For decades, American pain specialists promoted the idea that physicians should use patients’ subjective, self-reported pain as a valid measurement and prescribe medications accordingly. This logic has been called into question in the context of the opioid epidemic of the 2010s. To address overprescription, leading medical organizations have published new patient care guidelines that put a tight cap on the use of oral opioids for treating chronic, non-cancer pain in the outpatient setting. To date, however, there is no professional consensus on how severe pain should be treated in the inpatient setting. The subjective nature of pain has long rendered it a source of clinical uncertainty, and the current vacuum in guidance for inpatient pain management has compounded this incertitude. Drawing on a two-year ethnography of an academic medical center, I examine how hospitals grapple with the ambiguity of medical decision-making around pain and opioids. By conceptualizing hospitals as organizations that balance multiple, overlapping, and conflicting goals, I leverage the case of pain management to demonstrate how medical decision-making has the potential to advance or work against hospital goals. I find that, in the absence of clear institutional standards around pain management, organizational goals inform how healthcare workers think about pain, how they interpret both clinical interactions and medical knowledge, and how they develop plans for treating patients. From this perspective, pain represents not a value-neutral site for the practice of scientific medicine, but rather one where competing organizational priorities come into conflict. Ultimately, I argue that medical decision-making and patient-doctor interactions are influenced by organizational goals in ways that are consequential for patient care and exacerbate healthcare inequalities.