“The tramadol’s not touching it — I need something stronger”

Long-term opioids are largely ineffective for chronic non-cancer pain and carry real harms (tolerance, dependence, hyperalgesia, sedation, falls, overdose), so a request for "something stronger" usually reflects tolerance/dependence rather than under-treatment — and escalation rarely helps and often harms. Both failure modes must be avoided: simply escalating (collusion) and a flat refusal/"it’s in your head" (abandonment and ruptured trust). The skill is honest, validating partnership: affirm the pain is real, explain why escalation won’t help and may harm, and pivot to an evidence-based whole-person plan — supported self-management, physical activity/physiotherapy, psychological approaches, treating mood/sleep, and social/occupational support — plus a STRUCTURED, supported opioid reduction (never abrupt), framed as reducing harm and often improving pain/function. The examinable hidden agenda is fear of abandonment and being judged ("I’m not a drug seeker") plus profound loss of job/identity and low mood the opioids are also medicating; surface and treat that, hold the line with warmth not coldness, and walk the plan with him.