The use of long-term opioid therapy for the management of chronic pain remains controversial. The highlighted consequences of long-term opioid therapy are aberrant drug-taking behaviors, abuse, and dependence. However, the limitations of this treatment modality usually can be attributed to a lack of efficacy and adverse events. Patients that remain refractory to long-term opioid therapy for chronic pain often have a psychiatric disorder that is acting as a barrier to effectiveness. While standardized approaches to the evaluation of a patient to receive long-term opioid therapy are established, little data exists to document their ability to limit opioid abuse or enhance their efficacy. Screening questionnaires and other attempts at predicting or detecting opioid-related substance use disorders fail to determine the presence of comorbid psychiatric disorders. A comprehensive approach for the psychiatric evaluation of patients with chronic pain will address specific barriers to successful chronic pain management and optimize the chances for success with long-term opioid therapy.