Summary Substance abuse is a major problem with significant relevance to perioperative anaesthesiological care. Drug addiction necessitates specific strategies for deal­ing with an altered need for analgesics and anaesthetics, possible specific sub­stitution therapies and/or co-morbidities. Despite the significant impact of addiction, relevant therapeutic recommendations derived from evidence-based in­formation for the anaesthesiological management of these patients is lacking. Perioperative care must give consideration to the altered specific needs of such patients as well as to the specific idiosyncrasies of accompanying and replace­ment drugs. In addition, the specifics of chronic addiction must be accepted. Treatment of the underlying condition is not the primary consideration, rather, equal weight must be given to: 1. stabilisation of physical dependence through substitution therapies, 2. avoidance of distress or craving, 3. perioperative stress relief, 4. strict avoidance of inadequate analgesia, 5. postoperative optimisation of regional or systemic analgesia with non-opioids, opioids and co-analgesics, 6. consideration of specific physical or psychological comorbidities. Inadequate analgesic treatment is known to be responsible for relapses into addiction, and must be avoided at all costs. Since patients in a long period of abstinence are always at risk of a relapse, the above strategic principles of anaesthesiological management must apply to them also.