Three hundred ninety-seven insulin-dependent diabetic dialysis patients were screened by nursing staff for analgesic-seeking behavior. Thirty-eight patients were identified and classified as prescription abusers (n = 26) or illicit drug users (n = 12). The nine cocaine users, when compared with 14 insulin-dependent diabetics on dialysis matched by protocol, were found to be similar in terms of diabetic retinopathy and metabolic neuropathy. Although statistically not significant, cerebrovascular and cardiovascular complications were more common in the study group. Gastroenteropathy with malnutrition was more common the study group (P less than 0.025). Infection rate and severity were markedly worse in the cocaine group: bacterial cellulitis, sepsis, and abscess each increased greater than fourfold. All the visceral infections were in the cocaine-using group. Hepatitis viral antigen and antibody was increased 10-fold in the cocaine users. Recommendations for management of dialysis patients with analgesic-seeking behavior are formulated in light of these findings.