Objective: This study was designed to describe and compare individuals in rural Appalachia prescribed, abusing or diverting OxyContin® a region with high rates of prescription medication abuse and misuse. Setting and participants: Fifty subjects treated for OxyContin® abuse, 34 subjects prescribed OxyContin® for pain and 50 subjects incarcerated due to OxyContin®-related charges from rural Appalachia. Interventions: The Addiction Severity Index, DSM-IV Checklist, and an investigator developed questionnaire were administered to all three groups. Results: All three groups included individuals prescribed OxyContin® for pain and demographic variables and psychiatric/medical histories failed to discriminate between the pain and substance abuse (SA) subjects. SA and criminal justice subjects were significantly more likely to have a current DSM-IV diagnosis of psychoactive abuse/ dependence and more likely to be younger and unmarried. Conclusion: This study found that these groups are not distinct and in depth evaluations, including a detailed SA history, are needed to identify the pain patient at risk for abuse and/or diversion of prescribed opioids.