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Abstract Guideline concordant opioid therapy is a key part of the concerted effort to address the opioid crisis in the United States. The study aimed to compare the rates of guideline concordant care between veterans who solely used VA services (mono users) and veterans who used both VA services and community care (dual-system users). We used electronic health record data from the Washington DC and Baltimore VA Medical Centers from 2015 to 2019. We provided descriptive statistics as well as generalized estimating equations models to find associations between mono vs. dual-system users and each guideline outcome, controlling for demographic factors and comorbid conditions. The study found that overall rates of guideline concordant care were high in both mono and dual-system users with over 90% adherence rates for the majority of recommendations. However, there were variations in adherence to specific guidelines, with urine drug screening at initiation being the least commonly followed recommendation (8.9% of mono-user opioid initiators and 11.2% of dual-user initiators). This study also found that there was no consistent pattern of higher guideline adherence in mono vs. dual-system users but did show that through the course of this study (2015–2019) overall rates of guideline concordance increased. Future research will explore additional guideline recommendations and potential coordination issues among dual-system users.