The FDA is critical in ensuring that medications are safe and effective. However, the FDA's decision-making process for opioid analgesics is complicated by the need to address patients with complex clinical pain syndromes while balancing public safety concerns involving opioid misuse and abuse. Several recent regulatory decisions by FDA have exposed the complexity of this regulatory tug of war. For example, the FDA's decision to include a requirement for tamper resistance for extended-release oxycodone products but not for extended-release oxymorphone or hydrocodone preparations is concerning. Although tamper resistance is an imperfect solution, it provides a modicum of abuse prevention. Additionally, the rewording of the labeled indication (from 'moderate to severe pain' to 'severe enough pain') for extended-release opioid analgesics, in an attempt to provide clarity, resulted in an equally if not more vague statement of appropriate use. Furthermore, the postmarketing requirement for continued data regarding safety and efficacy have been affirmed by FDA but some of the proposed means to acquire those data will likely result in unclear answers and may have undesired consequences. We fully support the important role of the FDA but raise concerns about the occasional lack of consistency and transparency.