At the turn of the 21st century, pain management became a major public health concern, recognized as the 5th vital sign in VA healthcare, while opioid prescribing for chronic pain surged, leading to a fivefold increase in morphine milligram equivalents by 2010. In 2013, the DSM-5 redefined Substance Use Disorder (SUD) criteria, excluding tolerance and withdrawal for medically prescribed opioids. As the opioid epidemic unfolded, the limitations of long-term opioid therapy for chronic pain became evident, prompting current guidelines to discourage opioid initiation in favor of non-opioid approaches. However, some patients remain on long-term opioid therapy, struggling to taper without functional improvement, raising questions about whether these cases fit under mild Opioid Use Disorder (OUD) or require a new diagnostic category. This talk will address this ambiguity, outlining a clinical decision-making framework, and exploring the need for new diagnostic approaches when opioid harms outweigh benefits.