Pain following spinal cord injury (SCI) has been well described in the literature, with specific treatments emerging in recent years for the different subtypes of pain. Treatment of pain and the concomitant reduction of suffering are ethical imperatives for treating staff. In most cases, no ethical dilemmas are present when treatment decisions are made between patient and staff. In the specific case of medications with the potential for abuse and/or diversion, however, ethical issues have arisen. Because of increasing regulatory scrutiny, many physicians are increasingly reluctant to prescribe control led substances. Persons with SCI who are well managed on such medications and who present with no history of abuse or diversion may be left without access to treatment that appropriately and effectively reduces their pain and suffering. We will review the forces involved in the development of these conditions, present three cases illustrative of the ethical dilemmas raised, and offer some general suggestions about how these dilemmas might be solved. © 2008 Thomas Land Publishers, Inc.