Intravenous drug users present significant clinical challenges to the hospitalist. With the Opioid epidemic, this issue continues to be an increasing issue in hospital medicine. In this chapter, we review common clinical dilemmas faced by hospitalists when managing intravenous drug users. We summarize data from relevant sources concerning medical management, behavioral issues, and the special concerns of under insured populations. We also offer recommendations for hospital discharge planning. When applied in a consistent manner strategies for treatment and the initiation of withdrawal are effective.