This column will feature a series of focused overviews with practical suggestions for managing the manifold tricky needs of your patient population. This series started with a primer for addressing the sexual health questions of patients-paired with a healthy dose of required self-reflection (“Teach them to fish: Addressing the sexual health needs of patients and practice culture”). The series will continue with this dive into problematic substance use and next to coverage of other important but thorny issues including personality disorders, patient safety in the home (exposure to violence, abuse, or self-harm), cognitive impairment vis-à-vis medical decision-making, and the de-escalation of agitated, angry patients. There are other dozens of other difficult conversations, so please get in touch with suggestions.