Difficult conversations in medicine are those conversations that raise negative feelings such as frustration, anxiety, and guilt, within the healthcare team and patients alike.  It is understandable and predictable for patients to express strong feelings when presented with the need to change behavior such as reducing or eliminating prescription opioids. Pain medications can become a patient’s primary coping strategy for dealing with physical, emotional, psychological and post-traumatic pain. Delivering the change message can be triggering and even terrifying for patients and families.  Strong emotions are commonly expressed and directed toward the healthcare team. Communication that demonstrates empathy, compassion and strong limit setting, will lead to more positive clinical outcomes. Health care teams can develop their capacity to authentically engage in difficult conversations with their patients.

The resources that follow are intended to help healthcare teams transform difficult conversations into a type of medicine that is safe, effective, and satisfying for patients and families as well as the healthcare team.


  1. The Art of Difficult Conversations: Courtesy of Laura Heesacker, LCSW-A handout to set the tone for navigating emotionally laden clinical situations. This handout offers five principals; Belief and Confidence, Values, Realistic Expectations, Relationship as a Resource and Willingness to Feel Uncomfortable, to successfully navigate difficult conversations.
  2. VEMA-Validate, Educate, Motivate, and Activate: Courtesy of Anthony J. Mariano, PhD-An acronym to help successfully guide difficult conversations based on Motivational Interviewing concepts
  3. Common Traps and Negotiation Strategies: Courtesy of Brad Anderson, MD-Brings awareness to the areas providers/team can find themselves “trapped” into unhelpful conversations that leave all parties unsatisfied and defeated.
  4. Navigation Strategies for Compassion-Based Patient Interactions: Courtesy of Barry Egener, MD- A Five Step Process for Navigating Challenging Patient Conversations: Navigating the emotional landscape; elicit the patient’s perspective; present your perspective; agree on common goals; and set limits.
  5. Helpful Hints for Compassionate-Based Conversations: Courtesy of Laura Heesacker, LCSW-offers supportive principals for outside as well as inside the exam room.
  6. S.O.A.R. – Shared Decision Making, Outcomes, Assurance, and Risk/Redirect: Based on the principals of E. Krebs, MD for the Safer Management of Opioids for Chronic Pain. Offers an acronym to guide conversations.
  7. Pocket Cards (4 to a page): Designed to print, cut and laminate.  Brief and simple strategies to maximize effective communication strategies during emotionally laden clinical situations.


Conversations Gone Bad

Example of the doctor engaging in denial, splitting, and passive aggression toward the drug-seeking patient (A. Lembke)

Example of a doctor’s narcissistic rage and retaliation, leading to opioid refugees (A. Lembke)

Examples of Positive Outcome Difficult Conversations

Diversion Scenario (4 min)—Provider suspects patient is diverting medication and demonstrates compassion and boundary setting.

Positive UDS Scenario (3 min)—Patient positive for un-prescribed benzodiazepine, provider does good job of setting boundaries and using safe decision making.

High Risk Low Benefit (5 min)—Provider uses good listening skills, motivational interviewing, and over all effective communication strategies in the face of a poorly motivated patient.

Scope of Pain-Boston University—Offers videos that model complicated provider-patient interactions around prescribing opioids for chronic pain including provider debriefs and reflections.


Lembke, Anna. (2016). Drug Dealer, MD: How doctors were duped, patients got hooked, and why it’s so hard to stop. Johns Hopkins University.

O’Sullivan, Suzanne. (2016). Is it all in your head? Vintage Books.

Articles and Commentaries

Kahn, Michael W. (2016). The uses of benevolent clinical despotism. The American Journal of Medicine. Volume 129, Issue 11, November 2016, Pages 1143–1144.

Lembke, Anna. (2016). Why doctors prescribe opioids to known opioid abusers. The New England Journal of Medicine, 11-19-2016 Copyright 2012 Massachusetts Medical Society.

Matthias, Marianne S. (2010). The patient-provider relationship in chronic pain care: providers’ perspectives. Pain Medicine, 2010 Nov;11(11):1688-97. doi: 10.1111/j.1526-4637.2010.00980.x.

Muench, John. (2016). Seeing the patient through the opium haze. Oregon Health & Sciences University, Department of Medicine Portland, Oregon 97202.

Ofri, Danielle. (2017). The conversation placebo. The New York Times, January 19, 2017.

Ouyang, Helen. (2016). Seeking painkillers in the emergency room. The New York Times, March 25, 2016.

Saal, Daniel. (2015). Rewriting the scriptJAMA. 2015;313(23):2323-2324. doi:10.1001/jama.2015.2653

Wasan, Ajay D, Wootton, Joshua, Jamison, Robert N. (2005). Dealing with Difficult Patients in Your Pain Practice. Regional Anesthesia and Pain Medicine, 30:184-192.