When You Need to Say No

By Emily Clegg, JD, MBA, CPHRM

In conversations about opioid prescriptions, there can be unspoken fears and motivations swirling beneath the surface. The patient may be fearful, aggressive or even dishonest. The clinician may fear backlash if the answer is no, but also knows that saying no could save a life.

Dan O’Connell, PhD, is a clinical psychologist who trains, coaches and consults with clinicians on improving communication and patient relationships. He promotes the idea that patients are not the problem, but neither is the clinician. “The problem,” he says, “is that opioids may be causing more harm than good.”

A Simple Strategy

When the answer may be saying “no,” a conversation is one place to start. Dr. O’Connell suggests talking about safety and effectiveness, then using the patient’s answers to balance the two.

Safety: Draw out the patient’s understanding related to safety, then educate to fill in gaps. Ask, “Do you find yourself needing more and more?” or, “How would you know if you were becoming addicted?”

Effectiveness: Reflect the patient’s own complaints back to them. For example, “If opioids were the most effective way to help, I would expect them to be making more of a difference,” or, “I’m hearing your biggest issues are stress and lack of sleep—let me propose a more effective approach.”

Balancing safety and effectiveness: Reframe the conversation: “I’m open to considering any plan we both agree is the safest, most effective way to help your pain, and which we are certain won’t do more harm than good.”

Concluding the Conversation

After following this format, present a clear conclusion. If opioids may be doing more harm than good, agreeing to a different plan or to a contract that includes opioids and parameters to ensure they aren’t doing harm are two possibilities.

If a patient grows angry or disagrees, Dr. O’Connell suggests using a defusing technique such as getting a second opinion or the input of a specialist. He advises “Be soft on the people, but be hard on the problem.”

Emily Clegg, JD, MBA, CPHRM, is DIrector of Risk Management and Client Services, UMIA/MMIC

This article originally appeared in the Summer 2017 issue of Brink magazine, a patient safety and risk management magazine published by Constellation.

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