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The Palliative Recovery Engagement Program (P- REP) at the University of Pittsburgh Medical Center (UPMC), U.S.A, is an interdisciplinary clinic housed within an outpatient addiction program. It was formed in 2020 to care for individuals who have advanced illness, primarily cancer, who also experience substance misuse. We conducted semi-structured interviews with clinic patients to better understand their experience with pain management prior to arrival and while at P-REP. We identified factors that can influence the therapeutic relationship in this setting where conflict often predominates, such as a patient\u2019s coping mechanisms, their prior experiences with stigma, recovery programs, buprenorphine, and their ideas about abstinence, recovery, and the safety of their own patterns of opioid use. 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