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For the primary care clinician treating patients with unhealthy alcohol use, pain syndromes are frequently clinical issues that pose unique challenges relative to the management of low risk or non-alcohol users with pain. Unhealthy alcohol use and its consequences may impact both the assessment and management of pain. Such considerations are particularly important when prescribing medications that can interact with alcohol or alcohol-related comorbidities, such as acetaminophen, nonsteroidal anti-inflammatory drugs (NSAIDs), and opioid medications. Rather than a comprehensive review of general pain management, this chapter provides recommendations on how to approach the patient with unhealthy alcohol use and pain. Special attention is devoted to the safe and effective use of opioid analgesics, given the inherent risks of interactions and misuse, and that observational studies demonstrate that patients with current or past alcohol use disorders are at higher risk for subsequent prescription opioid misuse.