discharge. Results indicate: 1) a generally high rate of opiate medication misuse even in a carefully monitored pain clinic, 2) a small improvement in pain related outcome using the AR versus TP guideline, and 3) AR guidelines may be appropriate for patients without abuse history as seen by the improved pain control and lower discharge rate. Supported by VA HSR&D.